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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a power wheelchair with full recline and power-elevating leg rests for treatment of the enrollees lymphedema. Findings:  The physician reviewer found that the documentation does not reveal that the requested power mobility device is medically necessary for treatment of this patients lymphedema. Power mobility devices are recommended for use when a patient has a personal mobility deficit that impairs their participation in mobility related activities of daily living (MRADLs) such as toileting, feeding, grooming and bathing in customary locations within the home. The patients condition much be such that it is not able to be ameliorated by a walker, cane or manual wheelchair. This patients documentation indicates that she has a fully functioning power mobility device, she can ambulate within her home with a walker, and she is currently independent with her MRADLs. The records indicate that the patients physical therapist encouraged ambulation daily in the house. A review of the literature reveals that exercise in encouraged for lymphedema management and to aid in weight reduction as obesity can increase lymphedema. Furthermore, per the National Lymphedema Network (NLN), stage 2 or worse lymphedema does not respond to simple elevation alone. Additionally, the patient can elevate her legs on a stool or other object rather than using a power mobility device for this purpose. Thus, the request for a power wheelchair with full recline and power-elevating leg rests is not medically necessary. Final Result: The reviewer determined that the requested equipment 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for mental health inpatient treatment for treatment of the enrollees behavioral health conditions.Findings:  The physician reviewer found that the patient met the criteria for treatment at the partial hospitalization program level of care.  The patient required a near-daily structured program to promote progress through the stages of change because of poor treatment engagement, which is consistent with partial hospitalization program level of care.  The records do not demonstrate the need for mental health inpatient treatment during the dates of services at issue.  Based on the medical records, he could have been safely treated at a lower level of care.  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 physician 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 reimbursement for inpatient hospital stay for treatment of the enrollees abdominal pain. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient had markedly elevated transaminases and clinical signs compatible with acute hepatitis superimposed on chronic hepatitis.  There were no signs of liver failure, although liver failure can develop rapidly due to a number of causes, such as acute viral hepatitis associated with cytomegalovirus, herpes viruses, or Epstein-Barr virus.  Rapid decompensation can result in a need for intensive care, and in acute liver failure with a need for urgent liver transplant.  This patients presentation was also consistent with serious hepatic and gastrointestinal infections more common in patients with immunosuppression.  Given the potential for acute decompensation, ongoing symptoms, and a lack of a clear etiology for the presenting symptoms, inpatient monitoring was medically indicated.  All told, inpatient hospital stay was medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one 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 Zepatier for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found according to the 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, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results. However, NS5A resistance testing is not provided, so the appropriate treatment duration cannot be determined. For these reasons, treatment with Zepatier for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication 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 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 breast tomosynthesis for evaluation of the enrollee, who presented for a breast screening mammogram.Findings:  Two physician reviewers found that the medical studies have shown that the addition of three dimensional digital breast tomosynthesis reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional digital breast tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. Final Result: Two 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Viekira Pak 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive, genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks.  The guidelines do not state that six months of testing is required to establish chronicity of hepatitis C prior to treatment, and state that acute hepatitis C is characterized by low or fluctuating viral load, which is not seen in this case.  This medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  Two physician reviewers found that tomosynthesis is approved for clinical use by the U.S. Food and Drug Administration (FDA), and 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 imaging alone. 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: 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 20 hours per week of direct applied behavioral analysis (ABA) therapy and 11.5 hours per month of supervision for treatment of the enrollees autism. Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. A study found that intensive behavioral treatment for children with autism is effective. The Health Plan has recommended a decrease of ABA hours due to minimal progress. Although the patient has not had significant progress, the factors that support the need for intensive ABA therapy at the requested frequency include the patients self-injurious behaviors, tantrums and level of severity for stereotypy repetitive behavior. In sum, there is sufficient documentation supporting 20 hours per week of direct ABA therapy and 11.5 hours per month of supervision for treatment of the patients medical condition.  Final Result: The reviewers 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: Physician reviewer number one is board certified in pediatrics with sub-specialty certification in developmental-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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for laparoscopic anti-reflux surgery utilizing LINX. Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with maximal acid suppression therapy, mild to moderate GERD, and a hiatal hernia less than 3 cm. This patient meets these criteria. Finally, five-year cohort data was recently published establishing the durability of the device. In a group of 85 patients, augmentation of the lower esophageal sphincter with a magnetic device provided significant and sustained control of reflux, with minimal side effects or complications. All told, this patient meets the specific criteria for treatment with the LINX system. Thus, the requested laparoscopic anti-reflux surgery utilizing LINX is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested procedure 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: the physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 Lovaza for treatment of the enrollees hypercholesterolemia. Findings:  The physician reviewer found that current evidence supports that elevated triglyceride levels are independently associated with cardiovascular risk. The medical records provided does not document a triglyceride level of more than 500 mg/dL while off medication.  However, there is documentation of hypertriglyceridemia of more than 200 mg/dl and documentation of intolerance to others form of cholesterol medication. In this clinical setting of known coronary disease and documented intolerance to most lipid therapies it is reasonable and appropriate to treat the patient with Lovaza even when only moderate hypertriglyceridemia (200 to 500 mg/dl) is present if patients are intolerant to statin therapy and other targeted therapies to reduce triglyceride levels such as with 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 cardiovascular disease 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 Afirma Gene Expression Classifier for evaluation of the enrollees thyroid nodule. Findings:  Three physician reviewers found that the cytopathology was consistent with follicular lesion of undetermined significance (FLUS). The size of the solitary nodule was 1.8 cm. The Bethesda System recommends a second fine needle aspiration (FNA) when the cytopathology is consistent with FLUS. The newest 2015 American Thyroid Associations guidelines state: For nodules with AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. FNA with molecular testing is considered standard of care following this cytopathology diagnosis rather than repeat biopsy or diagnostic surgery. The risk of malignancy on FLUS lesions is 5-15%. If the genetic test is suspicious, the risk of malignancy increases to 40%. However, the risk of malignancy decreases to less than 6% with benign findings by genetic testing. Therefore, the test is beneficial for the medical decision making without an additional procedure. Proceeding directly to the genetic testing helped this patient and the provider with medical decision making. If the result was benign continued observation would have been appropriate, which was the case with this patient. However, with a suspicious result, the recommendation would have been to perform thyroidectomy with no additional delay due to the increased risk for cancer.  All told, proceeding with genetic testing was appropriate and in line with current standards. Final Result: Three reviewers determined that the testing 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endoluminal ablation of varicose veins in the lower extremities for treatment of the enrollees varicose veins of the lower extremitiesFindings:  Two physician reviewers found that the patient has a family history of coronary artery disease and has a history of smoking, hypertension, hyperlipidemia, and leg pain with cramping and possible ulceration resistant to compression stockings. In this clinical setting, the records do not demonstrate that the patients symptoms are attributable to accessory vein reflux without an assessment of lower extremity arterial perfusion. In the absence of an assessment of the lower extremity arterial perfusion, endoluminal ablation of varicose veins in the lower extremities has not been established likely to be more beneficial for treatment of the patients medical condition 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 vascular surgery 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: Upheld 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 risk for breast cancer. Findings:  Two physician reviewers found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved. That is, the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. While in this patient the extra radiation dose is not a factor, as the 2D images were reconstructed from the primary tomosynthesis acquisition, a routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms over 11 years. Final Result: Two reviewers determined that the diagnostic 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: 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.