Persius/hicric huggingface dataset:
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 an annual breast screening examination. Findings:  The 3 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 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.  It was stated that this patient has dense breasts as well as scattered benign nodules.  It is specifically those patients who have dense breasts that can benefit most from digital tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 3 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 reimbursement for substance abuse residential treatment center services (RTC) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that in this clinical setting, the services at issue were not medically necessary for the treatment of this patient. The patient reported no post-acute withdrawal symptoms.  He was not a danger to himself or others.  His hypertension was stable and controlled on medications. He was psychiatrically stable to the extent that he did not need a 24 hour seven day per week facility to provide the remainder of his care. There was no evidence of a high degree of impulsivity, aggression, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was accepting the principles of treatment and involving himself in his recovery. Given the recidivistic nature of his illness with multiple relapses and subsequent treatments, he already had a groundwork of relapse prevention education. There was no evidence to suggest that additional residential services would have provided further benefit. The patient no longer met American Society of Addiction Medicine clinical guidelines for residential level of care and could have been treated at an ambulatory level of care such as partial hospitalization program or intensive outpatient services with concomitant sober living.  For the reasons stated above, the services at issue were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Aubagio 14 mg tablets for treatment of the enrollees relapsing-remitting multiple sclerosis. Findings:  The physician reviewer found that the medical literature supports the requested medication in this clinical setting.  Aubagio is a medication that is approved by the U.S. Food and Drug and Administration for the treatment of relapsing and remitting multiple sclerosis. It is a medication that is widely used by patients who are not able to tolerate or have failed injectable interferon therapies. The studies show that the newer agents like Aubagio are better tolerated and provide a potentially higher efficacy with more likelihood of compliance. In this patients case, the Health Plans preferred medications, Extavia and Rebif, are both injectable interferon medications. The provider noted that this patient is not able to tolerate medications that are injected. For these reasons, Aubagio 14 mg tablets is medically necessary 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested inpatient psychiatric hospitalization (IPH) services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the services at issue. The medical record shows that the patient improved markedly during his time of treatment.  A review of the progress notes indicated fairly good behavioral control that did not meet criteria for inpatient level of care. One of the patients treating providers wrote a letter and noted improvement in the patients behavior. The patient was observed to adhere to rules involving use of utensils and limited use of his room. The patient was also observed to doing well during group sessions. There was a notation of hyperactive and disruptive behavior but the report noted that the behaviors were manageable. The patient was hyperverbal, irritable, silly, and immature, not following directions, needed constant redirection and would not stay in his room at bedtime. There were no acute concerns and behaviors were manageable. All told, the documentation provided does not demonstrate that this patient required the structured 24-hour setting of inpatient psychiatric hospitalization level of care. A review of the progress notes indicated fairly good behavioral control that did not meet criteria for inpatient psychiatric hospitalization level of care. Therefore, for these reasons, the inpatient psychiatric hospitalization services provided were not medically necessary for 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested continued skilled nursing facility (SNF) care including physical therapy, occupational therapy, and speech therapy for treatment of the enrollees medical condition status post tumor resection.  Findings: The physician reviewer found that this patients records do not demonstrate that continued SNF care including physical therapy, occupational therapy, and speech therapy is medically necessary. There is a lack of evidence that the patient currently requires such SNF services as intravenous or enteral feeding, tracheotomy aspiration, suprapubic catheter care, or treatment of a stage 3 or greater decubitus ulcer, institution of a bowel/bladder training program, colostomy care or other skilled nursing need. In addition, the documentation does not support that the patient requires skilled therapy services on a daily basis or inpatient services in a SNF. The patient is not expected to make measurable gains within a reasonable and predictable period of time given her therapy notes which reveal inconsistency in progress due to cognitive fluctuations. The patient does not require skilled therapy on a daily basis to prevent deterioration with mobility and/or ADLs. Moreover, the patient does not reveal that she has medical needs that require SNF services to prevent deterioration in her condition or to establish a safe and effective maintenance program as the patient and caregivers were educated in the patients care. Furthermore, the patient does not have continued complex medical conditions that require close involvement from a rehabilitation provider with specialized training and experience in rehabilitation. Therefore, this patient does not require the necessary services on a SNF level of care. Her current needs can be met at a lower level of care such as home with 24-hour support or long-term custodial care.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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 pelvic magnetic resonance imaging (MRI for evaluation of the enrollees chronic low back pain).  Findings: The physician reviewer found that the medical literature supports the requested pelvic MRI in this clinical setting. In this patients case, the treating provider is considering an assessment of ischial bursitis as the cause of this patients pain. Ischiogluteal bursitis refers to damage and inflammation to the bursa (small fluid filled sac) between the hamstring tendon and the pelvic bone. The main symptom is pain, and it can occur from excessive force, repetitive actions or prolonged pressure during activities such as sitting, running, kicking, climbing and jumping. It is generally treated conservatively, and is not treated surgically. In this particular case, the patient had prior imaging findings that could be associated with his symptoms, but were not definitive. Plain x-rays, in this clinical setting would be of very limited value. X-rays serve to evaluate the patient for significant structural abnormalities such as fractures, misalignments, or congenital anomalies. The treating provider is trying to determine if the patients symptoms could be related to an ischiogluteal bursitis, or if it could be related to inflammatory change along the hamstring insertion. As such, the requested pelvic MRI would be of value, especially if there is significant asymmetry when the two ischial tuberosities are compared.  The prior lumbar spine MRI performed is not sufficient for the evaluation of this patient, as the ischial tuberosities are not generally included on a lumbar spine MRI. Therefore, the requested MRI of the pelvis is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 methadone (50 mg capsule form) for treatment of the enrollees chronic pain. Findings: The physician reviewer found that Based on the medical literature and the presented clinical records, methadone (50 mg capsule form) is not medically necessary. The requested dosage and quantity are only indicated for malignant pain. The medical records show the patient to have chronic non-malignant pain. The current standard of care for chronic pain associated with disc herniation or joint disease is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. Based on a study by Mafi and colleagues there are Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy. There are a variety of anticonvulsants and anti-depressants considered adjunctive to pain management therapy. High dose opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. Short-acting opiates are more likely to cause adverse outcomes. Therefore, methadone (50 mg capsule form) to be picked up at a local Kaiser facility is not medically necessary in this clinical setting.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis. Findings:  Three physician reviewers found that tomosynthesis is rapidly becoming a standard tool in evaluating dense breasts or suspicious calcifications. In this case, the patient has breasts that have been described as 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. Final Result: Three 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: 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that beast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue, such as this patient.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural disorder, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. 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: the 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested intravenous immunoglobulin (IVIG) 30 grams (Gammagard 30 grams) for treatment of the enrollees multiple sclerosis. Findings: The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. Intravenous immunoglobulin therapy has sometimes been utilized for the treatment of multiple sclerosis exacerbation when traditional therapies have failed. The use of IVIG as a primary disease modifying treatment is currently not recommended and is not considered the standard of care. For most cases, IVIG is used in patients who have tried and failed treatment with currently available monoclonal antibody therapies such as Tysabri. As such, there is a lack of support in the medical literature for the use of IVIG as a first line treatment of multiple sclerosis. In this patients case, the submitted records do not show that Tysabri has been tried and failed for the treatment of this patient. Therefore, IVIG 30 grams (Gammagard 30 grams) twice per week, for one year, is not medically necessary for treatment of this patients multiple sclerosis.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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency ablation for treatment of the enrollees low back pain. Findings: Two reviewers found that there is sufficient support for the requested services in this clinical setting.  The records noted low back pain from spondylolisthesis and facet arthropathy at L4-5.  The patient reported a good response to medial branch blocks, with greater than 70% reduction of axial back pain on the left side. Additionally, prior radiofrequency ablation provided 85% relief of her axial low back pain for five months. Therefore, given the prior response to radiofrequency ablation as well as the 70% diagnostic benefit from the medial branch blocks, the requested radiofrequency ablation is likely to be more efficacious than other treatment options.Final Result: Two reviewers determined that the requested services are 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: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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 Epclusa for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to the 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. The recommendations apply regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive, genotype 3 patients.  This is based on the ASTRAL-3 trial for Epclusa, which showed a 98% cure rate (Foster, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, Epclusa for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C virus.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.