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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees hypertension. Findings:  The physician reviewers found that 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. 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. Randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits. Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by basing treatment on routinely obtained abnormal results. Final Result: All 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the office visit and related services required on an emergent or urgent basis.  Findings:  The physician reviewer found that the patient presented with a concern for a recurrence of testicular cancer. The physical examination did not demonstrate a palpable mass. Moreover, an ultrasound is not indicated in the setting of a negative physical examination. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care. The patient presented with a history of testicular cancer and presented to an out-of-network urologist due to testicular pain and a concern for a recurrence of cancer. In this clinical setting an urgent evaluation of the reported palpable lesion by an urologist was necessary to prevent serious deterioration of the health of the patient for which treatment cannot be delayed until the he returned to the Health Plans service area. However, the patients physical examination was negative and the ultrasound performed was not necessary to prevent serious deterioration of the patients health resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the Health Plans service area. Final Result: The reviewer determined that a portion of the services at issue were required on an urgent basis. Therefore, the Health Plans denial should be partially overturned.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing (CPT codes 82172 and 83704) for evaluation of the enrollees hyperlipidemia. Findings:  The physician reviewers found that based on the documentation provided for review, the patient presents with some coronary risk including hyperlipidemia. In this circumstance 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 (Lp-PLA2), lipid particle number, sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, 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. Therefore, the advanced lipoprotein testing (CPT codes 82172 and 83704) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All 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: Physician reviewer number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and actively practicing. The reviewer 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 transcranial magnetic stimulation (TMS) therapy for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that in this clinical setting the requested services are medically indicated for treatment of this patient. The patient suffers from treatment refractory major depressive disorder and generalized anxiety disorder.  She has failed multiple medications and ECT.  She has a history of two psychiatric hospitalizations, one of which was exacerbated by discontinuation of TMS treatment.  She has had treatment with remarkable results as evidenced quantitatively by her rating scales, reported mood, and objective findings by her treating provider. In sum, continued TMS treatments are 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 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 reimbursement and prospective authorization and coverage for pragmatic speech therapy services for treatment of the enrollees medical condition. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the services at issue. Pragmatic language difficulties are common in children with features of ADHD. The type of therapy required for pragmatic language difficulties is different than speech therapy, as speech therapy does not address language delays or articulation problems. Social communication interventions can be useful for children with pragmatic language impairment. In this case, pragmatic speech therapy is indicated for treatment of the patients diagnosis of social communication disorder.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral cataract surgical services on an emergent or urgent basis. Findings:  The physician reviewer found that the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the dates in question. In general, clinical situations that may require emergency cataract surgery are phacomorphic and phacolytic glaucoma. In the setting of phacomorphic and phacolytic glaucoma, the lens (cataract) leads to significant elevation in eye pressure. Based on the records, there is no evidence that the patient had these conditions. The patient presented with early cataracts with a lack of evidence demonstrating elevated eye pressure. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe the patient was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care. Further, it has not been established that criteria for urgently needed services were met. In this case, the patient presented with no signs or symptoms evident of a serious medical condition. The patient underwent cataract surgery of the right eye, and three weeks later the patient underwent cataract surgery of the left eye. The documentation submitted for review fails to demonstrate a condition which cannot be delayed until she returned to the plans service area. The patient did not have an urgent condition such as phacomorphic or phacolytic glaucoma. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a coronary computed tomography angiography (CCTA). Findings: Two physician reviewers found that some preoperative assessment of coronary anatomy is reasonable and appropriate, since concomitant coronary artery bypass would be strongly considered if significant stenosis were identified.  Both CCTA and conventional coronary angiography assess coronary anatomy but conventional coronary angiography is preferred, given its improved accuracy relative to CCTA. In this patients case, conventional preoperative coronary angiography is appropriate and considered standard accepted practice in the medical community. Final Result: The reviewers determined that the procedure at issue was 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested proton beam radiation therapy for treatment of the enrollees diffusing grade II astrocytoma.   Findings: Two physician reviewers found that proton beam radiation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques. The data regarding central nervous system (CNS) tumors treated with proton therapy is limited to retrospective series, small prospective studies with no strong evidence that proton beam therapy is associated with superior control rates, a decrease in toxicity or a decrease in secondary malignancies compared to treatment with conventional fractionated radiation therapy using intensity modulated radiation therapy. In addition, the National Comprehensive Cancer Network (NCCN) guidelines do not support the routine use of proton therapy in the treatment of CNS malignancies. Also, the American Society of Therapeutic Radiation Oncology (ASTRO) emerging technology committee report on proton therapy states that more clinical data (published clinical trials) are needed to fully establish the role of [proton beam radiation therapy] PBT in CNS tumors. Therefore, proton beam radiation therapy has not been established as likely to be more beneficial for treatment of the patients low grade glioma than any available standard therapy.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 radiation oncology 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 enrollees medical condition.  Findings: Two physician reviewers found that there is sufficient support for the services 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 biopsies and callbacks and increase in 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 with two-dimensional imaging alone. Therefore, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni (ledipasvir 90 mg/sofosbuvir 400 mg 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 nonliver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, genotype 1 patients who have failed PEG-interferon and ribavirin should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials. The medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage (Afdhal, et al, Lawitz, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 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.  This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni.  Non-cirrhotic patients with a viral load less than 6,000,000 IU/mL, such as this patient, can be treated for eight weeks. The guidelines cite data showing reduced survival with delayed treatment.  Therefore, Harvoni for eight weeks is medically indicated for the treatment of this patient.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 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. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks, as in this patients case. 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). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for eight weeks 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical conditionFindings:  Two physician reviewers found that 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 biopsies and callbacks and increase in detection of small cancers compared to two-dimensional imaging alone.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three 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