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 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, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. For this patient, this is the specific clinical setting in which tomosynthesis has its greatest value.  The ability to separate overlapping structures enables visualization of an occult tumor which might otherwise have been missed. Therefore, 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Afirma Gene Expression Classifier testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that there is sufficient support for the Afirma gene test in this clinical setting. This patients biopsy revealed follicular lesion of undetermined significance. The genetic testing noted that the left thyroid was benign, and the right thyroid was suspicious. The Afirma test was a determining factor in delineating the further course of action to assess whether a surgical procedure was warranted with its resultant possible concomitant co-morbidity. Afirma testing is considered standard protocol on fine needle aspirations performed on thyroid nodules. In sum, the testing at issue 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 testing 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 internal medicine with sub-specialty certification in endocrinology and metabolism 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:  The parent of an enrollee has requested speech therapy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that review of the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested services. An article by Myers and colleagues recommends a comprehensive educational program to include speech therapy for children with autism spectrum disorder (ASD). In this case, the patients scores show continued maintenance of her language skills and some improvements with age, but not improvements beyond what would be expected based on time passing. Per a recent speech therapy evaluation, the patient currently receives speech therapy services through the school district. The Health Plans recommendation of continued speech therapy services through the school district is medically reasonable and appropriate in this clinical setting. For the reasons stated, speech therapy services are not medically necessary in this clinical setting. 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 pediatrics with sub-specialty certification in developmental and 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his 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. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive non-cirrhotic genotype 1b patients should be treated with Harvoni for 12 weeks, or with Viekira Pak without ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials.  However, in this case, Viekira Pak is contraindicated due to use of clopidogrel (a strong CYP2C8 enzyme inhibitor) which can result in cardiac arrhythmias due to QT interval prolongation.  Harvoni has no such drug interaction.  For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this 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 physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a Tumor Necrosis Factor antagonists and antibodies test for evaluation of the enrollees Crohns disease.   Findings:  Three physician reviewers found that the use of a Tumor Necrosis Factor antagonists and antibodies test has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of a Tumor Necrosis Factor antagonists and antibodies test compared with conventional courses of action remains unproven. Clinical guidelines for management of inflammatory bowel disease do not recommend testing for anti-drug antibody during clinical management (Lichtenstein, et al). A review article reported that the available data do not allow final conclusions about the relevance of anti-adalimumab antibodies to the clinical efficacy of adalimumab, and another concluded that prospective controlled trials are direly needed to investigate the optimal tailored management in individual patients who lose response (Assche, et al; Yanai, et al). Therefore, the medical literature does not support the Tumor Necrosis Factor antagonists and antibodies test as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   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 internal medicine with sub-specialty certification in gastroenterology 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 greater occipital nerve block (facet blocks) for treatment of her medical condition.  Findings: The physician reviewer found that there is sufficient support for the requested services in this patients case.  This patient currently has chronic neck pain with radiculopathy and headache pain.  The records noted that her prior treatment has included physical therapy, injections and multiple medications.  The current medical evidence supports the requested services in this patients case.  In the article by Saracco and colleagues, the objective of this study was to determine whether adding triamcinolone to local anesthetics increased the efficacy of greater occipital nerve block and trigger point injections for chronic migraine.  In both groups, the procedure resulted in significant and rapid relief of headache, neck pain, photophobia and phonophobia.  There is a lack of treatment options in this patients case.  All told, the requested greater occipital nerve block (facet blocks) is medically necessary 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 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 intravenous rituximab for treatment of her medical condition. Findings: Two reviewers found that there is sufficient support for the requested medication in this clinical setting.  This patient has refractory myasthenia gravis.  She is already on a very aggressive regimen with immunosuppression and intravenous immune globulin.  Rituximab has been used for myasthenia gravis for a number of years, and it is currently recommended for patients with refractory disease.  Given the significant literature about the use of rituximab in refractory patients, like this patient, and given her currently non-optimal disease control despite very aggressive therapy, intravenous rituximab is likely to be superior over other treatment options.Final Result: Two reviewers determined that the requested medication 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 neurology 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 capsule endoscopy for evaluation of her medical condition. Findings: The reviewer found that in this case, capsule endoscopy is medically necessary to evaluate abdominal pain in this patient with prior cancers and history of possible mass on imaging. This was not seen on subsequent imaging. The complete small intestine cannot be examined during endoscopy or enteroscopy. Capsule endoscopy is more sensitive for small intestine mass than imaging (which was negative). According to the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy, evaluation for suspected small intestinal tumors, which this patient has had in the past, is a valid indication for capsule endoscopy. Capsule endoscopy is capable of discovering small bowel tumors missed by endoscopy and traditional radiologic imaging. Computed tomography (CT) enterography has 84.7% sensitivity for the detection of small bowel tumors, meaning that over 15% of tumors are missed. Magnetic resonance enterography misses a similar number of tumors.  Capsule endoscopy is reported as having high sensitivity in identifying small-bowel tumors. One comparison of these modalities for evaluation of small bowel tumors reported that the techniques complement each other, providing information that the other cannot. Based on the literature, further evaluation is needed, and capsule endoscopy (a high-sensitivity modality for this) is medically necessary in this clinical setting.Final Result: The reviewer determined that the requested services are 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 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 inpatient psychiatric hospitalization for treatment of her behavioral health condition. Findings: The physician reviewer found that according to the documentation submitted for review, the patient did not meet criteria to support ongoing treatment at the inpatient psychiatric hospitalization level of care. Inpatient hospitalization was initially safe, reasonable and consistent with good medical practice. The patient was not psychotic. She was not cognitively impaired. She was sleeping an adequate amount per night. She was consuming 100% of reported meals. She was tolerating her medications well and they were provisionally helpful. The patient denied any anxiety or depression. She was resistive to meet with a social worker to discuss disability benefits. She was not fully engaged with unit activities, suggestive that the setting did not fully align with her clinical needs. In sum, the acute psychiatric syndrome that prompted the admission had resolved. In conclusion, placement at the inpatient psychiatric hospitalization level of care was not and is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not and 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested medical transport to orthopedic physical therapy twice a week for eight weeks for the treatment of his shoulder bone spur. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The records do not indicate that the patient has any health, physical or other functional impairments that would preclude ambulation, driving or taking public or private transportation to his appointments. A left shoulder bone spur would not preclude him from these activities. Physical activity, moreover, is generally appropriate and recommended for conditions such as asthma, hypertension, hypercholesterolemia, diabetes, obesity, and for general musculoskeletal health.  All told, the requested medical transport to physical therapy twice a week for eight weeks 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his 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. This applies regardless of fibrosis stage or viral load. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni 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 1 regardless of fibrosis stage.  For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this 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 breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that breast tomosynthesis often allows the provider to separate dense glandular elements from architectural distortion/mass, thereby reducing callbacks and increasing the detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional views on the screening study was likely more beneficial to the patient than had the screening exam been done with two-dimensional technique alone.  Since breast tomosynthesis had been done and calcifications noted, a second diagnostic mammogram likely did not require a repeat tomosynthesis portion of the exam.  Rather, magnification views should have been sufficient in order to characterize the calcifications as suspicious.  Thus, breast tomosynthesis performed initially was likely to have been more effective than other methods of evaluating this patient.  However, the superior efficacy of breast tomosynthesis performed subsequently has not been established.   Final Result: Two reviewers determined that a portion of the services 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 partially 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 Harvoni for treatment of his hepatitis C virus.   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 nonliver-related conditions. This applies regardless of fibrosis stage or viral load. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni 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 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Non-cirrhotic patients who have failed the PEG-interferon/ribavirin with or without a protease inhibitor are recommended to have the same treatment (Lawitz, et al).  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). No alternative therapies have been approved. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this 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.