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

Nature of Statutory Criteria/Case Summary: An enrollee requested breast tomosynthesis for medical evaluation of her risk for breast cancer.   Findings:  Three 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. All told, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone.Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that although there is a lack of long term studies demonstrating increased survival rates when tomosynthesis has been added to the usual screening mammography protocol the addition of the technique has gained worldwide popularity among providers due to an associated significant decrease in callbacks and increased detection of small cancers.  Thus, the addition of the technique is considered more beneficial for the patient than mammography alone. Final Result: Three 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested gastric sleeve surgery for treatment of the enrollees obesity and low back pain status post placement and removal of Lap-Band.  The physician reviewer found that this patient has a history of a prior Lap-Band which was removed secondary to complications that were not the fault of the patient. Without a weight loss tool in place, she has regained the weight that was originally lost. Given the high complication rate of the Lap-Band after one procedure, replacement of the Lap-Band would not be recommended. Moreover, the requested laparoscopic sleeve gastrectomy is a standard treatment for morbid obesity and is thus an appropriate option for repeat bariatric surgery for this patient. In addition, the patient currently meets standard guidelines for bariatric surgery including Centers for Medicare and Medicaid Services (CMS), the National Institutes of Health, and the American Society for Metabolic and Bariatric Surgery. The patient has morbid obesity with a BMI of 45 and she has completed an updated multidisciplinary evaluation and was not found to have any dietary, behavioral, or medical barriers to surgery. Moreover, the records document failed dietary efforts in the past including supervised dietary efforts. Given these findings, the requested gastric sleeve surgery is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 general surgery with sub-specialty certification in bariatric 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 the Elan electronic mobile ankle system (L5973) for treatment of the enrollees amputation below the knee.  Two physician reviewers found that the device at issue is not likely to be more beneficial for treatment of the patients medical condition than available standard modalities. There are multiple options for this patient to pursue short of a computerized ankle foot system. According to the documentation submitted for review, the patient has an ankle that is fixed at 90 degrees which is inappropriate for his functional needs. A multi-axial or dynamic response ankle-foot system and a flex-walk system would be appropriate for his functional and endurance needs. There is no indication that a microprocessor controlled system would be more beneficial than these other options. All told, the Elan electronic mobile ankle system (L5973) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the device at issue 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 physical medicine and rehabilitation 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 requested the transcutaneous electrical nerve stimulation (TENS) supply two leads per month and the functional electrical stimulator for treatment of his embolic stroke. Findings:  Two physician reviewers found that compared with standard therapy including continued use of an ankle foot orthoses, the Bioness L300 FES is likely to provide this patient with more functional gait. This is supported by the literature and has been demonstrated with a trial of the device by the patient. The peer-reviewed medical literature showed that use of the Bioness L300 FES makes gait more symmetric, reduces stride variability, and improves walking speed. All of these measures are relevant to a patient who requires maximum gait safety and efficiency for his demanding clinical work. Consistent with these findings, the TENS supply two leads per month and the FES was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the equipment at issue was and 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: Reviewer 1 is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. Reviewer 2 is board certified in neurology and is actively practicing.  Reviewer 3 is board certified in neurology with sub-specialty certification in neuromuscular medicine and is 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 requested Xiaflex for medical treatment of his Peyronies disease.   Findings:  Two physician reviewers found that Xiaflex has been shown to have modest efficacy in clinical trials and is U.S. Food and Drug Administration (FDA) approved for use in patients with Peyronies disease with at least 30 degrees of curvature and a palpable plaque. In addition, Xiaflex is the only FDA approved drug for Peyronies disease. This patient has failed conservative therapy, has a greater degree of dorsal penile curvature, and has a palpable penile plaque. All told, the requested Xiaflex is supported as likely to be more beneficial for treatment for treatment of this patients Peyronies disease.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: Reviewers 1, 2, and 3 are board certified in urology 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested mental health inpatient treatment services for treatment of the enrollees depression and attention deficit disorder (ADD).  The physician reviewer found that the records indicate that this patient could have been safely discharged as he was no longer suicidal and had no homicidal thoughts or psychosis. In addition, the patient already had an outpatient psychotherapist who referred him to the hospital and he had a psychiatrist who was managing his medications. No significant changes were made to his medications while in the hospital. He was no longer a threat to himself or others and was not psychotic or having problems with performing activities of daily living. All told, the requested mental health inpatient treatment services were not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested psychiatric services on an emergent basis. The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that the patient had a psychiatric emergency medical condition that required the services at issue on an emergent basis. Based on the documentation submitted for review, the patient expressed suicidal ideation to his camp counselor with intent to get run over by the bus. However, the patient was not seen by a provider on that day. In a letter the patients parent indicates he needed to be seen by a child psychologist that knew him, was familiar with him and that he felt comfortable with. On mental exam the patient was described as cordial, respectful, expressive speech within normal limits, oriented, a short attention span, difficulty concentrating and easily distracted. The patient stated that he really doesnt want to die and that he was depressed. Moreover, the treatment notes documented that the patient did not have active suicidal thoughts nor suicidal intent or plan. In sum, the patient was not an immediate danger to himself or others at the time of the services in dispute. Based on the documentation provided, the patient did not have a psychiatric emergency medical condition that required services on an emergent basis.  Final Result: The reviewer determined that the patient was not experiencing a psychiatric emergency medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Two physician reviewers found that in this patients case, there is a lack of documentation of advanced hepatic fibrosis.  This has import relative to prioritizing medically necessary treatment on the basis of nationally-recognized American Association for the Study of Liver Diseases and Infectious Diseases Society of America treatment guidelines.  The guidelines noted that immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C. Based on available resources, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority.  In this patients case, he does not meet classification per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines as highest priority, high priority, or even at increased risk for medically necessary treatment.  All told, the requested medication Harvoni for 12 weeks is not medically indicated for the treatment of this patient. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 Harvoni for eight weeks for treatment of her chronic hepatitis C virus genotype 1a and 1b.  Findings:  Two physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. FDA approved antiviral therapy regardless of fibrosis score. The recommended treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. The guidelines note that treatment duration of eight weeks can be considered in treatment-naive patients without cirrhosis who have a baseline viral load less than 6 million IU/mL. Since this patient is treatment-naive and has a viral load of less than 6 million IU/mL, the requested eight week course of Harvoni is medically necessary.  Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 Harvoni for 12 weeks for treatment of her chronic hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. FDA approved antiviral therapy regardless of fibrosis score. Consistent with this support, the requested 12 week course of Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 three dimensional (3D) digital breast tomosynthesis for evaluation of her risk for breast cancer. Three 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. All told, the use of 3D digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested an evaluative test of amniotic fluid protein for evaluation of her pregnancy.  Three physician reviewers found that in this patients case, the services at issue were not likely to have been of greater benefit than other methods of evaluation.  The diagnosis of ruptured membranes can generally be made on the basis of clinical examination and nitrazine and fern testing.  There have been false positive results from AmniSure.  There is nothing in the record to suggest that there was clinical confusion as to the presence of ruptured membranes by physical examination, nitrazine testing, or ferning.  It does not appear that these standard evaluations were performed.  The routine use of AmniSure to diagnose ruptured membranes is not recommended.  All told, the evaluative test of amniotic fluid protein was not likely to have been more effective than other options for evaluating this patient. Final Result: 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: All three reviewers are board certified in obstetrics and gynecology 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.