Persius/hicric huggingface dataset:
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 medical condition.  Findings:  Three 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.  As noted by a researcher, this technology has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  Per the medical evidence, those patients who have dense breasts can benefit most from tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and Ribasphere RibaPak for treatment of his 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 limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage. The AASLD/IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. The guidelines also cite data showing increased survival with earlier treatment. However, there is a lack of literature demonstrating superior safety or efficacy of Ribasphere RibaPak versus generic ribavirin. For these reasons, treatment with Sovaldi and ribavirin for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection, but treatment with Ribasphere RibaPak is not medically necessary. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested rituximab for treatment of his primary progressive multiple sclerosis. Findings:  The physician reviewer found that this patients presentation is consistent with primary progressive MS (PPMS). There is currently no U.S. Food and Drug Administration (FDA)-approved treatment for PPMS. Rituxan (rituximab) was studied in a multicenter placebo-controlled study and did not meet the primary endpoint of delaying disability. The authors concluded the drug was no more effective than placebo except in a small subset of men under age 50. Based upon the lack of compelling peer-reviewed data supporting the use of rituximab for the treatment of PPMS, there is inadequate evidence of the efficacy of rituximab to support its use in this setting. As such, the requested rituximab is not medically necessary for treatment of this patients medical condition. 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 in neurology 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 the Optune electrical stimulation device (Tumor Treatment Fields Therapy) and NovoTAL (Transducer Array Layout) System for treatment of his medical condition.   Findings:  Three physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Optune TTF, formerly known as NovoTTF, delivers alternating electric fields which are thought to disrupt mitotic activity. The patients wear this device most of the day which delivers electric fields via a portable device through electrodes placed on the patients scalp. NovoTAL allows for better customization of the treatment fields delivered by the Optune device. According to a large multi-institutional prospective randomized controlled trial, the Optune device appeared to be as effective as chemotherapy. Another study included 457 recurrent GBM patients who received TTF therapy. The authors concluded that NovoTTF Therapy offers clinical benefit to patients with recurrent GBM. NovoTTF Therapy has high patient tolerability and favorable safety profile in the real-world, clinical practice setting. In this case, the patient had already received first line salvage systemic therapy with Avastin. TTF therapy was indicated as an effective treatment for this patients disease.   Final Result: Three 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:  One reviewer is board certified in radiation oncology and is actively practicing.  One reviewer is board certified in neurological surgery and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in oncology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a colonoscopy for evaluation of his medical condition. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested colonoscopy. There is a lack of high quality support in the medical literature concerning the timing of surveillance colonoscopy in this clinical setting. Surveillance at five years would be appropriate if no polyps were found in this high risk individual. However, adenomatous polyps were found in this high risk patients previous colonoscopy. In this clinical setting the appropriate surveillance should be in the 3-5 year range. Therefore, a colonoscopy is medically indicated for 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 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 an inpatient stay for treatment of her medical condition.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for inpatient stay has not been established. In this case, the patients symptoms had resolved prior to admission, the vital signs were stable at the time of admission and the physical examination did not show signs of congestive heart failure or arrhythmia. In addition, the physician documentation did not include any reasoning for assignment of the inpatient status. All of the ordered services such as telemetry monitoring, repeat EKGs and diagnostic testing were of the intensity that could have been safely provided at the observation level. Had any complication or problem occurred, or the subsequent testing indicated myocardial ischemia, the patient could have appropriately been converted to inpatient status at that time. For the reasons provided, the services at issue were not medically necessary. 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 internal 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:  An enrollee has requested treatment at a residential level of care for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patients substance abuse clearly necessitated specialty services.  However, the patient had not failed any less restrictive interventions, such as community-based services, intensive outpatient programming or partial hospitalization with supportive living environment, during the episode of illness.  The patient acknowledged that substance use was problem, and she was motivated for sobriety.  She was not suffering from an acute psychiatric syndrome and there was no mention of a complicated detoxification.  Finally, the documentation provided did not include a treatment plan, psychiatric evaluation, interpretive summary or a clinical rationale supporting the need for residential placement as opposed to treatment at a lower level of care.  Considering the clinical presentation and patient history, coupled with relevant peer-reviewed medical literature and current practice guidelines, treatment services provided at the residential level of care were not medically necessary for treatment of the 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 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 residential treatment center services on an emergent or urgent basis.  Findings:  The physician reviewer found that at issue in this case is whether the enrollee was experiencing a psychiatric emergency medical condition. A psychiatric emergency medical condition is defined as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following: (A) an immediate danger to himself or herself or others  or (B) immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. Urgently needed services are defined as those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plans service area. In this case, the patient did not meet criteria for a psychiatric emergency medical condition as he did not pose an imminent danger to self or others and was able to appropriately utilize food, shelter and clothing. Based on the patients presenting symptoms and through his stay, he was not experiencing a psychiatric emergency medical condition. Further, it has not been established that criteria for urgently needed services were met on the date in dispute. The patients behavioral health conditions were not of sufficient intensity to warrant the services in dispute to prevent serious deterioration of his health resulting from an unforeseen illness, injury or complication of an existing condition. The symptomatology presented initially on admission and throughout the course of stay did not suggest the patients condition was likely to significantly deteriorate absent admission to a residential treatment level of care. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential mental health treatment services for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the residential mental health treatment services were not and are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, almost none of the symptoms that prompted admission to residential care persisted. Given the lack of this symptomatology, it does not appear that the patient required ongoing residential treatment. The patient did not appear at risk to himself or others, did not appear disorganized or exhibit psychotic symptoms, did not exhibit poor activities of daily living to the degree that would require residential treatment. The treatment notes provided reflect goals, assessments, and plans that could have been provided in an outpatient setting.  Moreover, there is a lack of evidence to support that the patient has a psychiatric disorder that affects all areas of functioning that require residential level of care. All told, the patient could have been safely treated at a lower level of care.  Final Result: The reviewer determined that the services at issue are not and is 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Corlanor for treatment of her medical condition. Findings:  The physician reviewer found that based on the records provided, the patient has Postural Orthostatic Tachycardia Syndrome (POTS)  and is unable to tolerate therapies that further lower blood pressure due to symptoms of presyncope. The optimal therapy of POTS has not been established, but it is generally recommended to avoid precipitating factors and to encourage physical activity in addition to volume repletion and fludrocortisone (0.05 to 0.2 mg per day) as first-line therapy, none of which should exacerbate hypotension. Some patients may benefit from midodrine, another therapy that would not exacerbate hypotension. The records provided do not document the patient has tried and failed any of the above treatment options. In addition, other therapies to treat POTS are controversial, including the use of Corlanor (ivrabradine). While there is some literature that has evaluated Corlanor in patients with inappropriate sinus tachycardia, this is a different patient population compared to patients with POTS syndrome.  In sum, the use of Corlanor for treatment of POTS has not been established as medically necessary.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment center level of care for the treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the service at issue.  The patients developmental task of identity consolidation has been hampered by chronic anxiety and affective dysregulation exacerbated by interpersonal struggles and family discord.  Her psychiatric comorbidity and illness burden negatively impacted multiple domains of functionality.  Despite being treated previously in the outpatient, partial and acute levels of care, which included school-based services, psychotherapy and complex pharmacotherapy, the patient had not consolidated significant treatment gains.  Based on the medical documentation and clinical status at the time, safe and effective care could not have been adequately delivered in a less restrictive setting.  The record reflects that the patient was passively suicidal, anxious and hopeless. However, she was motivated to engage in therapy. Thereafter, the record describes systematic exposure therapy in addition to the other modalities afforded by the clinical setting.  The residential treatment provided has been reasonably expected to improve her condition and prevent a more serious episode of illness. Accordingly, residential treatment center level of care was and is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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 skilled nursing facility treatment services (medications, nursing, physical therapy and occupational therapy) for treatment of her medical condition. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for skilled nursing facility care has not been established. In this case, the patient has Guillian-Barre Syndrome (GBS) which is a polyneuropathy that can manifest with extreme weakness. Recovery occurs over months to years. GBS is accompanied by deficits of functional mobility and self-care that are at times profound. The functional deficits have traditionally been treated with comprehensive rehabilitation. A systematic review of multidisciplinary rehabilitation found low quality evidence that inpatient multidisciplinary rehabilitation may improve disability and quality of life in the short term. In this case, the patient has shown improvement to the point where intensive physical therapy in the inpatient setting was no longer needed. She did not demonstrate a need for skilled nursing or speech therapy services. She had continued deficits of self-care that can be addressed with custodial care and outpatient therapy. Continued skilled nursing facility treatment services were not and are not medically necessary for treatment of the patients medical condition.Final Result: The reviewers determined that the services at issue were not and 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 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.