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

Nature of Statutory Criteria/Case Summary: An enrollee, who is diagnosed with peripheral neuropathy and neuromuscular disorders, has requested a power scooter for mobility assistance. Findings: The physician reviewer found that the documentation submitted does not support the medical necessity of the requested equipment in this clinical setting. Power mobility can benefit specific individuals. While this patient demonstrates that he has a personal mobility deficit, he does not meet criteria for safe usage of a power scooter. According to the records, a previous power scooter nearly led to falls due to his communitys terrain. Additionally, he is not able to safely convey a power scooter from his apartment to the community. The patient plans to break down the scooter and move it up and down the stairs to his abode for storage after using the scooter outside the home. A scooter that can be disassembled in such a manner is not medical grade. The patients safety would be compromised as he tries to move these scooter pieces up and down the stairs. Therefore, a power scooter is not medically necessary for treatment of this patients mobility deficits. This equipment cannot be safely deployed and used by this patient. As such, the requested coverage for a power scooter is not medically necessary for treatment of this patient.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: 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 enrollee, who was asymptomatic. Findings:  The 3 physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, a mass as well as indeterminate calcifications were noted in the left breast.  Breast tomosynthesis is an excellent means to better evaluate calcifications and identify masses that may not be apparent on routine mammography.  The medical evidence supports the service at issue in this patients case.  Therefore, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 3 reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested colonoscopy for evaluation of the enrollees risk of colon cancer. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrate the medical necessity of the requested colonoscopy. More than one million patients will manifest colorectal cancer (CRC) this year of which, conservatively, approximately 3% (approximately 30,700 cases) will have Lynch syndrome (LS), the most common hereditary CRC predisposing syndrome. Due to its early age of onset (average 45 years of age), colonoscopy needs to start by age 25, and because of its accelerated carcinogenesis, it should be repeated every 1 to 2 years through age 40 and then annually thereafter (Lynch, et al). Although the patient may not have definitive Lynch syndrome, her family history places her at unequivocally high risk for colon polyps and cancer. According to the U.S. Multi-Society Task Force on Colorectal Cancer CRC age-adjusted risk varies based on patient demographic characteristics. In this case, a colonoscopy is clinically appropriate given the patients risk for colon polyps and cancer. In addition, her positive first-degree and second-degree family history significantly increases her risk. Therefore, the requested colonoscopy has been established as medically necessary for evaluation of the patients medical condition.  Final Result: The reviewer determined that the requested service 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 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

An enrollee has requested authorization and coverage for additional non-emergency transportation. Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  The patients documented history and examination findings do not indicate that she has any impairments that would preclude the regular use of public or private transportation to go to her medical appointments.  Increased physical activity, moreover, is generally appropriate and recommended for conditions such as obesity, hypertension, diabetes, fibromyalgia, and for general musculoskeletal health.  In sum, additional non-emergency transportation is not medically indicated for the 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: Findings:  Three physician reviewers found that the patient has Crohns disease (ileocolitis) and with prior ileocolonic resection in 2004. Per the providers office note , the patient was reported to have started on Humira in March 2015, after Remicade was discontinued due to development of antibodies and loss of response.  On that date, she also reported diarrhea. C-reactive protein was elevated at 1.5 mg/L.  For these reasons, there was concern for under dosing of Humira or the development of anti-Humira antibodies. Anser ADA testing was ordered and performed. The test showed Humira level of 9.2 ug/mL and lack of anti-Humira antibodies.  In this case, Anser ADA was ordered to direct the management of the patients Crohns disease. The use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature. These small studies demonstrated, at best, correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. One study found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. A review article reported that the available data does not allow final conclusions about the relevance of anti-adalimumab antibodies to the clinical efficacy of adalimumab. Another review concluded that prospective controlled trials are directly needed to investigate the optimal tailored management in individual patients who lose response. Final Result: Three reviewers have 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Repatha Sureclick 140 for treatment of high cholesterol.  Findings: The physician reviewer found that the patient has documented peripheral vascular disease, dyslipidemia with elevated LDL cholesterol and intolerance to two statin medications. The provided records do not document coronary disease. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol in spite of standard therapy with proven outcomes benefit.  Based on the records provided, this patient has no documentation of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia by usual criteria (Raal and Santos).  This patient has no documented coronary artery disease.  In addition, the documentation does not support trials and intolerance to other different statin medications at low doses including fluvastatin or pitavastatin, both of which have lower side effect profiles. There is also no documentation that this patient has tried and failed Zetia which has proven outcome evidence of benefit (Cannon, et al). This patient has not exhausted proven standard therapy for treatment of his medical condition. As such, the medical necessity criteria for the use of a PCSK-9 inhibitor has not been met. Therefore, the requested Repatha Sureclick 140 mg/mL pen injector is not medically necessary for the treatment of this patient.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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that 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 except those with life expectancy less than 12 months due to non-liver-related conditions. Patients with cirrhosis are reported to be high priority for treatment. Per the guidelines, cirrhotic patients who have failed Sovaldi, peg-interferon, and ribavirin should be treated with a different regimen. Treatment with Harvoni and ribavirin for 24 weeks is recommended based on a study of 352 prior treatment failures, with cure rate of 95-98% (Reddy, et al). Treatment with Sovaldi with Viekira Pak and ribavirin is not recommended. The requested regimen of Sovaldi with Viekira Pak and ribavirin, is only recommended by AASLD/IDSA guidelines for patients who have failed an NS5A inhibitor and who have both NS3 and NS5A resistance-associated variants, which is not reported in this case (Poordad, et al).  For these reasons, the request for Sovaldi 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Enablex. Findings:  The physician reviewer found that anticholinergics are considered the mainstay of pharmacotherapy for overactive bladder. According to the American Urological Association (AUA), there are at least five anticholinergics which can be utilized to treat patients with overactive bladder. The records indicate that this patient has been treated with Enablex. The records provided for review document that this patient has had an adequate response to brand name Enablex, but not to its generic equivalent. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested positron emission tomography (PET) with concurrently acquired computed tomography (CT); skull base to mid-thigh and fluorodeoxyglucose for evaluation of the enrollees rectal cancer. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested diagnostic procedure. The records provided for review do not show a treatment plan for surgery, nor is the provider planning new chemotherapy or radiation therapy. The medical records do not indicate any evidence of possible recurrent neoplasm. In addition, previous imaging does not show results suspicious or inconclusive for recurrent neoplasm. Therefore, the request for PET with concurrently acquired CT; skull base to mid-thigh (CPT 78815) and fluorodeoxyglucose F-18 FDG (HCPCS A9562) has not been established as medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollee who initially presented as asymptomatic. Findings: Two physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting screening mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her screening examination been done with two-dimensional imaging alone.  However, once the area of concern had been identified in the right breast, conventional imaging including spot compression views and ultrasound without breast tomosynthesis would have produced the same results and guidance for tissue sampling.  Therefore, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  However, the submitted records fail to demonstrate the superior efficacy of the breast tomosynthesis.Final Result: Two reviewers determined that a portion of the services 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 partially 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 direct 40 hours per week applied behavioral analysis (ABA) therapy and seven hours per week of supervision for treatment of the enrollees autism.  Findings: The physician reviewer found that the evidence for the effectiveness of early intensive behavioral intervention (EIBI) in increasing the functional behaviors and skills of children with autism. The authors reported improvements in cognitive skills, adaptive skills and communication. In this case, the documentation supports that ABA has been effective for this patient. However he continues to have maladaptive behaviors that include mouthing/licking, placing hands on others and grabbing behaviors. In addition, the patient has had an increase in maladaptive behaviors due to a decrease in ABA services. Therefore, a reduction of services is not indicated for this patient. Accordingly, the request for 40 hours per week of direct ABA therapy and seven hours per week of supervision are medically necessary for treatment of the patients medical condition.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 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

Nature of Statutory Criteria/Case Summary: The representative of a deceased enrollee has requested reimbursement for the electric tumor field treatment (Optune) for treatment of the enrollees recurrent glioblastoma multiforme.  Findings: Two physician reviewers found that Electric tumor field therapy is considered the standard of care as both adjuvant therapy in combination with Temodar and for recurrent disease per the National Comprehensive Cancer Network (NCCN) guidelines. Electric tumor field therapy is U.S. Food and Drug Administration (FDA) approved based on a study showing better quality of life with use of alternating electric field therapy (Stupp, et al). Given the lack of treatment options for high grade gliomas and the efficacy and good tolerability of electric tumor field therapy, the treatment was likely to be superior to other treatment options. Therefore, the electric tumor field treatment (Optune) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the services at issue were 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and hematology 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.