Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the cardiologist consultation for evaluation of the enrollees heart murmur. Findings:  The physician reviewer found that in this circumstance thorough screening for signs of inherited connective tissue disease by a cardiologist was medically necessary and appropriate, especially when there are physical manifestations to raise suspicion. In this case, there was documented hyperextensibility and concern over abnormal heart sounds. Moreover, the cardiologists impression included abnormal findings not previously identified and assessed for potential critical findings of aortic dilation not previously addressed. Therefore, the cardiologist consultation was medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the service at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary. An enrollee has requested authorization and coverage for ketamine infusion for treatment of the enrollees complex regional pain syndrome. Findings:  The physician reviewers found that the patient is diagnosed with complex regional pain syndrome (CRPS). The submitted records noted that the patient has tried several medications but these medications were not effective. The records reported physical therapy as an ineffective modality for treatment of her medical condition. She has history of right upper extremity and left lower extremity CRPS. She has had sympathetic blocks but developed blisters afterwards. The records indicated that she has had multiple procedures without any true efficacy. The patient has not tried ketamine intravenously. The patients provider would like to trial an infusion of ketamine. The Health Plan has denied coverage for ketamine infusion as investigational for the treatment of this patient. The superior efficacy of the requested ketamine infusion has not been established in this patients case. The documentation does not mention trial and failure of standard treatment options for this patient. The patients psychologist had requested therapy and the physical therapist felt desensitization therapy would be helpful. However, there are no progress notes that comment as to how these requested modalities were working for this patient or if they were performed. While there is evidence of medication failure, there is no clear documentation of failure of the psychologists or physical therapists treatment recommendations. For all these reasons, the requested ketamine infusion is not likely to be more beneficial for the treatment of this patient than other treatment options.  Final Result: All three reviewers determined the requested ted services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in anesthesiology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis 5 mg, 15 tablets per month for treatment of the enrollees erectile dysfunction. Findings:  The physician reviewer found that the current limit of six tablets per month is appropriate based on available medical literature supporting the frequency on intercourse in adult males. One study reported that on average, adults report engaging in intercourse 57 times per year. Further, only 9.5% of married men 60-69 years of age reported having vaginal intercourse more than two to three times per week. Final Result: The reviewer determined that the requested medication quantity is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested exploratory laparotomy and tumor cytoreduction for treatment of the enrollees neurofibromatosis type 1 with metastatic gastrointestinal stromal tumor.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has an aggressive drug resistant tumor.  Surgery would be beneficial if a complete resection with no microscopic residual tumor or complete resection with no grossly visible tumor could be achieved.  The likelihood of that given her two prior operations and rapid progression makes this unlikely.  Surgery for advanced disease in the setting of drug resistance is also of unknown benefit.  The records indicate that the patient has been managed in a complete, multidisciplinary format.  The provider who previously performed the cytoreduction did not believe that complete resection was feasible or that the associated morbidity was in her best interest.  There is a lack of support for the requested services in this clinical setting.  All told, the requested exploratory laparotomy and tumor cytoreduction is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested orthotics for treatment of the enrollees flat feet.  Findings: The physician reviewer found that the submitted documentation supports the requested equipment in this clinical setting.  Flat foot can be divided into two general categories, flexible and rigid.  In flexible flat foot, the collapsed arch is present only when the patient bears weight.  In rigid flat foot, the arch is fixed in position regardless of weight-bearing status.  Most of the time, flexible flat foot is asymptomatic and requires no treatment. However, according to the literature, symptomatic flat foot requires treatment.  Options include activity modification, proper shoes and orthoses, stretching and strengthening exercises, and non-steroidal anti-inflammatory medications.  Surgery may be considered if all other treatment options fail.  In this patients case, she has multiple medical problems as a result of and in addition to her chromosomal disorder, and she has muscle weakness and gait characterized by in-toeing.  She has been diagnosed with flexible pes planus with collapsed medial arch bilaterally, and she has been prescribed custom orthotics to offer improvement in gait and stability.  Based on the current literature, the requested orthotics are medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. In addition, the guidelines recommend that treatment-naive genotype 4 patients should be treated with Harvoni for 12 weeks. This is based on the SYNERGY trial for Harvoni, which showed a 100% cure rate despite including some patients who had failed prior therapy (Kohli, et al). The AASLD/IDSA guidelines cite data showing decreased survival with delay in therapy (Jezequel, et al). For these reasons, treatment with Harvoni for 12 weeks is medically necessary for the treatment of the patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings: Three physician reviewers found that the American College of Radiology (ACR) urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional (2D) imaging alone. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had the exam been done with 2D imaging only. Therefore, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Two physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on 7/6/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Two physician reviewers found that the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is support in the medical literature showing that the addition of digital breast tomosynthesis to two-dimensional mammography reduces false positives and increases cancer detection when compared to mammography alone (Ciatto, et al). According to Skaane and colleagues The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Based on the support in the peer-reviewed literature, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested custom molded foot orthotics for treatment of the enrollees foot pain. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested custom molded foot orthotics. Orthotics are utilized to improve the biomechanics of a painful foot to allow for pain-free ambulation. In this case, the patient presents with painful peroneal tendinitis of the left side. His pain is noted upon palpation to the peroneal tendons, and he is noted to have a pathologic foot structure including a cavus foot structure with a hypermobile first ray of the left side. In this clinical setting orthotics are medically necessary to support the cavus foot and offload pressure from the peroneal tendon on the left side. In sum, the requested equipment is medically necessary for treatment of the patients cavus foot structure, hypermobile first ray, and painful peroneal tendinitis.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 3.  Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This patient should be considered treatment-naive due to failure of a partial interferon course rather than a complete course of peg-interferon and ribavirin. Per the guidelines, in treatment-naive genotype 3 patients, Sovaldi and Daklinza for 12 weeks is a recommended regimen. This is based on the ALLY-3 trial showing a 97% cure rate in this population (Nelson, et al). In addition, a delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, hepatitis C treatment is needed, and Sovaldi with Daklinza for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for applied behavioral analysis (ABA) program evaluation for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the gold standard for establishing the diagnosis of autism is the utilization of the ADOS. However, the ADOS can provide false positives in the clinic setting. More impairment was indicated when a module with more language and task demands was administered. Clinical judgment of the most appropriate module for administration was found to be important. In this case, the patient presents with language delays and inattention. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria listed by the out-of-Plan clinical psychologist was minimally positive. The evaluation performed by the in-Plan developmental-behavioral pediatrician was decidedly negative. The ADOS-2, Module 2 utilized was likely too difficult for this patient given his language delays and inattention. Based on the clinical documentation provided for review, the diagnosis of autism spectrum disorder has not been established. Therefore, the request for an ABA program evaluation is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary. An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that the patient presented for a follow-up targeted left breast ultrasound and left breast diagnostic mammogram with tomosynthesis. A previously seen nodule medially in the posterior left breast was not seen on the diagnostic mammogram.  There was no abnormality on the ultrasound. The evaluating provider reported that the nodule may have been a cyst which resolved in the interval. The assessment was BI-RADS category 1, negative. Routine screening mammogram was recommended in 12 months. The Health Plan denied reimbursement for the digital breast tomosynthesis. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is clinical support for the service at issue. According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.Final Result: Two physician reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.