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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Botox for treatment of her migraines. Two physician reviewers found that this patient has chronic migraine as defined by the International Classification of Headache Disorders III per the description of the treating neurologist who is a headache specialist. In addition, the patient has tried and failed three different classes of migraine preventive therapies. As this patient does have chronic migraine by definition, and meets the criteria for use, the requested Botox is more likely to be beneficial than standard therapy. 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: One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  Two 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.  Two physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited due to breast density. For these reasons, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography 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 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 a referral to a gastroenterologist for evaluation of the enrollees constipation.  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested referral. According to the documentation submitted for review, the patient presents with gastrointestinal (GI) symptoms that warrant further evaluation. Care provided by gastroenterologists for GI bleeding and diverticulitis resulted in significantly shorter length of hospital stay. Gastroenterologists diagnosed celiac disease more accurately than generalists, and more adequately diagnosed colorectal cancer and prescribed antimicrobials for peptic ulcer disease. Gastroenterologists were more likely to test and treat for Helicobacter pylori in patients with peptic ulcer disease, and were more likely recommended for medical versus surgical therapy. Gastroenterologists had a lower threshold for ordering [endoscopic retrograde cholangiopancreatography] ERCP before cholecystectomy than surgeons, but had similar responses regarding indications for surgery in inflammatory bowel disease. Finally, primary care physicians were less likely to associate symptoms of profuse watery diarrhea with cryptosporidium infection compared with gastroenterologists and infectious disease specialists. Based on the clinical documentation submitted and the medical literature a gastroenterology specialty evaluation is medically necessary for evaluation of the patients unexplained weight loss, bloody stool, and persistent abdominal distress. Final Result: The reviewer determined that the requested referral is 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 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 breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The peer-reviewed literature has not demonstrated the superior efficacy of digital breast tomosynthesis in this clinical setting.  The records do not establish the indication for breast tomosynthesis for the evaluation of this patient.  Although breast tomosynthesis may be a promising technique, the superior clinical efficacy has not been demonstrated in this patients case. Final Result:  Two 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested stem cell breast reconstruction (cell-assisted lipotransfer (CAL) technique) for both breasts for treatment of the enrollees carcinoma in situ. The physician reviewer found that the American Society of Plastic Surgeons (ASPS) and American Society for Aesthetic Plastic Surgery (ASAPS) noted that until further evidence is available, stem cell therapies in aesthetic and reconstructive surgery should be conducted within clinical studies under Institutional Review Board approval, including compliance with all guidelines for human medical studies. Paik and colleagues concluded that, although these cells may have great promise as a cellular therapy in a variety of settings, we must continue to probe their complex roles as a stem cell population to make full use of their clinical potential. Overall, although stem cell assisted lipotransfer may provide benefit its use has not been shown to replace traditional fat transfer in this clinical setting, which is considered the standard of care. Given these findings, the requested stem cell breast reconstruction CAL technique for both breasts is not medically necessary. The patient has a documented right breast deformity secondary to lumpectomy followed by radiation therapy. The patient has a well-defined defect secondary to the right breast following oncologic treatment. The defect on the left side is not well-defined. Although the patient has a well-defined abnormal appearance of the right breast resulting from oncologic treatment, its proposed correction with stem cell using the CAL technique would not be expected to create more than a minimal improvement in the abnormal appearance. Accordingly, the requested stem cell breast reconstruction CAL technique for both breasts is not reconstructive in nature. Thus, the requested stem cell breast reconstruction CAL technique for both breasts is not reconstructive in nature and not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested services are not reconstructive in nature and 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that in this patients case, the services at issue were not likely to have been of greater benefit than other alternatives.  The peer-reviewed literature has not demonstrated the superior effectiveness of breast tomosynthesis compared to currently available techniques.  Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in this clinical setting.  All told, digital breast tomosynthesis was not likely to have been more effective than other modalities. Final Result:  Two 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 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 Otezla for treatment of his psoriasis. The physician reviewer found that psoriasis typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Otezla has been shown to result in significant improvements in mean percentage change in psoriasis area and severity index (PASI) score and in pruritus. PASI response was maintained over 52 weeks with continued Otezla treatment. In addition, the U.S. Food and Drug Administration (FDA) has approved Otezla for use in this clinical setting. Given this support, the requested Otezla is medically necessary for treatment of this patients chronic plaque psoriasis. 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested services on an emergent or urgent basis.  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a lesion on her face. It was not painful. There was no indication the lesion had suddenly worsened. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not 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 on the date in dispute. In this case, the patient presented with a lesion on her face and assessed with pyogenic granuloma, which is a slow growing inflammatory vascular lesion that is not malignant. The patient was not experiencing any systemic symptoms or signs of acute infection such as fever or purulent drainage. Treatment could have been safely delayed until the patient returned to her service area. 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. In sum, based on the patients clinical presentation, the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a left foot x-ray for evaluation of her medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  While it is likely that motor deficits of foot drop and changes in sensation in the left foot are determined primarily by residuals of compartment syndrome and peroneal nerve injury, an x-ray of the left foot will establish the presence of normal skeletal anatomy.  If there is no evidence of fracture, then appropriate orthotics and possible surgical stabilization may be necessary.  The medical records document severe stab wounds with soft tissue and neurological injury.  All told, the requested left foot x-ray is medically indicated for the evaluation of this patient.  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 orthopedic 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Cyramza for treatment of his hepatocellular carcinoma.  The physician reviewer found that there is a lack of support for the requested medication in this patients case.  There is a lack of standard systemic therapies approved for use in the second-line after failure of sorafenib for hepatocellular carcinoma.  Ramucirumab (Cyramza) was thought to have potential efficacy in this role.  However, a phase III clinical trial by Zhu and colleagues recently concluded that it offered no survival advantage over placebo.  Per the current medical evidence, the use of Cyramza in the treatment of hepatocellular carcinoma is not supported by clinical evidence.  All told, the superior efficacy of the requested medication Cyramza has not been established.  Final Result: Two reviewers determined that the requested medication is 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 digital breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the use of breast tomosynthesis in this clinical setting. Ciatto and colleagues investigated the effect of integrated two dimensional (2D) and three dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast-cancer detection and has the potential to reduce false positive recalls. Based on the documentation submitted for review and medical literature cited above, the use of 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 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a separate anesthesiologist to administer anesthesia during a facet injection procedure for treatment of the enrollees upper thoracic pain. The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for a separate anesthesiologist to administer anesthesia during the facet injection procedure has not been established. In this case, the patient does not present with a significant history that would require monitored anesthesia care. The standard of care for administering monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are not medically necessary for treatment of the patients medical condition. 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power wheelchair with specifications noted, for treatment of her spinal muscular atrophy.   The physician reviewer found that the submitted documentation supports the medical necessity of the requested power wheelchair with each of the requested specifications.  Spinal muscular atrophy is a disease without a cure that requires accommodation of functional impairments for treatment.  This patient has significant impairments and requires a power wheelchair to remain independent.  She requires each of the requested components for various reasons.  Power tilt and power recline are needed for pressure relief and repositioning.  Power seat height and anterior tilt are needed for independence with transfers.  She uses the power wheelchair in the community on uneven ground and also drives a motor vehicle from her power wheelchair, so the harness and hip belt are needed for safety.  A backrest frame is needed to accommodate a custom cushion that is appropriate for her pelvic obliquity and spinal deformities.  A swing away joystick and adjustable mount kit are needed for her to be able to transfer into and out of the wheelchair independently.  An expandable controller, seat function control kit, control module and compact joystick are needed for maneuvering the wheelchair and operating the seat functions of the wheelchair.  Group 24 gel cell batteries are needed to operate the power wheelchair and provide enough battery power to operate the wheelchair for the full duration of a day.  All told, the requested equipment is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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.