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

An enrollee has requested reimbursement for mitral valve replacement by transvenous procedure provided . Findings:  The physician reviewer found that the patient has multiple co-morbid conditions including CAD, hypertension, acute on chronic CHF with acute decompensation, obesity as well as the requirement for a revision mitral valve replacement if this procedure were performed via open procedure. The cardiovascular surgical pre-operative evaluation found the patient was at a high surgical risk for a revision open heart procedure. Based on his multiple co-morbidities in the setting of prior mitral valve replacement surgery, the transcutaneous mitral valve-in-valve replacement provided this patient with the greatest chance of survival with the fewest post-operative complications. The current peer-reviewed medical literature provides support for the feasibility and efficacy of transcutaneous mitral valve replacement in selected circumstances as well as noting greater peri-operative risk in the setting of surgical revision mitral valve replacement. Based on these findings and the patients assessment, the mitral valve replacement by transvenous procedure provided was likely to be more beneficial to this patient than a revision open mitral valve replacement.  Final Result: The reviewers determined that the services at issue were 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: the physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for phase 2 orthodontic treatment with extraction of upper bicuspids (ADA code D8080 comprehensive orthodontic treatment of the adolescent dentition) for treatment of the enrollees severe Class II protrusion. Findings:  The physician reviewer found that review of the HLD, line 11, shows that the mandible and the maxilla show obvious anterior crowding, which add five more points to the HLD score. Using standard orthodontic practice, the overbite measured it be at least 5 mm from lower anterior incisal edge to upper anterior incisal edge when in full posterior occlusal contact and line 6B, overjet, should be about 10 mm. The HLD score would then be 25 and this would also change line 6A. In addition, the occlusal relationship between the upper and lower arches when in full intercuspation is cusp tip to cusp tip, making the patient a Class II division I malocclusion. The potential exists that the occlusion can worsen as the patient ages and temporomandibular joint issues may emerge as the upper anterior teeth continue to move forward. The request for removal of the upper left and right first bicuspids is also dentally necessary to create space for tooth movement forcing the upper anterior teeth back to correct the Class II malocclusion. Taking these factors into consideration, the requested phase 2 orthodontic treatment with extraction of upper bicuspids (ADA code D8080 comprehensive orthodontic treatment of the adolescent dentition) is supported as dentally necessary for treatment of this patients Class II protrusion. Final Result: The reviewer determined that the requested services are dentally necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that tomosynthesis allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the physician reviewers are 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 authorization and coverage for general anesthesia during dental procedure CPT 41899 for treatment of the enrollee, who needs a dental procedure for full crown of tooth #15.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity for the requested services in this clinical setting. The medical records from multiple sources affirm a degree of handicapping that has historically made routine dental care difficult or dangerous to the providers and the patient. The records show that the patient is not able to comprehend and cooperate to the level necessary to conduct the dental procedure. These sources include dental providers who have documented past attempts to treat the patient in a conventional setting with local anesthesia and oral sedation with a lack of success. The documentation also shows that the patient is not able to follow simple instructions. Moreover, the patient has acute situational anxiety due to immature cognitive functioning, a condition diagnosed by the patients medical providers. The patient is uncooperative due to certain physical or mental compromising conditions, which has been affirmed by the dental providers in past attempts at treatment.  The dental literature demonstrates a deficiency in treatment for the developmentally disabled population. As the patients condition has been well documented to preclude extensive treatment such as the requested crown on tooth #15, the requested general anesthesia during dental procedure CPT 41899 is shown to be medically necessary for treatment of the patients medical condition. 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 reviewer is board certified in dentistry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient mental health level of care services for treatment of the enrollees schizoaffective disorder and polysubstance abuse.Findings:  The physician reviewer found that the records provided for review document that the patient was not a danger to herself or others. She was not aggressive or violent. Her hygiene and grooming were good, demonstrating the ability to care for herself adequately. She was cooperative and compliant with her medications. She participated in group activities. She experienced no medication side effects. Given her demonstrated stability, there was no reason to believe that there was risk of decompensation or immediate rehospitalization at acute inpatient level of care if she was discharged. The services provided to the patient were custodial in nature. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fecal calprotectin testing for evaluation of the enrollees diarrhea. Findings:  The physician reviewers found that fecal calprotectin testing has been recognized for several years as an effective way to assess the likelihood of a patient having inflammatory bowel disease need for sedation with a colonoscopy. Once diagnosis is made, fecal calprotectin is also a tool for monitoring disease activity, as it correlates with endoscopic measures of intestinal inflammation. For this patient, the provider noted that at the time that the test was ordered that he would not recommend a colonoscopy if the calprotectin results were normal. All told, the fecal calprotectin testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  Physician reviewers number one, two, and three are board certified in pediatrics with sub-specialty certification in pediatric gastroenterology and 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 reimbursement for positron emission tomography/computerized tomography (PET/CT). Findings:  The physician reviewer found that there is support in the medical literature for the services at issue in this clinical setting. POEMS is a rare syndrome that is a variant of myeloma. Since it is rare, specific PET/CT scan guidelines do not exist in evaluation of POEMS syndrome. However, there are medical guidelines to support the use of PET/CT for evaluation of myeloma. Since POEMS is so closely related to myeloma, where PET/CT has known diagnostic significance, the services at issue were medically indicated. 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 authorization and coverage for 32 to 40 hours per week of in home skilled nursing services from a registered nurse (RN) and 12 hours per week of in home skilled nursing services from a licensed vocational nurse (LVN) for treatment of the enrollees cerebral palsy, epilepsy, dependence on supplemental oxygen, and legal blindness. Findings:  The physician reviewer found that the patients medical history includes high risk of aspiration, requirement of gastrostomy tube feedings, respiratory suctioning and treatments, skin care, and seizure monitoring. Enteral feeding and the patients respiratory suctioning are skilled nursing needs that require skilled nursing rather than a home health care provider to ensure continuity of care and effective treatment. The patient requires ongoing supervision that can be met from a long-term care facility or after intense family training by 24-hour family support. The family of this patient will need skilled nursing services to establish a safe and effective maintenance program if the patient is stable to be transitioned to 24-hour family support after the family has had proper training. Skilled nursing is typically an intermittent service that is provided less than seven days per week and less than eight hours per day. This treatment will allow assessment of patient stability and ability of family to be trained and/or care for patient in a proper and effective manner. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for opioid pain management for treatment of the enrollees right trigeminal neuralgia and migraine. Findings:  The physician reviewer found that that opioid risk mitigation tools should be part of practice and when patient safety issues are identified, such as lack of compliance, lack of adherence to prescription, or aberrant use, opioids should not be continued. Opioids are generally not recommended as first-line therapy and when used providers should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. Urine drug testing may be used as a tool to monitor for aberrant behavior or drug misuse and opioids should be tapered when patient safety risks are identified. Overall, peer-reviewed guidelines support use of opioids with ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects. Pain assessment should include current pain, the least reported pain over the period since last assessment, average pain, and intensity of pain after taking the opioid, as well as how long it takes for pain relief and how long pain relief lasts. Satisfactory response to treatment may be indicated by the patients decreased pain, increased level of function, or improved quality of life. This patients medical records report chronic pain and document use of ongoing opioid risk mitigation tools that support compliance with medication regimen. Further, the records describe functional benefit from the use of opioids and failure of other conservative care. Congruent with current guidelines, the requested for opioid pain management services are supported as medically necessary for treatment of this patients medical condition.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 reviewer is board certified in neurology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the enrollees breast cancer screening. Findings:  Three physician reviewers found that the patient has a history of having had a right sided stereotactic biopsy of her right breast and then an excisional biopsy of her right breast.  In addition, she has had prior augmentation mammoplasty. However, the implants were removed. She underwent a routine screening mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination.  The current images were compared to prior mammograms and no interval changes were noted. There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis performed.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. 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 scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, she has breast tissue that was described as being heterogeneously dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three 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 authorization and coverage for the medication, Trulicity.Findings:  The physician reviewer found that there is support for the requested medication in this clinical setting. Trulicity is a member of  the glucagon-like peptide 1 (GLP-1) analogues, a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1.  This class of medications has shown significant improvements in glycemic control hemoglobin A1c reductions of 0.8-1% across studies, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors.  Another important possible additional benefit of Trulicity relates to potential improvements in beta cell function. By initiating treatment with Trulicity relatively early in the course of diabetes, one may be able preserve beta cell function for the long term, halting or slowing down the progression of diabetes. In this patients case, he has not been able to optimize his glycemic control with Janumet and insulin.  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 endocrinology, diabetes, and metabolism 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.