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

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage for Afirma Gene Expression Classifier (CPT code 81545) for evaluation of the enrollees thyroid nodules.  Findings: Two physician reviewers found that based on the findings on the Afirma gene expression testing, nodule A was benign and no further testing was necessary. Nodule B was a follicular lesion of unknown significance but has high risk features of solid, hypoechoic and microcalcifications. Per the National Comprehensive Cancer Network (NCCN) guidelines, if a lesion has high risk features, thyroidectomy should be performed. While some data suggests that Afirma may ameliorate the need for surgery, high risk sonographic features support an indication for surgery (Chan, et al). Thus, the Afirma Gene Expression Classifier (CPT code 81545) was not likely to be more beneficial than standard available options including surgery for evaluation of this patients thyroid nodule.Final Result: Two reviewers determined that the testing 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 internal medicine with sub-specialty certification in medical oncology 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 direct applied behavioral analysis (ABA) therapy (0365T) for treatment of the enrollees autism.  Findings: The physician reviewer found that the request for 18 hours per week (36 units) of direct ABA therapy (0365T), three hours per week (6 units) of oversight (0369T) and four units per month of multi-family treatment guidance (0371T) has not been established as medically necessary for treatment of the patients Autism Spectrum Disorder (ASD). In general, ABA therapy is effective when initiated at an early age, preferably before the age of two (Spreckley and Boyd). For older children and young adults, therapy is generally directed away from ABA therapy toward social skills development (Reichow, et al). In this case, the patient presents with significant issues of language delay, impulsivity, and stereotypical and ritualistic behaviors. The ABA progress report shows a lack of significant improvements over the past six months. As such, a reduction of ABA hours to 10 hours per week of ABA therapy (0365T), two hours per week of oversight (0369T) and two units per month of multi-family guidance (0370T) as authorized by the Health Plan is medically reasonable for treatment of the patients ASD.  Final Result: The reviewer determined that the services at issue 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 pediatrics with sub-specialty qualification in child 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: The parent of an enrollee has requested automated external defibrillator (AED) for treatment of the enrollees long QT syndrome. Findings: Two physician reviewers found that the request for an AED has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patient does not fulfill the requirements for an implantable cardioverter defibrillator (ICD) as he has not been treated with beta blockers and is currently asymptomatic with no syncope or documented arrhythmias. Although, the patient does not meet the criteria for an ICD, he remains at high risk of having arrhythmia. An AED is necessary in the event that the patient does have a life threatening arrhythmia. AEDs have been proven to save lives. Survival is greatest when the AED is placed within three to five minutes of a witnessed collapse. In this case, the patient has a QTc greater than 500 milliseconds which puts him in a high risk category for a malignant arrhythmia. Accordingly, a personal AED 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 requested device 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:  All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 modafinil for treatment of the enrollee, who has a history of an anoxic brain injury.  Findings: The physician reviewer found that the submitted documentation supports the requested medication in this patients case.  This patient has had severe traumatic brain injury and has major neurologic deficits.  His medications have caused fatigue, and modafinil has alleviated that.  As a result, he has been more able to participate in therapies, as evidenced by his decline once modafinil was discontinued.  Kaiser and colleagues performed a study of modafinil in post traumatic brain injury fatigue.  The authors noted that excessive daytime sleepiness improved significantly in patients with traumatic brain injury who were treated with modafinil, compared with the placebo group.  There is sufficient support for the requested medication in this patients case.  All told, modafinil 200 mg is medically indicated for the treatment of 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested skilled nursing/rehabilitative services for treatment of the enrollee, who is status post cerebral vascular accident.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Functional impairments due to acquired brain insults such as stroke can be profound.  Nevertheless, some recovery is expected with time, and many of these impairments are amenable or addressable by compensatory measures by directed rehabilitation efforts.  The role of inpatient rehabilitative care for persons with significant functional deficits following stroke is relatively well-established in the medical literature.  In this case, the patient has had major functional deficits following his stroke.  He has been undergoing rehabilitative care at the skilled nursing facility level of care, but has made only modest progress.  His prognosis for functional recovery that will make a significant difference in his assistance needs in the near term is poor, in large part due to his persistent residual dense hemiplegia, as well as his cognitive impairments.  He is anticipated to require significant, if not total, levels of assistance for most aspects of his care, including his self-care and transfers.  While ongoing rehabilitative services are appropriate and indicated, these services can be provided in a community setting, with custodial level services for the patients basic self-care.  There are otherwise no documented ongoing medical or skilled nursing needs, such as complex wound care, initiation of self-care related to enteral feeding or ostomy care, requiring ongoing inpatient care.  All told, skilled nursing/rehabilitative services were not and are not medically indicated for the treatment of this patient.Final Result: The reviewer 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 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 digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Three physician reviewers found that there is sufficient support in the peer-reviewed literature for the diagnostic procedure at issue in this clinical setting. Skaane and colleagues performed a large prospective screening trial To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis. The authors concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Given the support in the medical literature, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast exam than conventional mammogram and is due to improved cancer detection rate.   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 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 reconstructive surgery for removal of excess skin on breast, abdomen, and arms for treatment of the enrollees excess skin.   Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  The medical records document massive weight loss.  She has evidence of functional deficits related to her resulting in excess soft tissue of the breasts and abdomen.  Photographs support that this is a severely abnormal condition of the abdomen and breasts, but not for the arms.  With regards to the patients case, the photographs only support a moderate condition and a functional deficit has not been adequately described.  However, this determination is also dependent on the timing of the reconstruction.  Per the medical evidence, there is a strong correlation with increased complications in body contouring patients who have surgery with a body mass index greater than 30.  Therefore, it is reasonable to have evidence of a stable weight prior to body contouring procedures.  However, this patient has had evidence of a stable weight for at least one year.  Her continued weight loss was based on recommendations to satisfy a cut-off body mass index of 30.  Given her overall clinical scenario, waiting an additional six months does not appear to be indicated for this patient.  In sum, removal of excess skin on breast and abdomen before a six-month waiting period is medically necessary.  However, the records do not indicate that the brachioplasty is medically indicated for the treatment of this patient.Final Result: The physician reviewer determined that a portion of the requested services is 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential alcohol use disorder treatment services for treatment of the enrollees alcohol use disorder. Findings:  The physician reviewer found that this patients records do not include a psychiatric evaluation, daily notes, medication administration records, individual therapy notes, nursing notes, vital signs, or Clinical Institute Withdrawal Assessment (CIWA) scores. The patient was medically stable and psychiatrically stable to the extent that she did not require treatment in a 24-hour facility. There was no evidence of a high degree of impulsivity, aggression, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with her care in a less restrictive treatment setting. She has had multiple prior treatments at residential but not at intensive outpatient program (IOP) or partial hospitalization program (PHP) levels of care. Further, there is a lack of evidence to suggest that she was unlikely to respond to a lower level of care. Overall, she did not meet the American Society of Addiction Medicine (ASAM) clinical guidelines for residential level of care and could have been successfully treated at an ambulatory level of care such as PHP or IOP with concomitant sober living. 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 addiction 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 retroactive authorization and coverage of digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.  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.  In this patients case, her breast tissue density was described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  In sum, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested colonoscopy for evaluation of the enrollees colon polyp.  Findings: The physician reviewer found that the information provided does not establish that the patient has a first-degree relative such as a brother or father with a diagnosis of adenoma or colorectal cancer before age 60. Further, there is no information that the patient had an adenomatous polyp in the past. The American Cancer Society (ACS) guidelines for colon cancer screening state that in patients with colorectal cancer or adenomatous polyps in any first-degree relative aged 60 or older, the first colonoscopy should be performed at age 40 and subsequent colonoscopies at the same intervals as those at average risk, which is every 10 years unless non-hyperplastic polyps are found. Based on these guidelines, the next colonoscopy would be 10 years after the first. The joint guidelines issued by the American College of Gastroenterology (ACG), American Gastroenterological Association Institute (AGAI), and American Society for Gastrointestinal Endoscopy (ASGE) for surveillance after a screening colonoscopy state that if colonoscopy is performed and the finding is normal, the recommended interval for repeat screening should be five years if the first-degree relative was younger than 60 years and 10 years if the first-degree relative was 60 years or older (Lieberman, et al). In addition, the United States Preventive Services Task Force (USPSTF) guidelines do not make any recommendations regarding colonoscopy intervals based on prior polyp pathology in patients with a high risk family history. Based on the information provided and current guidelines, this patient should undergo subsequent colonoscopies in 10-year intervals. Thus, the requested colonoscopy is not medically necessary for evaluation of this 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 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 retroactive authorization and coverage for Afirma Gene Expression Classifier for evaluation of the enrollees thyroid nodule.  Findings: Two physician reviewers found that thyroid nodules are commonly managed by diagnostic FNA to evaluate the cytopathology (Hamberger, et al). In this case, the finding by this standard technique was atypia of undetermined significance (Baloch, et al). This diagnostic category creates a dilemma with regards to recommended surgery. This patient was facing total thyroidectomy if malignancy was present and but only subtotal thyroidectomy if the lesion was benign. Hence, the sample was submitted for the Afirma gene expression testing for analysis. In a large study of over 500 patients, 6-14% of patients with atypia of undetermined significance were found to have malignancy on pathology review but no mutation in several known oncogenic pathways (Nikiforov, et al). In contrast, the Afirma gene expression test has demonstrated a very high negative predictive value for malignancy (Alexander, et al; Chudova, et al). Since unnecessary thyroid surgeries may be prevented by implementation of the gene expression test, the use of the Afirma Gene Expression Classifier was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the testing 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 internal medicine with sub-specialty certification in medical oncology 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 retroactive authorization and coverage for digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three 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.