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

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for evaluation of the enrollees hypercholesterolemia.  Findings: Two physician reviewers found that the superior efficacy of the services at issue has not been established.  This patient had an increased risk of coronary vascular disease.  In this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  All told, advanced lipoprotein testing is not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Two reviewers determined that the services at issue is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and 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 treatment from 3/01/15 through 5/19/16.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  There was no evidence of self-injurious behavior.  Per the medical records, the patient did not have suicidal or homicidal ideation.  He did not have any psychosis, mania, delusions, hallucinations, or agitation.  The patient was calm, cooperative, and participated in groups.  He was compliant with medications.  He has a supportive family. The patient had no comorbid medical problems necessitating 24-hour monitoring. The patient had received several months of inpatient and residential treatment learning coping skills which could have been practiced in a less restrictive environment in a home and school environment.  He continued to require treatment for his anxiety and depression, but this could have been done in a less restrictive environment. 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 evaluation for autologous systemic immune suppression trial #NCT01445821 for evaluation of the enrollees scleroderma. Findings:  The physician reviewer found that when patients with advanced cancers have exhausted standard regimens, the National Cancer Institute Physicians Data Query recommends enrollment in a clinical trial. In this case, the patient has a terminally progressive disease that has been resistant to standard treatment options. As requested, he would be enrolled in a clinical trial testing auto-HSCT versus pulse dose cyclophosphamide for his disease but the underlying treatment modality of auto-HSCT is considered standard for advanced scleroderma. All told, enrolling this patient in the clinical trial being considered is medically appropriate. Thus, the requested evaluation for autologous systemic immune suppression trial #NCT01445821 is medically necessary for evaluation of this patients scleroderma.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 oncology and hematology 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 high intensity focused ultrasound (HIFU for treatment of the enrollees prostate cancer.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. HIFU consists of focused ultrasound waves, emitted from a transducer that causes tissue damage by mechanical and thermal effects as well as by cavitation. The goal of HIFU is to heat malignant tissues above 65C so that they are destroyed by coagulative necrosis. However, the available literature mainly consists of prospective case series and retrospective studies from Europe showing short to intermediate term outcomes for localized prostate cancer. Controlled trials and long-term survival data for the requested services are lacking. Moreover, validated biochemical and surrogate end-point for cure of patients who have undergone HIFU are also deficient. The National Comprehensive Cancer Network (Guideline Version 1.2015) panel states that focal therapy and HIFU warrant further study. In this clinical setting, there are other available methods of treatment. As such, the requested authorization and coverage for HIFU is not medically necessary for 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 urology 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 endovascular therapy for treatment of the enrollees brain aneurysm, non-ruptured.  Findings: The physician reviewer found that the medical literature supports the requested services in this clinical setting. The patient has an aneurysm that is 1 mm below what is recommended for endovascular intervention. She was also recently diagnosed with breast cancer. The provider noted that the patient required operative intervention for treatment of her breast cancer. However, the surgery will put her aneurysm at higher risk of rupture. In addition, the aneurysm is slightly larger on the most recent imaging compared to a previous imaging (6 mm versus 5 mm). Given these additional circumstances as well as the anticipated stressors of surgery and potential for blood pressure spikes with intubation for non-aneurysm surgery, the requested services are both medically indicated and within standard practice. All told, the requested endovascular therapy is medically necessary for 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 neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested resumption of physical therapy and occupational therapy in a skilled nursing facility (SNF for treatment of the enrollees medical condition status post resection for pituitary macroadenoma.  Findings: The physician reviewer found that SNF or skilled rehabilitation services are services that must be performed by or under the supervision of a professional for a condition that required inpatient hospital services or that arose while receiving care in a SNF and are required on a daily basis. This patients documentation does not support that this patient requires SNF services with ongoing physical therapy and occupational therapy. Overall, there is a lack of evidence that the patient requires such SNF services as intravenous or enteral feeding that comprises at least 26% of daily calorie requirements and provides at least 501 milliliters of fluid per day, tracheotomy aspiration, suprapubic catheter care, treatment of a stage 3 or greater decubitus ulcer, institution of a bowel/bladder training program, colostomy care or other SNF service. While the patient would benefit from continued therapy the records do not demonstrate that he requires these services on a daily basis or that the services could only be provided while he is an inpatient in a SNF. The patient has made progress in therapy but is not expected to make measurable gains within a reasonable and predictable period of time given his prior physical therapy and occupational therapy notes, which reveal that the patient has made gradual progress in therapy. The patient does not require skilled therapy on a daily basis to prevent deterioration with mobility, or activities of daily living, or to prevent a deterioration in his condition. In addition, the patient does not require skilled therapy to establish a safe and effective maintenance program. Speech therapy noted that the patient was tolerating a soft diet without aspiration and he was planned to follow-up with a provider regarding feeding tube dependence. Without clear skilled nursing needs the patient does not require SNF services to establish a safe and effective maintenance program. Therefore, this patients current needs can be met at a lower level of care. For these reasons, the request for authorization and coverage for resumption of physical therapy and occupational therapy in a SNF is not medically necessary.Final Result: The reviewer determined that 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested radiofrequency ablation of thoracic facet joints for treatment of the enrollees back pain. Findings: Two physician reviewers found that there is lack of support for the requested services in this clinical setting.  The records do not document a pain diary for the medial branch block done prior to the radiofrequency ablation.  The literature describes how diagnostic medical branch blocks should be performed prior to radiofrequency ablation.  Specifically, the literature discusses using a pain diary for the day to verify when the local anesthetic wore off, and not using sedation.  It is unclear how long the patient experienced pain relief from the Marcaine injections, since the documents range with pain relief from five days to two to three months.  In sum, radiofrequency ablation of thoracic facet joints is not likely to be of greater benefit than other methods of evaluating this patient.  Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Two 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) 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 and architectural distortion resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging especially in patients with dense tissue such as in this case. Thus, the addition of 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 diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee, who had a left breast lump.  Findings: Three 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, there were two valid indications for tomosynthesis.  First, her breast tissue was heterogeneously dense.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Second, the presence of a palpable mass, especially with dense breast tissue, must be fully evaluated.  There is sufficient support for the service at issue in this patients case. Thus, digital breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.  Final Result: 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: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage for an Afirma Gene Expression Classifier test for evaluation of the enrollees thyroid nodule.  Findings: Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  The Afirma Gene Expression Classifier test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, the Afirma Gene Expression Classifier test was likely to have been more efficacious than other methods of evaluating this patient.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 anesthesia services for treatment of the enrollee, who underwent a colonoscopy.  Findings: The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  This patient has Class I obesity.  Judgment of the need for monitored anesthesia care requires consideration of procedure requirements and potential risks.  Patients with Class I obesity have been found to be at significantly higher risk for desaturation during endoscopic procedures.  Wani and colleagues noted a higher risk for sedation-related complications with a body mass index greater than 30 during endoscopic procedures.  Based on the current medical literature, this patient was at increased risk for sedation-related complications.  All told, anesthesia services are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage for monitored anesthesia care endoscopic gastrointestinal procedures for treatment of the enrollee, who has a history of intolerance to narcotics and severe anxiety.  Findings: The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  Monitored anesthesia care is warranted in patients with psychological impediments to cooperation (such as severe anxiety in this case), as well as patients undergoing long procedures, such as combined endoscopy and colonoscopy.  Endoscopy can be performed using conscious sedation with a benzodiazepine and opioid.  Per the medical evidence, when a benzodiazepine and opioid may not be effective, as in this patient with reported opioid intolerance, other agents such as propofol may need to be used.  All told, monitored anesthesia care was medically indicated for the treatment of this patient.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 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: A parent of an enrollee has requested authorization and coverage of the treatment proposed by Neil Hirschenbein, MD, PhD on 9/17/16.Findings:  The physician reviewer found that the clinical evidence provided for review does not support a diagnosis of Lyme disease. The patients symptoms of fever, headache and sore throat are non-specific complaints. The provided photograph is not a typical bulls-eye lesion. The skin lesion does not appear to be classic erythema migrans that is normally associated with Lyme disease. Moreover, a normal immune system will have a positive Borrelia IgG Western Blot at six to eight weeks after infection. The IgG for this patient was negative. The submitted records do not document that this patient had the rash typical of early Lyme disease, and her reported symptoms are not suggestive of this diagnosis. 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 internal medicine with sub-specialty certification in infectious diseases 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.