Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that the patient who was asymptomatic with respect to her breasts.  On the date of dispute, the patient underwent a routine screening mammogram consisting of a synthetically reconstructed two dimensional views with three dimensional tomosynthesis study. In addition, the patient had an automated whole breast sonogram examination.  The current images were compared to a prior mammogram dated six years prior, and no interval changes were noted on the mammographic portion of the study.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion on the mammogram.  However, the automated whole breast sonogram indicated a questionably increasing nodule in the left breast, for which additional imaging was recommended.  Her breasts were described as heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis performed on the date of dispute.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast 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 scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, there are two distinct reasonable indications for tomosynthesis. First, she has breast tissue that was noted as heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. Second, the presence of a questionably increasing nodule on the sonogram necessitates a degree of certainty that a biopsy is not necessary. The ability to separate out the overlapping structures enables the possibility of demonstrating or excluding an otherwise occult tumor. Therefore, digital breast tomosynthesis performed on the date of dispute was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The 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: Physician reviewers 1,2 & 3 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: The parent of an enrollee has requested authorization and coverage for a nebulizer for treatment of his asthma. Findings:  The physician reviewer found that there are step-wise recommendations and guidelines for controller medications, medications for acute exacerbations, and management of worsening illness. The goal of asthma control is providing benefit with the least amount of medication. The use of inhaled corticosteroids is universally supported, and may need to be augmented with leukotriene modifiers, long-acting inhaled beta-agonists, and at some point, biologic modifiers. When used for management of obstructive pulmonary diseases such as asthma, the provider must consider use of metered dose inhaler with and without a reservoir or spacer device and decide whether it is sufficient for the administration of needed inhalation drugs. The medical literature does not wholly support one method of delivery over another. According to a recent Cochrane review by van Geffen and colleagues, there is lack of evidence supporting one method of delivery over another for exacerbations of chronic obstructive pulmonary disease. In a second earlier study with asthma patients, inhaler and nebulizer were considered approximately equivalent. In practical terms, however, when a child is having an acute exacerbation with distress, it may be more efficient to administer inhaled medication with a nebulizer if that is what the child is accustomed to using. In this patients case, the parent considers the nebulizer to work better for the patient when he is having an acute exacerbation and he is in need of delivery bronchodilator therapy. Given the significant morbidity and mortality still associated with asthma, cooperation on the part of the patient is essential. Therefore, in this clinical setting, the requested nebulizer is medically necessary for 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 with sub-specialty certification in pediatric critical care 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 authorization and coverage for immune globulin therapy for treatment of diabetic amyotrophy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting.  There is a lack of evidence demonstrating that intravenous immune globulin is effective in treating diabetic neuropathy, lumbosacral plexopathy or the pain associated with these conditions.  The evidence of efficacy of intravenous immune globulin has been found in small studies without adequate controls. Intravenous immune globulin, from a neurologic perspective, is indicated for the treatment of chronic demyelinating inflammatory neuropathy, for which there is no evidence in this case.  The elevation of the spinal fluid protein is a nonspecific finding seen disproportionally in diabetics and is not specific for the diagnosis of chronic demyelinating inflammatory neuropathy.  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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for a bilateral mastectomy with reconstruction for treatment of the enrollees left breast infiltrating ductal carcinoma with metastases to lymph nodes. Findings:  The physician reviewer found that Breast cancer procedures have varied waiting times, generally because procedures must be scheduled into available operating room time, and longer procedures, those requiring coordination with other departments, and those involving coordination between surgeons may be more difficult to schedule. This is demonstrated by greater times for mastectomies, radionuclide use for sentinel node biopsy, and cases involving simultaneous reconstruction. Time-specific quality indicators for breast cancer have previously been developed. The National Comprehensive Cancer Network (NCCN) and American Society of Clinical Oncology (ASCO) endorsed three such criteria, namely the start of radiotherapy within one year of diagnosis, hormonal agent use within one year of diagnosis, and receipt of adjuvant chemotherapy within 120 days of diagnosis. The National Quality Forum has endorsed this last measure for women with hormone receptor-negative breast cancer based on an average of 30 days from initial diagnosis to completing surgery. However, outcome differences have not been noted in several studies evaluating delays in waiting times to surgery, chemotherapy administration up to 12 weeks, and radiotherapy up to 20 weeks. It is reasonable to wait seven additional days for the scheduled surgery based on the current medical literature and guidelines for the combined surgical procedure of bilateral mastectomy, complete axillary dissection, and immediate reconstruction with plastic surgery. The surgery is medically necessary, but the request to complete the surgery prior to */*/** is not medically necessary. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the magnetic resonance imaging (MRI) of the pelvis and of the abdomen for evaluation of the enrollees asymptomatic microscopic hematuria.  Findings:  The physician reviewer found that This patient has a longstanding history of microhematuria and a work-up in the past which has reportedly been negative. Recently, the increase of red blood cells in the urine was noted to be an indication for additional imaging of the urinary tract. However, the exam of choice is a CT of the abdomen and pelvis to evaluate the kidneys and bladder as well as the entire genitourinary tract including the collecting systems, ureters and bladder. The American College of Radiology (ACR) appropriateness criteria supports the use of CT as the best procedure of choice in this clinical setting. Although the patient declined a CT due to concerns regarding radiation exposure, the MRI would not have been an effective alternative without the intravenous contrast. Intravenous contrast was needed to thoroughly evaluate the patient for an uroepithelial tumor, which requires opacification of the collecting systems and bladder. All told, the MRI of the pelvis and the MRI of the abdomen were not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the diagnostic procedures at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 a power wheelchair for treatment of amyotrophic lateral sclerosis. Findings:  The physician reviewer found that the patient is reported to have amyotrophic lateral sclerosis, a disorder which inexorably causes loss of physical functions such as swallowing, intelligibility of speech, ventilatory function and limb control.  Treatment generally revolves around optimal supportive and palliative care, including non-invasive ventilation support, percutaneous enteral feeding in the setting of dysphagia, custodial level assistance for basic self-care, wheelchairs as needed for mobility, and supportive bedding and other strategies for the prevention and management of pressure sores.  In this case, the records do not indicate that the patient is able to safely, reliably and independently operate a power wheelchair via any means, such as with head control, eye control, mouth control, or upper limb control.  A recent in-home physical therapy evaluation, notably, recommended a manual tilt-in-space wheelchair as best fitting for his overall needs. 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 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 reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  The physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to 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 increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: Thwo of three 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Two physician reviewers found that there is sufficient support for the service at issue in this clinical setting. Breast tomosynthesis provides advantages to 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 increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done using two-dimensional imaging alone. Final Result: The 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential mental health and substance abuse treatment services for treatment of the enrollees polysubstance abuse and generalized anxiety disorder. Findings:  The physician reviewer found that the records provided for review do not support the medical necessity of residential mental health and substance abuse treatment services for treatment of this patients polysubstance abuse and anxiety. There was no evidence that the patient had any suicidal or homicidal ideations or evidence of psychosis. Further, the patient was able to conduct activities of daily living. Based on the available documentation, the patient could reasonably have been treated at a less restrictive level of care, such as intensive outpatient program (IOP) for chemical dependency and mental health treatment. Final Result: The reviewer determined that the services at issue were 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50 mg-100 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found.  The current guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance services.Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  Air ambulance is considered medically necessary under certain circumstances. These circumstances can include when the point of pickup is inaccessible by land or when there is a great distance or obstacle involved in land transport.  Another circumstance would be when the time needed to transport the patient by land poses a threat to a patients survival or the proper equipment needed for the patient is not available on a land ambulance.  A patient might also require air ambulance services in order to be transferred from one institution to another in order to receive specialized services such as trauma care or a burn unit.  The medical conditions to be considered include unstable vital signs, spinal cord injury, severe chest or abdominal injury, severe burns, or amputations.  Generally, ground transport times greater than 30 minutes would justify the initiation of air transportation.  The total estimated time from the initial call for transportation to arrival of the patient at the receiving facility should be projected to be significantly shorter by one hour.  This takes into account the availability of appropriate ambulance crews and the time required to mobilize the aircraft as well as including distance travelled.  This patient was transferred from a rural hospital after orthopedic consultation determined he required a higher level of care.  Ground transportation was estimated at 2 hours and 50 minutes.  However, on the day in question, there was road work along that route so the estimated travel times by ground would have been longer.  Transfer needed to be timely, as there was concern from the accepting provider that the patient might require emergent surgical intervention.  Additionally, the patient had an elevated white blood cell count and was persistently tachycardic.  This raises concern for systemic inflammatory response syndrome, if not sepsis.  Final Result: The reviewer determined that the services at issue were 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 emergency 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cyst removal by a plastic surgeon.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has been evaluated by his dermatologist and dermatologic surgeon, and he was further referred to plastic surgery for excision.  The cyst has been draining, painful and inflamed, meeting requirements for treatment of a benign lesion.  As the Mohs micrographic surgeon recommended that excision take place with a plastic surgeon, the records support the requested services in this clinical setting.  All told, the requested cyst removal by a plastic surgeon is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 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.