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

Nature of Statutory Criteria/Case Summary:    An enrollee has requested an acute inpatient stay for treatment of her medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was admitted with mental decline and found to have HIV/AIDS related rapidly progressive dementia and probable lymphoma.  Initially, the enrollee received a chest tube due to an iatrogenic pneumothorax.   Subsequently, the enrollee was tolerating an oral diet, oral medications and had remained stable for 24 hours after removal of the chest tube.  The patient was stable and no further inpatient medical treatment was planned after that point.  She could have been safely discharged to a lower level of care.  All told, acute inpatient stay was not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested gene testing for evaluation of her pain medication intolerance.  Three physician reviewers found that Cytochrome testing for opioid metabolism is not considered the standard of care to ascertain a patients intolerance to opioids. Moreover, the results of such testing will not assist in the ability to select the proper opioid to manage the side effects of nausea and vomiting. While genetic testing may help guide therapy in terms of codeine dosing parameters, routine pharmacogenetic testing based on common opioid related side effects of nausea and vomiting are not supported by the literature. Given these findings, gene testing was not 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 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 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. Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  The addition of breast tomosynthesis to screening studies has gained popularity among radiologists due to an associated decrease in callbacks and increase in detection of small cancers.  This patient was found to have extremely dense breast tissue on her mammogram, and the addition of tomosynthesis has proven especially valuable in this setting due to the tomographic qualities of tomosynthesis.  All told, the addition of breast tomosynthesis to the screening study was likely to be more beneficial to the patient than digital mammography alone. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viekira Pak for treatment of his chronic hepatitis C virus genotype 1b.  The physician reviewer found that according to 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions. Per the guidelines, non-cirrhotic genotype 1b patients should be treated with Viekira Pak for 12 weeks whether they are treatment-naive or have failed therapy with interferon and ribavirin. The AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Viekira Pak for 12 weeks is 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, hepatitis C is considered a serious systemic infection which causes substantial morbidity. Treatment is safe and effective, and can mitigate the serious consequences of this disease, and thus all patients, with the exception of those with life expectancy limited to less than 12 months due to non-related conditions, should be considered for treatment. This is a Level 1 recommendation from the AASLD/IDSA. Candidacy for treatment is limited mainly by the presence of contraindications to the available regimens which this patient does not have. As such, the medical necessity for Harvoni for 12 weeks has been established in this clinical setting. 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 a referral to a dermatologist for evaluation of her medical condition. The physician reviewer found that according to Rodriguez and colleagues Physician visits provide invaluable opportunities to screen patients for skin cancer, yielding earlier detection and improved survival. The Health Plan indicates the patients general skin exam can be performed by her primary care provider. According to the documentation submitted for review, the patient has not had a generalized skin exam performed by her primary care provider. In this case it would be considered safe and medically appropriate for the primary care provider to perform the patients general skin exam. Therefore, a referral to a dermatologist is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested referral is 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 dermatology 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 the peripheral bone density test for evaluation of her osteoporosis.  Two physician reviewers found that peripheral bone density of forearm CPT code 77081 is recommended when the spine or hip cannot be measured accurately for any reason. In this case, the patient had no indication for peripheral bone density as the spine and hip measurements were adequate. The measurements of hip and spine were reliable and sufficient to make an assessment and recommendations. Thus, the addition of the peripheral bone density test was not likely to be more beneficial for evaluation of the patients medical condition than standard DEXA without a peripheral bone density test.  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 internal medicine with sub-specialty certification in endocrinology and metabolism 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 eight weeks for treatment of his chronic hepatitis C virus genotype 1a.  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. Per the AASLD/IDSA guidelines, treatment naive genotype 1 patients should be treated with Harvoni for eight weeks in patients with viral load of less than 6 million IU/mL. 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 genotype 1 hepatitis C regardless of fibrosis stage. AASLD guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni for eight weeks is 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested speech therapy for treatment of the enrollees autism and speech delay.  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. According to Myers and colleagues  People with ASDs have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. Moreover, speech therapy is recommended for pragmatic language problems in children with ASD. In this case, the patient has pragmatic language deficits as described by the speech therapist. For the reasons stated, speech therapy is medically necessary in this clinical setting.  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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 the cooling device (Water Circ Cold pad with pump CPT HCPCS-E0218) for treatment of the enrollees left knee anterior cruciate ligament (ACL) tear and sprain bone injury status post arthroscopic reduction and internal fixation of tibial eminence fracture.  Three physician reviewers found that the continuous flow cryotherapy units provide regulated temperatures through use of power to circulate ice water in the cooling packs. However, the available scientific data are insufficient to establish that the use of continuous flow cooling systems versus ice packs is associated with a benefit beyond convenience and patient compliance. Mechanical circulating units with pumps have not been proven to be more effective than passive hot and cold therapy. All told, the current evidence does not suggest that the cooling device (Water Circ Cold pad with pump CPT HCPCS-E0218) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result:  Three reviewers determined that the device at issue was 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 orthopedic surgery 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 Xifaxan for treatment of his irritable bowel syndrome.  The physician reviewer found that Xifaxan has proven effective for eradication of bacterial overgrowth and for symptom relief in randomized and retrospective studies at high dose. Eradication was demonstrated in 80% versus 54% for placebo. The medication had greater effectiveness with fewer side effects than alternatives such as metronidazole and levofloxacin. Xifaxan has also proven effective to alleviate symptoms in patients with irritable bowel syndrome with positive lactulose breath test. This improvement was observed for a period of three months after two weeks of treatment with rifaximin 800 mg daily. In addition, a prospective trial of patients with IBS and a positive breath test found that 86% responded to rifaximin, and IBS symptoms were reduced as well. For these reasons, the request for Xifaxan is supported as medically necessary for the treatment of the patients irritable bowel syndrome with bacterial overgrowth. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested cryopreservation of oocytes for treatment of the enrollee's medical condition.  Two physician reviewers found that upon review of the submitted documentation, it is not clear that the patient has expressed a desire to procreate in the future and/or to preserve his fertility via cryopreservation of oocytes. While the clinical documentation provided discusses the patients desire to transition to the male gender by pursuing hormonal therapy and breast removal surgery, there is no evidence the patient has discussed the issue of fertility preservation with his providers. Before such services can be determined to be medically necessary, there must be compelling evidence that the patient has the requisite understanding of the ramifications of the impact that hormonal treatment will have on later childbearing as well as comprehension of the consequences of the decision to attempt to preserve fertility via cryopreservation. In the absence of such findings, the medical necessity of the requested cryopreservation of oocytes has not been established. Final Result: Two reviewers determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: One reviewer is board certified in endocrinology and is actively practicing. One reviewer is board certified in psychiatry and is actively practicing. Both 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 24 weeks for treatment of her hepatitis C. Findings:  The physician reviewer found that according to 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions.  Per the guidelines, cirrhotic genotype 1a patients who have failed treatment with Sovaldi and ribavirin should be retreated with Harvoni and ribavirin for 24 weeks. However, studies have shown efficacy without ribavirin.  For these reasons, the requested treatment with Harvoni for 24 weeks is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging, skull base to mid-thigh for evaluation of her left eye lesion. Findings:  The physician reviewer found that the medical literature noted that whole body PET/CT imaging has a high rate of detection of a primary tumor in patients with a carcinoma of unknown origin. The medical literature reported that PET with CT attenuation can demonstrate primary neoplasms and the whole-body total burden of disease. The medical literature found that carcinoma of breast is the most common primary malignancy that accounts for choroidal metastasis in females. Thus, the literature suggests that most intraocular masses are metastases, especially from lung and breast and these lesions have been successfully evaluated with PET/CT. All told, the requested PET with concurrently acquired CT for attenuation correction and anatomical localization imaging, skull base to mid-thigh is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure 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.