Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested daily outpatient skilled rehabilitation services for treatment of her medical condition. Findings: The physician reviewer found that based on the documentation submitted for review, daily outpatient skilled rehabilitation services provided have not been established as medically necessary. The patients functional mobility and self-care were at a level that did not require additional skilled intervention. A home exercise program and outpatient care of a physiatrist were sufficient. The patient did continue to have language deficits. A review of speech and language therapy (SLT) following stroke by reviewers concluded that Our review provides some evidence of the effectiveness of SLT for people with aphasia following stroke in terms of improved functional communication, receptive and expressive language. This review included studies that compared SLT to social support or stimulation (an intervention that provides social support and communication stimulation but does not include targeted therapeutic interventions). The authors found that More participants also withdrew from social support than SLT interventions. Based on this review, SLT appears to have some degree of efficacy in the treatment of aphasia secondary to stroke. However, there is a lack of support for a specific duration of therapy. In this case, the patient was treated with intensive speech therapy. The medical literature does not show that further intensive speech therapy is medically necessary in this clinical setting. Given the above, 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 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.
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 the enrollees medical condition. Findings: Two physician reviewers found that the American College of Radiology (ACR) statement has urged tomosynthesis be removed from the investigational category due to the advantages this technique brings to radiologists in the interpretation of mammograms. The advantages the technique offers relates to the tomographic nature of tomosynthesis which helps radiologists differentiate dense glandular tissue from architectural distortion which in turn decreases callbacks and increases detection of small cancers. For these reasons provided, the addition of tomosynthesis to the usual two-dimensional (2D) images was likely of more benefit to the patient than had the exam been done with 2D technique only.  Final Result: Two 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 radiofrequency neurolysis for treatment of her medical condition. Findings: Two physician reviewers found that the patient has chronic neck pain with successful past interventions including cervical facet injections and radiofrequency neurolysis of the nerves of the cervical spine. The patients last cervical radiofrequency neurolysis was noted with success for her pain at C3, C4, C5 bilaterally. Manchikanti and colleagues (2009) discuss the effectiveness of medial branch radiofrequency neurotomy in systematic reviews and randomized trials. However, in this case, the patient has not had repeat confirmation blocks after a significant amount of time post procedure. For these reasons, radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the 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: All three reviewers are board certified in anesthesiology 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: 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 tomosynthesis was approved by the Food and Drug Administration (FDA) for clinical use and by Centers for Medicare and Medicaid (CMS) for reimbursement.  The American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two dimensional imaging mammographic protocols was likely of more benefit to this patient than if the exam had been done with two dimensional technique alone. Therefore, breast tomosynthesis was likely to be 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 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 Harvoni for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials.  For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection.  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:   An enrollee has requested magnetic resonance imaging (MRI) of the right knee for evaluation of his medical condition.  Findings:  The physician reviewer found that the question of timing and necessity as to obtaining an MRI of the knee in the clinical setting of knee pain is critical in determining the appropriateness of the MRI.  Medical literature and evidenced based studies indicate that an MRI is the most optimal means to evaluate an internal derangement; plain x-rays are of only limited value; but these medical studies show that an MRI alone has little to offer for patients with non-traumatic knee pain, no mechanical symptoms, and findings of degenerative arthritis on plain films. (Miller) As noted in a paper by McCarty and colleagues, An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment. Because the incidence of abnormal findings such as meniscal tears is high in asymptomatic patients, any MRI finding must be carefully correlated with clinical signs and symptoms. Patients with persistent or recurrent unexplained pain after the trial period of conservative treatment may require MRI and may require referral to an orthopedist as a next step in the evaluation.  However, it should be noted that some orthopedic surgeons do not consider an MRI to be necessary before arthroscopic surgery or total knee replacement. (Miller). In this patients case, the submitted records do not show that the patient has a fracture. Whether or not the patient has a degenerative change has limited bearing to the issue of obtaining an MRI. Medical studies support obtaining baseline plain x-rays in the clinical setting experienced by the patient. Thus, obtaining an MRI without correlation with a detailed clinical examination can lead to unnecessary conclusions, and even worse, unnecessary surgery. This incidence of abnormal MRI findings in asymptomatic individuals was established by Boden and Davis, The high incidence of abnormal MRI findings in asymptomatic subjects underscores the danger of relying on a diagnostic test without careful correlation with clinical signs and symptoms. Medical studies support obtaining an MRI if it will change the course of treatment. With this particular patient, his physical examination did not support a meniscal tear or a ligamentous injury or tear. In sum, an MRI for the evaluation of this patients medical condition is not medically necessary.  Final Result: The reviewer determined that the requested services are 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 diagnostic radiology 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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. Therefore, the services at issue were likely to be 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that the American College of Radiology (ACR) statement has urged tomosynthesis be removed from the investigational category due to the advantages this technique brings to radiologists interpreting screening exams especially in cases of dense breast tissue.  These advantages have resulted in a decrease in callbacks and increase in detection of small cancers.  Thus, tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  However, since an abnormality was detected on the screening exam which included tomosynthesis it was not reasonable to repeat that portion of the diagnostic exam.  Since calcifications were questioned and were the reason for the diagnostic study at issue, conventional magnification views would have been sufficient to make a recommendation. Final Result: The reviewers determined that a portion of services 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 partially 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Oncotype DX testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the requested services in this patients case.  Adjuvant chemotherapy is of benefit to patients with stage III (node positive) colon cancer. It is much more controversial as to its benefit in node negative (stage II) colon cancer, as in this patients case.  Most oncologists make this decision based on specific pathologic and clinical features in an individual case. Among these features that identify a higher risk of recurrence are a poorly differentiated cancer, lymphovascular invasion, and presentation with obstruction.  Another approach to this dilemma is the use of gene panels, such as Oncotype, which is a 12-gene panel.  This assay helps to predict the risk of recurrence in both stage II and stage III colon cancer, and does so beyond the usual clinical and pathologic features.  The medical evidence supports the use of Oncotype assay in assessing risk of recurrence and the potential value of adjuvant chemotherapy.  Therefore, Oncotype DX testing is likely to be superior over other methods of evaluating this patient.  Final Result: Two reviewers determined that the requested services are 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 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 Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the most recent 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 the guidelines, genotype 1 patients who have failed PEG-interferon and ribavirin should be treated with Harvoni 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 1 regardless of fibrosis stage (Afdhal, et al; Lawitz et al). The patient is ineligible for any alternatives containing PEG-interferon and ribavirin due to a pre-existing medical condition, which can be exacerbated by either medication. For these reasons, the requested treatment with Harvoni supported as medically necessary for the treatment of this patients hepatitis C infection. 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: 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 tomosynthesis was approved by the Food and Drug Administration (FDA) for clinical use and by Centers for Medicare and Medicaid (CMS) for reimbursement.  The American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two dimensional imaging mammographic protocol was likely of more benefit to this patient than if the exam had been done with two dimensional technique alone. Therefore, breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast tissues 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: 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 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support for the services at issue in this clinical setting. The study by Skaane and colleagues 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. In sum, the services at issue are strongly supported by the medical literature cited above.  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 digital breast tomosynthesis for evaluation of her medical condition.  Findings:  Two 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.  However, in this patients case, she apparently had a routine screening mammogram and an abnormality was detected.  Per the records, she was evaluated with breast tomosynthesis examination at that time.  She was then recalled, and had a repeat tomosynthesis exam shortly thereafter.  One of the primary arguments supporting the use of tomosynthesis is that this technology lessens the incidence of callbacks.  The initial tomosynthesis was warranted.  However, there is a lack of support for the repeat tomosynthesis shortly thereafter.  Thus, the digital breast tomosynthesis in question was not likely to have been of greater benefit than other methods of evaluating this patient.  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 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.