Persius/hicric huggingface dataset:
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 medical condition.  Findings:  Two physician reviewers found that 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) has urged the technique 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/architectural distortion resulting in a decrease in callbacks and biopsies and increase in diagnostic accuracy and increase in detection of small cancers compared to when the study is done with only two-dimensional (2D) imaging. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had her exam been done with 2D imaging alone. 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 reviewers are board certified in diagnostic radiology and are actively practicing. All three 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 Sovaldi and ribavirin for treatment of her hepatitis C virus genotype 2b. Findings:  The physician reviewer found that according to the most recent 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. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage (Zeuzem, et al; Lawitz, et al; Jacobson, et al). The AASLD and IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. The guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, the requested Sovaldi and ribavirin 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 a referral to a neurologist for treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this patients case.  Intermittent explosive disorder (IED) is considered a psychiatric disorder which is characterized by a wide variety of aggressive outbursts.  Per the medical evidence, this disorder is often characterized by recurrent episodes of serious assaultive acts or destruction of property due to a failure to resist aggressive impulses.  Treatment for this disorder is typically by psychiatry, with recommendations including cognitive behavioral therapy and medications.  Treatment by neurology for this psychiatric diagnosis is not medically necessary, as it is a psychiatric diagnosis, with defined diagnostic criteria and treatments.  All told, the requested referral to a neurologist 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 neurology 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 the RT300 FES cycle therapy system for treatment of his medical condition.  Findings:  Two physician reviewers found that the FES cycle has been developed as a means to stimulate muscle activity in paralyzed limbs to reproduce physiological effects of exercise. The literature has explored the effects of FES cycling and the net weight of evidence has been positive, showing that FES cycling promotes improved health status in patients with spinal cord injury. The patient is paraplegic due to a spinal cord injury. This immobility is well known to often result in osteoporosis, atrophy, and increased risk for cardiovascular disease. Kahn and colleagues showed lower extremity cycle ergometry may reduce the risk of cardiovascular disease. Hammond and colleagues found a 42% decrease of developing osteoporosis in patients with spinal cord injury who use FES. Kuhn and colleagues evaluated FES use in spinal cord injury rehabilitation and demonstrated that it has a positive influence on spasticity and walking ability. The literature shows the requested RT300 FES cycle therapy system can provide many therapeutic benefits for this patient and is likely to be of more benefit than any available standard therapy.  Final Result: Two reviewers determined that the requested equipment is 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 reviewers are board certified in physical medicine and rehabilitation and are actively practicing. All three 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 platelet rich plasma (PRP) injections for treatment of her medical condition.  Findings:  Two physician reviewers found that based on the available documentation, it was not likely to be more beneficial for this patient to have had PRP injections for diagnosis of lateral epicondylosis than treatment with any available therapy. The platelets are cytoplasmic fragments from megacaryocytes. These bioactive proteins include substances active in forming fibrin scaffolds and introducing angioplastic factors into the tissue fields. PRP is harvested from the patients own centrifuged blood from the buffy coat of the centrifugate. PRP is used in a number of clinical situations including decubitus care, non-union fractures, and following total knee replacement and spinal fusions. However, the efficacy of PRP has not yet been established for use in this clinical setting. In the article by Sheth and colleagues, the authors found a lack of consistency in outcome measures across all studies. Montalvan and colleagues conducted a double blind placebo controlled randomized trial with evaluation at six months and found that two ultrasound guided PRP injections for epicondylitis were not more efficacious than saline injections at six month follow-up. All told, there is a lack of current peer-reviewed medical literature supporting the utility of PRP injections as likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were 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 reviewers are board certified in orthopedic surgery and are actively practicing. All three 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 Ambien CR for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Ambien has been approved for short-term treatment of insomnia (with difficulty of sleep onset), and Ambien CR has been approved for the long-term treatment of patients with insomnia manifesting as both difficulty with initiation and maintenance of sleep.  When treating insomnia, all patients should receive therapy for any medical condition, psychiatric illness, substance abuse, or sleep disorder that may be precipitating or exacerbating the insomnia.  For patients who continue to have insomnia that is severe enough to require intervention, cognitive behavioral therapy (CBT) is the initial therapy that is recommended.  If a patient requires a combination of behavioral therapy and medication, a short acting medication is recommended for six to eight weeks and then tapered.  If symptoms continue, an evaluation in a sleep disorder center prior to the institution of long-term medications may be appropriate.  In this case, the documentation does not support that the patient has received optimal non-pharmacologic treatment for insomnia that may include CBT or an evaluation by a sleep specialist.  There is a lack of support for the requested medication in this clinical setting.  All told, Ambien CR is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication 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 internal medicine 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 a mobility chair (powered wheelchair) for the treatment of his medical condition.  Findings:  The physician reviewer found that the requested equipment has not been established as medically necessary for treatment of the patients medical condition. Finlayson and colleagues reported on the prevalence of multiple mobility device use among adults with multiple sclerosis and examined the association between falls status (faller/non-faller) and the number of mobility devices used. The authors found an association between use of multiple mobility devices and falling. Although a power mobility chair can benefit specific individuals, in this case there is a lack of clinical evidence supporting its use. All told, the request for a mobility chair (powered wheelchair) is not medically necessary for treatment of the patients medical condition.   Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine 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 Norco for treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the requested medication in this patients case.  Norco is an opioid medication reserved for severe pain.  This patient presents with gastritis, bilateral knee osteoarthritis and lumbar spondylosis.  There is a lack of support for Norco in this clinical setting.  The records do not document failure of less potent pain medications. Further, a recent failed urine toxicology supports a formal opioid risk stratification profile prior to filling controlled substance prescriptions.  All told, the requested medication Norco is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication 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 anesthesiology with sub-specialty certification in pain medicine 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 genetic testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that in general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization, may well become a valuable tool in the treatment armamentarium for those plagued with psychiatric illness.  However, despite its promise, pharmacogenetics is not yet ready for mainstream clinical application.  In this case, the patient showed some signs of clinical improvement and was not experiencing an acute psychiatric syndrome at the time of the testing.  It appears that substance use and treatment adherence, rather than medication efficacy, significantly contributed to the patients suboptimal clinical response.  Notwithstanding, he tried several antipsychotic medications, but there were many others to consider.  Additionally, the patient had been resistive to non-pharmacologic interventions, such as cognitive behavioral or cognitive remediation therapies, family therapy and rehabilitation strategies.  Thus, it cannot be inferred that the patient had exhausted standard treatments available to treat his condition.  All told, genetic testing was not likely to have been more efficacious than other modalities for evaluating this patient.  Final Result: Three reviewers determined that the services at issue were 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 reviewers are board certified in psychiatry and are actively practicing. All three 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 Percocet for treatment of his chronic pain.  Findings:  The physician reviewer found that the submitted records do not indicate that all non-opioid treatment options have been utilized.  Behavior therapy has been discussed, but has not been completed despite much research to support its use. The records indicate that tolerance has taken place since the start of narcotics. Dose escalation is not a long term plan but a short term plan for the treatment of tolerance. When the dosage of opioids is increased, studies have shown that patients opioid tolerance level also increases and will take much longer to wean off.  In this patients case, it is clinically reasonable to consider alternatives to opioids. It should also be noted that opioids are not recommended treatments for sleep issues. Finally, the medical records indicate that a plan is in place to possibly treat and diagnosis his lower back pain without the need for oral medications. For all these reasons, Percocet is not medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication 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 anesthesiology with sub-specialty certification in pain medicine 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 the Levia ultraviolet B scalp comb for treatment of her medical condition. Findings:  Three physician reviewers found that the requested services are likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Psoriasis is a chronic inflammatory skin disease typically presenting with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. Treatment of psoriasis usually starts with topical agents, such as corticosteroids as well as phototherapy. More recently, narrow-band UVB (NBUVB) has emerged as an effective treatment modality. The spectral output of Levia is in the wavelength. With Levia UVB scalp comb, NBUVB is delivered directly to diseased tissue, without exposing neighboring, healthy skin. This targeted approach allows for the delivery of higher doses of UVB light than would be practical by the use of traditional light-box equipment. As a result, the cumulative dose of UVB light required for disease remission can be delivered in fewer treatment sessions. In this case, the patient presents with moderate to severe scalp psoriasis. In-home therapy is indicated as her treatment is expected to be long-term, and she requires frequent treatments. For the reasons stated above, the Levia UVB scalp comb is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three 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 reviewers are board certified in dermatology and are actively practicing. All three 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 residential treatment center for resumption of residential treatment services.  Findings: The physician reviewer found that the Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.  The submitted documentation supports the medical necessity of the services at issue.  This patient has a long pattern of unstable behavior that severely poses a threat to herself as well as other people.  Her enmeshment with her mother and anger towards her father pose a risk for her to continue her treatment unless she is removed from that environment to a residential treatment facility.  She has demonstrated that she was a risk to herself after her premature discharge from residential treatment center level of care.  Residential treatment level of care by definition is long-term treatment, and the program is constructed so that the first few days allow the patient to develop some comfort in her surroundings before any significant therapy begins.  The medical evidence supports the services at issue in this clinical setting.  All told, residential treatment center services and resumption of residential treatment services were and are medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were and 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 psychiatry with sub-specialty certification in child and adolescent psychiatry 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.