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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested single photon emission computed tomography (SPECT) scans of the brain for evaluation of her cognitive difficulties. Three physician reviewers found that the use of static brain imaging such as magnetic resonance imaging (MRI) and computed tomography (CT) has been used in the evaluation of psychiatric illness but is usually of no benefit. While physiologic scanning such as SPECT is not routinely used, the technique has shown some promise in a variety of psychiatric diseases including attention deficit disorder, bipolar disorder, and non-refractive depression. With SPECT imaging, the brain is functionally imaged to allow for evaluation of the metabolism of the various centers of the brain and the results have been beneficial in the diagnosis of complex cases, drug therapy trials, and even in post-traumatic brain injuries. In this particular case, the technique had the potential to provide more benefit to the patient than any other type of imaging modality. Thus, SPECT scans of the brain were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.  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 the ultrasound bone growth stimulator (CPT HCPCS-E0760 Osteogen Ultrasound Stimulator) for treatment of her medical condition.  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the device at issue.  According to the medical literature, further clinical trials are needed in order to determine the optimal role of ultrasound therapy and fracture healing.  The records did not include more recent clinical notes documenting the outcome of the start of physical therapy along with weight-bearing as tolerated.  Given that the patient was noted to have progression of healing with no documentation of updated repeat x-rays to show continued delayed union, the requested ultrasound bone growth stimulator was not and is not likely to be of greater benefit than available standard therapy.  Final Result:  Three reviewers determined that the device at issue was not and 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 orthopedic surgery 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 kyphoplasty (CPT 22513 and 22514) for treatment of her thoracic pain.  Two physician reviewers found that kyphoplasty (CPT 22513 and 22514) is not likely to be more beneficial for treatment of the patients medical condition than other modalities. The medical records do not demonstrate an adequate trial and failure of conservative measures to include bracing. Also, the medical literature indicates that kyphoplasty is not more effective than conservative or sham treatment for osteoporotic vertebral compression fractures. In sum, kyphoplasty is not indicated for this patient with thoracic spine pain and evidence of compression fracture. For the reasons provided, the requested services are not likely to be superior to conservative measures to relieve this patients thoracic spine pain. Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in orthopedic 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 a gene test for evaluation of the enrollee, who has a history of renal cell carcinoma.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical records note that the patient has a history of clear cell renal carcinoma and is status post nephrectomy. It appears as if genetic tests were recommended in order to determine the chemotherapeutic regimen.  However, there is a lack of support for the services at issue in this clinical setting.  The specific genetic test requested involves testing for JAK2 mutation, which is not known to have a relationship to renal cancer.  Therefore, the requested genetic test was not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the services at issue were 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 medical oncology 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 gene testing for evaluation of his renal cell carcinoma. Findings:  Two physician reviewers found that in this patients case, the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  There is lack of support for the services at issue.  Genomic assays may find multiple genetic alterations.  There is little data available to suggest that targeted genetic therapy affects outcomes.  There is a lack of evidence indicating that the gene testing performed was likely to have been more beneficial than available standard therapy.  All told, the gene testing at issue was not likely to have been of greater benefit than other modalities.  Final Result: Two 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 internal medicine with sub-specialty certification in medical oncology 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 whole body integumentary photography (mole mapping) for evaluation of her atypical nevi.  Findings:  The physician reviewer found that this patients clinical presentation of pigmented lesions is suggestive of the atypical nevus syndrome. Patients with this condition have a higher risk for developing melanoma. Various imaging methods are available that can be used in patients to evaluate pigmented lesions suspicious for malignant transformation to melanoma. Biopsy can be problematic because of the need to excise the entire lesion in order to avoid a sample error, and possible complications of this interventional procedure. Effective approaches to early melanoma detection should identify and evaluate both changing and new nevi. Therefore, the whole body photography is a standard of care approach to early diagnosis of melanoma in such patients. Consistent with these findings, whole body integumentary photography (mole mapping) was medically necessary.  Final Result: The reviewer determined that the services at issue were 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 dermatology 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 requested Foundation One genetic testing for evaluation of her colon cancer.  Findings:  Two physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available options. Foundation One testing is not considered a standard of care for the treatment of metastatic colon cancer. In this clinical setting, best supportive care is recommended. As such, the Foundation One testing setting was not likely to be more beneficial for evaluation and treatment of the patients medical condition than standard therapy.  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: Two reviewers are board certified in medical oncology and are actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in medical 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intensive outpatient program (IOP) services for treatment of the enrollees behavioral health condition.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. According to the documentation submitted for review, the patient was not at risk for withdrawals as his last use was three months prior. He was medically and psychiatrically stable on his medications. Although he had experienced psychotic symptoms in the past, he did not show evidence of psychosis. He denied suicidality or homicidality. He was not aggressive. He was physically and cognitively able to provide for his activities of daily living and continue in treatment. He verbalized his desire and his knowledge of triggers and negative consequences of substance use. He was aware of his risk of relapse. He lived with his mother and had her support. He had transitioned from a wilderness program, from which he had improved. It was unlikely that the structured setting of IOP would provide significant further improvement. The patient did not meet medical necessity criteria for IOP and could have been safely and effectively managed at a lower level of care. Thus, the services at issue were not and are not medically necessary for treatment of the patients medical condition. 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested weekly individual therapy for treatment of her behavioral health conditions.  The physician reviewer found that based on the patients clinical improvement, as evidenced in the documentation which culminated with a reasonable plan of care, weekly therapy is not medically indicated.  During the clinical encounter, the patient was psychiatrically stable.  She was demonstrating no signs of psychiatric distress or personality disordered behavior besides a need for reassurance and an aversion to disagreements.  She was expanding her resource base in the community with spiritual engagement.  The patients depressive illness has been treated with appropriate, evidence-based clinical interventions, including cognitive behavioral therapy and pharmacotherapy.  All told, the requested therapy is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested therapy 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested testing of serum concentration of infliximab and antibodies to infliximab for evaluation of his medical condition.  Three physician reviewers found that the current medical evidence has not established the superior efficacy of the services at issue.  Monitoring patients on infliximab with measurement of infliximab levels and antibodies to infliximab continues to be an area of intense investigation.  In general, infliximab levels correlate inversely with disease activity.  However, the target level of infliximab necessary to achieve clinical benefit remains unknown.  There is a lack of controlled data which have identified the optimal drug level.  All told, testing of serum concentration of infliximab and antibodies to infliximab was not likely to have been superior over other methods of evaluation. 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 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 his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for treating hepatitis C virus recommend a daily fixed-dose combination of ledipasvir/sofosbuvir (Harvoni) for 12 weeks for treatment-naive patients with hepatitis C virus genotype 1 infection. The AASLD/IDSA recommendation is not to deny patients treatment if they have early stage disease, but to treat patients with HCV to avoid untoward complications from advanced disease. For the reasons provided, the request for Harvoni for 12 weeks is medically necessary for treatment of the patients HCV.   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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified 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 a Saunders cervical traction unit for home use for treatment of her neck pain and arm radiculopathy.  Two physician reviewers found that a Saunders cervical traction unit for home use is likely to be more beneficial for treatment of the patients medical condition than other modalities. This patient has neck pain with upper extremity radicular symptoms and has responded well to cervical traction during physical therapy. A home cervical traction using a seated over-the-door device or a supine device in conjunction with a home exercise program is recommended. A supine device may be preferred due to greater forces or when there are co-morbid conditions such as temporomandibular joint disease. In addition, cervical traction is a well-established modality that can be self-administered when needed. In this case, the patient has utilized the requested unit with benefit, likely decreasing the number of therapy visits and providing a means of self-management to be used in conjunction with a home exercise program, which is a goal of skilled 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:  One reviewer is board certified in physical medicine and rehabilitation and is actively practicing. Two reviewers are board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine 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 a 12-week course of Sovaldi for treatment of her hepatitis C.  Findings:  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  There is sufficient support for the requested medication in this clinical setting.  All told, the requested 12-week course of Sovaldi is medically indicated for the treatment of this patient. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested implant of a hypoglossal nerve stimulator for treatment of his obstructive sleep apnea.   The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. According to the documentation submitted for review, the patient has positional sleep apnea and CPAP and BiPAP are therapeutic as they each decreased his AHI to normal. The patient is not overweight and his OSA is related to sleeping in the supine position. There are less invasive ways to address positional sleep apnea, such as utilization of a vest with a tennis ball pocket in the back to avoid supine sleep. Utilization of this method would likely normalize the patients AHI. Based on the documentation submitted for review, the request for implant of a hypoglossal nerve stimulator is not medically necessary for treatment of the patients medical condition.  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 internal medicine with sub-specialty certification in pulmonary 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 Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Two physician reviewers found that the current guidelines support the medical necessity of the requested medication in this clinical setting.  Harvoni has been demonstrated to be highly successful at treating hepatitis C virus among patient co-infected with HIV and hepatitis C, genotype 1.  Given that this patient is co-infected with HIV, he meets American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines as high priority for treatment.  All told, the requested medication Harvoni for 12 weeks is medically indicated for the treatment of this patient. 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.