Persius/hicric huggingface dataset:
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 her medical condition.  Findings:  Two physician reviewers found that based on the records provided the patient presents with hyperreflexivity and sudden coronary artery dissection but no other documented manifestation of systemic connective tissue disease and normal caliber aorta and branch vessels on CT scanning.  In this circumstance of isolated spontaneous coronary dissection current expert consensus recommendations do not include screening genetic testing for generalized connective tissue disease (Tweet, et al; Alfonso and Bastante). Likewise, treatment of spontaneous coronary artery dissection would likely not change regardless of results of genetic testing performed. Therefore, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than available standard 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 cardiovascular disease 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 peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, 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. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, the tomosynthesis used to screen this patient for breast cancer was likely to be more beneficial 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 treatment of her medical condition.   Findings:  Three physician reviewers found that the American College of Radiology (ACR) recommended that breast tomosynthesis 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 (2D) imaging mammographic protocol was likely of greater benefit to this patient than if the exam had been performed using the two dimensional 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.  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 the enrollees medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. For patients who have dense breasts tomosynthesis has been shown to have added benefit. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.   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 Adderall XR for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that Adderall XR is a psychostimulant medication used to treat ADHD.  It is composed of 50% immediate-release beads and 50% delayed-release beads designed to mimic the effects of two doses of immediate release Adderall given four hours apart.  The medication can have potent effects on neurotransmission and addictive neural circuits with subsequent untoward psychiatric side effects.  Adderall is well-known to be activating to the point of causing irritability and behavioral disinhibition.  Per the medical records, it appears that the patient experienced negative side effects while on the medication previously.  All told, the requested medication Adderall XR 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 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 a Cologuard test for evaluation of her medical condition. Findings:  Two physician reviewers found that a Cologuard test, was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Cologuard is U.S. Food and Drug Administration approved to test for colon cancer, and proved 92% sensitive for detection of colon cancer, and can detect most adenomas if they have high-grade dysplasia (Imperiale, et al). The limited evidence for Cologuard reports that 154 persons would have to be screened to find one cancer using colonoscopy, versus 166 persons using Cologuard (Imperiale, et al). However, the evidence of the impact of this information on patient care or health outcomes is lacking in the medical literature. Although Cologuard is able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop. The long-term health outcomes of foregoing regular polyp removal and instead using Cologuard have not been determined. Moreover, there is a lack of consensus in clinical guidelines and clinical literature to support that Cologuard has a positive impact on health outcomes.   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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested a lumbar sympathetic nerve block for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that the medical records do not demonstrate the superior efficacy of the services at issue.  While lumbar sympathetic blocks may be an appropriate treatment for complex regional pain syndrome when certain criteria are met, this is not an established treatment for conversion disorder, somatoform pain disorder or whole body allodynia.  The documentation is lacking in the current notes to support chronic regional pain syndrome. The patient may have met some of the criteria and may have met the minimal requirements in the past.  However, the provider noted that the timing and symptoms of the worsen state has led to an alternative diagnosis. For these reasons, the lumbar sympathetic nerve block was 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 services at issue were 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested skilled nursing facility (SNF) services for treatment of her medical condition.  Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  Per the medical records, this patient had severe disability post craniotomy.  She needed recovery of speech, motor function, and ability to ambulate and was admitted to a SNF for further treatment.  Initially, it was noted that the patient was not making progress with physical therapy.  However, an adjustment in timing of medicine enabled her to cooperate and continue to achieve improvement in functionality.  Due to the intensity of treatment, she was able to achieve a good outcome.  All told, SNF services provided were medically indicated for the treatment of this patient. 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 reviewer is board certified in internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested equipment that provides continuous passive motion therapy for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the equipment at issue. In this case, the patients provider recommended the use of continuous passive motion therapy in order to prevent hip stiffness. The use of continuous passive motion therapy was indicated to avoid a poor outcome. Therefore, based on the clinical documentation submitted, equipment that provides continuous passive motion therapy is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the equipment at issue was 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested facial laser hair removal for treatment of her gender dysphoria.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient has been diagnosed with gender dysphoria. Given the patients diagnosis, services that help ameliorate the patients male features can be considered medically necessary. In this patients case, the presence of male facial hair is contributing to the patients gender dysphoria. Thus, facial laser hair removal is medically necessary for treatment of her medical condition. Further, facial laser hair removal is considered reconstructive in this setting. The presence of facial hair in a female would be considered abnormal and is referred to as hirsutism. The `abnormal` hair is congenital, in that the hair growth is determined by the genetic and hormonal make-up of the patient. The requested laser hair removal will create a more normal feminine facial appearance. The requested laser hair removal can provide substantial improvement in the appearance of the patients terminal hair. As such, the requested service is considered reconstructive in this clinical setting.  Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be 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 magnetic resonance imaging (MRI) of the neck for treatment of her medical condition. Findings: The physician reviewer found that according to the documentation submitted for review, the patient has no red flags to support a medical indication for MRI. The x-rays show no fracture or abnormal motion. She has no neurological deficit on physical exam and the original emergency department physician declined to order MRI of the cervical spine absent a valid medical indication. Likewise the physical medicine specialist ordered physical therapy. At this time, prior to completion of a six week trial of conservative therapy MRI is not considered medically necessary.  All told, the requested services are not medically necessary for evaluation of the patients medical condition.  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 physician 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine for treatment of her medical condition.  Findings: The physician reviewer found that in this particular patient, an MRI is not medically necessary for evaluation of the patients medical condition. Medical literature supports obtaining an MRI in anticipation of some sort of intervention such as surgery or facet injections. Prior to an intervention, standard medical practice is to attempt a trial of conservative treatments such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs. The patient has had a relatively short duration of symptoms; lack of disc space narrowing on plain x-rays; and a lack of documented failure of conservative treatment.  As stated by Roudsari and Jarvik, `All of the guidelines emphasize the importance of a focused history and thorough physical examination before any imaging is ordered. In addition, all agree that for patients with acute LBP [low back pain] and without any risk factor for serious spine abnormalities, imaging within the initial 48 weeks should not be performed.`  Moreover, The American College of Radiology (ACR) has established appropriateness criteria for the evaluation of low back pain. The ACR agrees that MRI is not warranted in the acute setting. In the setting of low back pain in which the patient is a candidate for surgery or other intervention, then the ACR considers an MRI to be the most appropriate study, with no stipulation about delaying the MRI. Thus, a strong recommendation against the routine use of MRI for chronic low back pain (CLBP) evaluation is made. Chou and colleagues make the specific recommendation that, There is insufficient evidence to support the routine use of MRI in patients with CLBP.  For the reasons stated above, the medical necessity of the requested MRI has not been established.  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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested tramadol and oxycodone for treatment of her medical condition.   Findings:  The physician reviewer found that based on the documentation submitted for review, the medical necessity for the requested medications has not been established. Per the documentation, not all non-opioid treatment options have been utilized nor is there no documentation of pain scores. There is no mention the patient has trialed behavior therapy given the support for its use. In addition, the Health Plans recommendation for physical therapy is medically reasonable and appropriate in this clinical setting.  All told, the requested medications are not medically necessary for treatment of the patients medical condition.  Final Result:  The reviewer determined that the requested medications 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 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 Otrexup for treatment of her medical condition. Findings: The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The available medical records do not adequately document the inability of the patient to use the regular, injectable form of methotrexate. In addition, there is inadequate documentation of functional deficits that would preclude the patients use of the regular form of injectable methotrexate. Given the above, the requested medication is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician reviewer is board certified in rheumatology 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 Onfi for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient has had refractory seizures secondary to a focal brain lesion.  The patient has failed treatment with several prior seizure medications.  Onfi was tried and was beneficial.  Onfi has a restricted U.S. Food and Drug Administration (FDA) approval for a very refractory epilepsy syndrome, Lennox-Gastaut. However, the literature shows that it can be beneficial for multiple seizure phenotypes.  There is medical evidence supporting Onfi for focal seizures, and this medication has been beneficial for this patient.  All told, the requested Onfi 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 physician 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.