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

Nature of Statutory Criteria/Case Summary:The enrollee has requested authorization and coverage for 15830 excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen, infraumbilical panniculectomy; 15847 excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication); 15834, lipectomy, hip; 15835 lipectomy, buttock; 15832 lipectomy, thigh; 15836 lipectomy arm; and 19316 mastopexy for treatment of the enrollees hidradenitis suppurativa.  Findings:  The physician reviewer found that based on the medical documentation provided for review, the functional aspect of this case involves the condition of chronic hidradenitis of focal areas of the breasts, axilla and pubic area. However, the requested procedures are more consistent with typical body contouring procedures. The documentation does not demonstrate that the patients skin overlap is contributing to her functional deficit, which is most likely related to her focal areas of hidradenitis. The photographs show focal areas of the breasts and thighs that are consistent with possible hidradenitis as well as evidence of redundant skin of the breasts, arms and lower abdomen. Final Result: The reviewer determined that the requested surgery is 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer examination. Findings:  Two physician reviewers found that she presented for a mammogram because of a palpable abnormality in her right breast. She has a strong family history of breast cancer.  She has been tested for BRCA1, and is negative. She underwent a mammogram consisting of a three-dimensional (3D) tomosynthesis study with synthetically reconstructed two-dimensional (2D) views. In addition, she had a targeted sonogram of the palpable region of her right breast. The current images were compared to prior mammograms and no interval changes were noted. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Benign calcifications were seen. Her breasts were described as dense. The patient has requested reimbursement for the digital breast tomosynthesis. The Health Plan has denied this request as investigational. The digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient has breasts that have been described as 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. In addition, the ability to separate out the overlapping structures enables the possibility of demonstrating or excluding an otherwise occult tumor. For the reasons provided, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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. 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 and prospective authorization and coverage for the Nucca method for treatment of the enrollees brachioradial pruritus. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. There is a lack of peer-reviewed literature supporting the utility of the Nucca method for the treatment of the patients medical condition. In addition, there is a lack of evidence-based guidelines demonstrating that the Nucca method is more effective than other chiropractic manipulation techniques. In this case, the patient reports improvement with the Nucca method, however the relief is temporary. There is a lack of evidence-based guidelines supporting ongoing maintenance care in this clinical setting. Based on the lack of support in the peer-reviewed literature, the Nucca method was not and is not supported as 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 chiropractic care 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 reimbursement for acute inpatient stay for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that The submitted documentation does not support the medical necessity of the services at issue in this clinical setting. She was not a danger to herself or others, and her activities of daily living were intact.  She interacted with others appropriately and with the increase in Depakote reported improvement in symptoms.  She was cleared for discharge to another facility, and the reasons for her remaining an additional day were not given.  She was cognitively intact and able to attend to activities of daily living.  She no longer met criteria for remaining on a 5150 hold.  She was medically stable and showed no signs or symptoms of gastrointestinal distress.  She reported no pain, nausea, or vomiting.  Her laboratory testing and vital signs were within normal limits.  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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for individual speech therapy and occupational therapy for treatment of the enrollees autism spectrum disorder, attention deficit hyperactivity disorder (ADHD) and generalized anxiety disorder.  Findings:  The physician reviewer found that based on the out-of-Plan evaluation, the patient was diagnosed with developmental coordination disorder and was also found to have significant delays in self-help skills as measured on the Vineland Adaptive Behavior Scales. Occupational therapy targets self-help skills, and is therefore clinically indicated to ensure the highest level of future independence for the patient. Moreover, occupational therapy is medically necessary to promote the development of self-care skills such as dressing, manipulating fasteners, using utensils, personal hygiene along with academic skills such as cutting with scissors and writing. However, speech therapy is not medically necessary, given the patient has average receptive and expressive skills as measured during two separate evaluations. In this clinical setting, social skills group speech therapy is likely to be more appropriate intervention for the patient at this time. Based on the documentation submitted for review, individual speech therapy has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer 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: The 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy for treatment of the enrollees prostate cancer. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Colleagues evaluated the comparative effectiveness of intensity-modulated radiation therapy (IMRT), proton therapy, and conformal radiation therapy for prostate cancer. The authors found that in the comparison between IMRT and proton therapy, IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between IMRT and proton therapy. Yu and colleagues compared proton beam radiation therapy versus IMRT in regards to early toxicity among patients with prostate cancer. There was a statistically significant decrease in genitourinary toxicity at six months with proton therapy, however this difference disappeared by one year. In addition, the position statement by the American Society for Radiation Oncology (ASTRO) state At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. For the reasons provided, proton beam radiation therapy has not been established as medically necessary for the treatment of the patients prostate cancer. 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 radiation oncology 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 bilateral breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  The 3 physician reviewers found that 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 (CT) 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 patients case, her breast tissue was heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, bilateral breast tomosynthesis performed was likely to have been more efficacious than other available modalities for evaluating this patient. Final Result: The 3 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of anenrollee has requested authorization and coverage for gene panel testing. Findings:  Two physician reviewers found that given the description of this patients facial features and cardiac defect, testing for Noonans syndrome is appropriate. Children with Noonans syndrome also have more difficulties with verbal learning which is consistent with this patients presentation. If Noonans syndrome is diagnosed, then there is a known medical follow-up and protocol for this diagnosis. There are multiple possible genetic causes of Noonans syndrome. In addition, a study reported that children with congenital cardiac anomalies have a higher rate of genetic abnormalities. Another study found that infants with congenital heart defects had 25% chance of identifying a genetic cause and patients with dysmorphic features had a seven times higher chance of identifying a genetic cause. In this patient, Noonans syndrome panel testing is more likely to identify a reason for her cardiac problems, developmental delays and dysmorphic features. Identifying a genetic cause that is associated with known medical comorbidity is more beneficial for treatment of this patient than any available standard therapy. Final Result: Two reviewers determined that the requested testing is 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni tablets for treatment of the enrollees 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 non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1 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 approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica 300 mg three times per day. Findings:  The physician reviewer found that In the medical literature, a study reported that the use of Lyrica has shown favorable outcome for treatment of sciatica. Another studynoted that Lyrica has demonstrated benefit for various neuropathic pain conditions alone and in combination with other pharmacologic therapies. One more study found that Lyrica demonstrated improvement in pain related to radiculopathy in sciatic distribution similar to gabapentin. However, higher dosing at 900 mg per day is not recommended. Further, there are no circumstances in this case that suggest dosing beyond that approved by the U.S. Food and Drug Administration (FDA) would be appropriate. Thus, the requested dosage of Lyrica 300 mg three times per day is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested dosage 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 neurology 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 reimbursement and prospective authorization and coverage for Botox treatments provided from 6/16/16 forward. The Health Plan has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees migraine headaches. Findings:  The physician reviewers found that Botox is an effective, safe, and well-tolerated treatment for the prevention of headache for patients with chronic migraine. The medical records provided for review document failure of at least two prophylactic medications for migraine. The patient is having chronic headaches, migraine type, and does specifically delineate and quantity the frequency of the headaches in terms of days per month on an ongoing basis with headaches lasting at least four or more hours on 15 days or more per month for at least three months. Further, treatment with Botox has been effective in reducing the patients headache frequency and severity with positive functional benefit. All told, Botox treatments were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the services at issue were and 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: Physician reviewers number one, two, and three are board certified in neurology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for repetitive transcranial magnetic stimulation (TMS) for treatment of the enrollees depression. Findings: The physician reviewer found that although some preliminary positivism regarding the application of TMS therapy for the bipolar population can be found in the medical literature, the absence of well-controlled and adequately powered exploratory and confirmatory studies do not establish TMS as a treatment of bipolarity. Further, this patients records do not include a current psychiatric evaluation, progress notes or discharge summaries from the recent hospitalization and aftercare programming. Given the lack of documentation, the records do not support a diagnosis of bipolar disorder or major depressive disorder. All told, the requested repetitive TMS is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.