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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for abdominoplasty for treatment of the enrollees medical condition status post panniculectomy.  Findings: The physician reviewer found that as noted by the American Society for Plastic Surgeons (ASPS), cosmetic surgery is performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem. The ASPS defined reconstructive surgery as performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease...generally performed to improve function, but may also be done to approximate a normal appearance. The ASPS noted that when an abdominoplasty or panniculectomy are performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. Based on the entirety of the documentation provided for review, this patient does not have a defined functional deficit that would be improved with abdominoplasty. She has not been documented to have functional problems related to the surgical outcomes. Her primary concerns are aesthetic from her previous abdominoplasty and subsequent revision. There can be cases in which an abdominoplasty can be considered reconstructive, if the level of deformity is significant enough to be considered significantly abnormal. However, this is not the case for this patient. Consistent with these findings, the requested abdominoplasty is not medically necessary.Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition.Credentials/Qualifications: The reviewer is board certified in plastic 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested for varicose vein treatment for her bilateral venous insufficiency.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Prior to further intervention for this patient, it is important to reassess the patients current status in order to determine if she requires further vein treatment.  If she is still having debilitating symptoms following her right GSV ablation, sclerotherapy may be appropriate.  Without an assessment of the patients current status and condition, the medical necessity of the requested services cannot be established. Therefore, the requested varicose vein treatment is not medically necessary 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 physician reviewer is board certified in general surgery and vascular 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for evaluation of her medical condition. Findings: Three physician reviewers found that there is insufficient data to support the use of advanced lipoprotein analysis in this clinical setting. While some researchers have advocated use of the advanced lipoprotein analysis for evaluation of cardiovascular risk to help make treatment decisions for patients with hyperlipidemia, the guidelines of the American College of Cardiology (ACC) do not support the use of advanced lipoprotein analysis. There is insufficient data, according to the ACC, to document benefit for the advanced lipoprotein assay above the basic lipid profile. Therefore, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the test at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and is 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 enzyme-linked immunoelectrotransfer blot (EITB) test and magnetic resonance imaging (MRI) of the brain for evaluation of her chronic sinus problems.  Findings:  The physician reviewer found that based on the available documentation, the requested EIBT and MRI are not medically necessary for the evaluation and treatment of this patient. Based on guidelines for the diagnosis of neurocysticercosis, a CT scan can be used to make the diagnosis (Garcia, et al). The Centers for Disease Control and Prevention (CDC) recommends treatment with anti-helminthic chemotherapy as was done in this patients case. In addition, parasitic evaluations were negative per the providers notes. There is no indication for further evaluation given these findings. Accordingly, the requested EITB test and MRI of the brain are not medically necessary for further evaluation of this patients medical condition.Final Result: The reviewer determined that the requested EITB test and MRI of the brain are not medically necessary for evaluation of the patients medical condition.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested clobetasol foam for treatment of her rash. Findings: The physician reviewer found that in this patients case, the medication at issue was not medically necessary for treatment of her contact dermatitis on her legs. The patient used clobetasol cream without improvement prior to trying the clobetasol foam but given that she did not see improvement with the cream formulation, the foam formulation, of the same medication, would not have been indicated as an alternative therapy. Allergic contact dermatitis will self-resolve over time. Alternatively, a more aggressive therapy such as oral steroids, could have been prescribed.  Therefore, clobetasol foam used for treatment of the patients contact dermatitis was not medically necessary.Final Result: The reviewer determined that the medication at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician reviewer is board certified in dermatology 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 breast tomosynthesis for evaluation of her risk for breast cancer. Findings: Three physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, she has breasts that have been described as being dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, in this clinical setting, the use of 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 her risk for breast cancer.  Findings: Two physician reviewers found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography alone. The additional three dimensional imaging allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue, offers increased cancer detection, and allows better characterization of possible masses, spiculation, and architectural distortion. In this patients case, a routine screening mammogram detected a mass and she was called back for further imaging. Thus, in this clinical setting, the use of the digital breast tomosynthesis studies were 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 procedures at issue were 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested prostatic urethral lift (Urolift) procedure for treatment of his enlarged prostate with lower urinary tract symptoms.  Findings: Two reviewers found that while there is short-term data that supports symptomatic relief with the Urolift procedure, data on comparison to alternative benign prostatic hyperplasia (BPH) ablative techniques for short and long term symptomatic relief is not available in current peer reviewed medical literature. The minimally invasive nature of Urolift and low morbidity favors further post-market data collection to determine its appropriate place in treatment algorithms; however, at this time there are limited long term studies that support the conclusion of clinical equivalence or improvement over standard therapies. For these reasons, the requested prostatic urethral lift procedure (Urolift) is not likely to be more beneficial for treatment of this patients BPH than any available standard therapy.Final Result: Two reviewers determined that the requested procedure is 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: All three physician reviewers are board certified in urology 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 wireless capsule endoscopy for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that there is a concern that Crohns disease is affecting the small intestine and causing the patients symptoms. Imaging has been unremarkable, and there is concern about performing endoscopy or colonoscopy due to anesthesia issues with prior procedures. Wireless capsule endoscopy evaluates the small intestine and has proven useful for indications other than bleeding, including detection of occult Crohns disease. The American Society for Gastrointestinal Endoscopy guidelines for endoscopy in inflammatory bowel disease recommends the use of capsule endoscopy in the diagnosis of Crohns disease (Leighton, et al). Data from retrospective and prospective studies have shown that wireless capsule endoscopy is useful for the diagnosis of Crohns disease even when imaging tests such as small bowel follow through and ileoscopy are negative or unsuccessful (Caunedo, et al; Chong, et al; Voderholzer, et al). In these studies, capsule endoscopy has proven more sensitive in the detection of small bowel Crohns disease than alternatives such as CT scan, small bowel follow-through, and enteroclysis. The study by Dubcenco and colleagues reported that capsule endoscopy has sensitivity of 89.6% and specificity of 100%.  For these reasons, the wireless capsule endoscopy is likely to provide useful diagnostic information and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment 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 internal medicine with sub-specialty certification in gastroenterology 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: The parent of an enrollee has requested applied behavioral analysis (ABA) for treatment of the enrollees medical condition. Findings: Two physician reviewers found that ABA services at the frequency of 30 hours per week are not indicated in this clinical setting. Spreckley and Boyd noted that a nonsystematic review in their meta-analysis concluded that for best practice a minimum of 20 hours a week of intervention over two years, taking account of each childs strengths and weaknesses and family circumstances, was essential for young children with autism to make gains. In this case, the patient is in a home school program and therefore is already having a school day of at least six hours based on his grade level and taking into account the special education status. The request for 30 hour per week of ABA is excessive and may be detrimental of the desired effect. Therefore, based upon the medical literature and the documentation submitted for review, 20 hours per week of ABA therapy is medically necessary for treatment of the patients medical condition.Final Result: Two reviewers determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications:  All three reviewers are board certified in child neurology 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 medical condition.  Findings: Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient presents with breast tissue that have been described as being very dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. 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: Two reviewers determined that the services at issue were 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 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 performed with two dimensional imaging alone. Accordingly, the breast tomosynthesis that was 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injection for treatment of the enrollees medical condition. Findings: Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  This patients clinical presentation suggests proctalgia fugax.  Proctalgia fugax is a functional anorectal disorder characterized by severe, intermittent episodes of rectal pain/spasm that are self-limited.  The diagnosis of proctalgia fugax requires exclusion of other causes of rectal or anal pain.  Anorectal pain may be caused by hemorrhoids, anorectal abscesses, anal fissures, rectocele, rectal cancer, inflammatory bowel disease, chronic benign prostatitis, and coccydynia. These conditions appear to have been excluded by the evaluation. Topical therapy including nitroglycerin and diltiazem are first-line treatment. If this is ineffective, then biofeedback may be prescribed.  The medical evidence does not support Botox injection in this patients case.  All told, Botox injection is not likely to be superior over treatment options.Final Result: Two reviewers determined that the services at issue 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.