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 the American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it gives the radiologist interpreting mammograms especially in cases with extremely or heterogeneously dense tissue.  The advantage relates to the tomographic qualities of the new technique which often allow the reader to separate dense glandular elements from underlying mass/architectural distortion. This results in a decrease in callbacks and increase in detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional (2D) protocol was likely of greater benefit to the patient than had the exam been done with 2D technique 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested autologous fat grafts to right lateral thigh, implantation of biologic implant for soft tissue reinforcement, and suction assisted lipectomy for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient was noted to have a hematoma following a fall.  She is reported to have soft tissue changes and dimpling as a result.  The area of the thigh represents an abnormal occurrence of soft tissue changes and dimpling as the result of trauma.  There is no evidence that the requesting surgery of fat grafting is being done to improve function.  The aim is to correct contour defects, which would be in an attempt to create a more normal appearance.  However, the degree of severity of the condition is not adequately defined in the medical documentation.  The photographs do not show that there is a significant condition present.  Thus, without the degree of severity clearly defined and with photographs that do not show a significant defect, the fat grafting would not likely provide more than a minimal improvement in the appearance.  All told, the requested services are not medically necessary and are not reconstructive in nature.  Final Result: The reviewer determined that the requested services are not reconstructive in nature 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested epidural steroid injections for treatment of his medical condition. Findings: The physician reviewer found that lumbar epidural steroid injection is a well-documented therapy for low back pain with radiculopathy, using steroid to help decrease inflammation along a nerve root facilitating improvement with pain and symptoms of radiculopathy. Manchikanti and colleagues evaluated the effect of therapeutic transforaminal lumbar epidural steroid injections in managing low back and lower extremity pain. The authors found that for lumbar disc herniation, the evidence is good for epidural steroid injections with local anesthetic and steroids. In this case, the patient has previously been treated with epidural steroid injections with reported relief. Based on the peer-reviewed literature and clinical documentation, epidural steroid injections are clinically indicated for this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician reviewer is board certified in anesthesiology with sub-specialty certification in pain 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 Subsys for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain in this setting is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsants and antidepressants considered adjunctive to this therapy.  The reviewers reported that high-dose and short-acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  Long-term opiates are more likely to cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance and abnormal pain sensitivity.  The current medical evidence does not support the requested medication in this clinical setting.  All told, the requested Subsys is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested physical therapy for treatment of his medical condition. Findings: The physician reviewer found that the patient sustained a traumatic fracture requiring surgery and months of protected weight bearing.  He has had extensive physical therapy and is now functioning at a high level although he has not returned to all his pre-injury activities. The records show he continues to have a deficit of ankle range of motion. He is pain free. The literature on physical therapy for the patients fracture is limited. The reviewers describe a case of a young athlete with a roughly similar fracture who was aggressive in return to activity, sustaining a non-union and second surgery at 22 weeks after initial fixation surgery. The authors note Prognosis for return to sport in a tibia-fibula fracture due to a soccer injury is approximately 40 weeks, however many factors can influence the outcome. The patients fracture is comparable in severity and a 40 week recovery is a reasonable expectation. At this point the mainstay of treatment is independent stretching and strengthening with graded return to activities. Due to the fracture, the patient may not regain full range of motion or have the ability to run as he did before the fracture. In this clinical setting, four additional visits of physical therapy are reasonable and medically necessary. These physical therapy visits will evaluate for the development of pathology requiring correction and to adjust his exercise regimen. In sum, a portion of the services at issue were and are medically necessary. Final Result: The reviewers determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The physician 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient level of care services for treatment of her behavioral health condition.  Findings: The physician reviewer found that inpatient level of care services is not medically necessary for treatment of the patients behavioral health conditions. The patient feels disconnected, and the hospital setting furthers this sense of disconnection.  Therapeutically, the patient needs harmonized parental relations, social support and community connection to re-establish a sense of meaning and consolidate her identity formation. This will likely be a long-term endeavor, but an intermediate setting such as residential, partial hospital or intensive outpatient appears to be most appropriate.  In the absence of clinical documentation evidencing active treatment that is reasonably expected to improve the patients condition or prevent a more serious episode of illness, the clinical situation improved to the point where transition to a less restrictive setting would have been appropriate. Thus, the services at issue were not and are not medically necessary.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 physician reviewer is 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 Harvoni for 12 weeks for treatment of his hepatitis C virus. Findings: The physician reviewer found that per 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. The guidelines report that patients with cirrhosis are highest priority for therapy. Per the guidelines, cirrhotic genotype 1 patients who have failed interferon-based therapy should be treated with Harvoni for 24 weeks rather than 12 weeks; these guideline recommendations are based on multiple randomized clinical trials. Additionally, the guidelines report that patients with creatinine clearance below 30 mL/min should not be treated with Harvoni  alternative therapies are recommended instead. For these reasons, the requested treatment with Harvoni for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.   Credentials/Qualifications: The physician 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 mid-wife services for home birth treatment of her medical condition.  Findings: The physician reviewer found that the American College of Obstetricians and Gynecologists (ACOG) states that hospitals and birthing centers are the safest setting for birth. ACOG notes in its Committee Opinion Number 476 that although the absolute risk of planned home birth is low, published medical evidence shows it does carry a two to three fold increase in the risk of newborn death compared to planned hospital births. While ACOG does not support planned home births at this time, it states that it is especially important for women who decide to deliver at home be low risk. In this case, the patient has a medical condition where maternal platelets are low. This may put the mother at risk for increased bleeding at the time of delivery. In addition, this medical condition has been associated with bleeding complications in the newborn. With this diagnosis, the patient is considered high risk and does not meet the recommended criteria of being low risk. In conclusion, this patient is considered a high risk patient who should delivery in a hospital setting where there is appropriate support to deal with any complications that may arise at delivery.  All told, the requested services are 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 physician reviewer is board certified in obstetrics and gynecology 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: The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that based on the documentation submitted for review, residential treatment center services were medically necessary for treatment of the patients behavioral health conditions. The patient met American Psychiatric Association guidelines for services at this level.  The patient needed supervision to complete her meals. When outside of the facility, she showed signs of resistance to her eating plan and regression.  She continued to need support to prevent excessive exercising and purging.  In addition, her home environment was not stable and did not provide the full support she needed. Given the above, the services at issue were medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus (HCV).  Findings: The physician reviewer found that the medical necessity of HCV eradication as per American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations exists irrespective of fibrosis score. AASLD/IDSA guidelines, underscore this position with the following statement: Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months).  In this patients case, her medical records support the medical necessity of Harvoni to treat her hepatitis C virus. Consistent with current AASLD/IDSA guidelines, Harvoni is clinically appropriate and is likely to be efficacious for treatment of this patients condition. Thus, the medical necessity of the requested Harvoni has been established. Final Result: The reviewer determined that the requested medication is necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C. Findings: The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  The medical records noted that the patient has been diagnosed with hepatitis C, genotype 1a.  The request for Harvoni has been denied given the lack of evidence of moderate to severe liver disease.  However, per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, the medical necessity of hepatitis C eradication exists irrespective of fibrosis score.  All told, the requested Harvoni 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 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:   The parent of an enrollee has requested for human growth hormone Nutropin AQ for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that the requested medication has not been established as medically necessary for treatment of the patients medical condition. The patient presents with short stature, ADHD and Crohns disease. Inflammatory bowel disease, particularly Crohns disease, can cause growth failure and reduced adult final height; the etiology is multifactorial and includes poor nutrition, chronic inflammation, and medications used to treat the disease. In addition, ADHD is implicated in constitutional delay of growth, and medication to treat ADHD may further suppress appetite. Currently, the risk/benefit ratio of growth hormone therapy in the setting of Crohns disease is not known to be definitively in favor of therapy, and growth hormone treatment in this setting is considered controversial. Furthermore, in this patients case, epiphyses are nearly fused, and the addition of growth hormone at this point in time is unlikely to result in any improvement in the patients final adult height. 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 pediatric endocrinology 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 residential substance abuse services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Per the medical records, residential substance abuse treatment was not medically necessary. The patient was self-motivated and was cooperative with his treatment team.  His spouse was very supportive of his treatment.  He had no history of significant past treatment, so there is no evidence that he would relapse if discharged to a lower level of care.  He had a continuation of some of his previous medical problems and needed to have follow up visits with his cardiologist and primary care physician.  All told, residential substance abuse services were not medically indicated for the treatment of this patient.  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.