Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested medical services on an emergent basis or urgent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a complex combination of symptoms and exam findings, some of which were chronic and others acute. The acute nature of his findings warranted emergent intervention with EMG, MRI and eventually surgery. Due to the complex nature of his presentation and previous evaluations it was necessary to consult with rheumatology and dermatology to determine an accurate diagnosis. He needed immediate diagnostic testing and treatment to avoid further deterioration and permanent paralysis from cervical cord herniation and compression. The patients health would have been placed in serious jeopardy, serious impairment to bodily function. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe he was suffering from a serious medical condition. In sum, the patient was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services met prudent layperson criteria for emergency care.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orenitram ER for treatment of his medical condition.  Findings:  Three physician reviewers found that the management of pulmonary arterial hypertension (PAH) was initially limited to continuous intravenous infusions of prostacyclin, a difficult drug to administer and tolerate. In the past several decades there has been a significant increase in the number of compounds available and methods of administration. Recent data on the management of PAH found that among treatment naive patients, a two drug regimen demonstrated a significantly lower risk of treatment failure than starting drugs individually. With that in mind, the current issue is whether a patient already on a two drug regimen would benefit from the addition of a third drug, in this case a prostanoid (a class he is not on) and what the route of administration should be. Trepostinil, the compound recommended, is a prostacyclin analogue available as a subcutaneous infusion (Remodulin), inhaled solution (Tyvaso) and a pill (Orenitram). Regarding this patient in particular, he is already on a proven two drug regimen and he is beginning to decline clinically with complaints of worsened exercise tolerance and physiologically (exertional hypoxia) and physically (worsening echocardiogram). Given the above indications, the patient would benefit from more aggressive therapy.  Therefore Orenitram ER, is likely to be a superior drug therapy than any available standard therapy for treatment of this patients PAH.  Final Result: Three reviewers determined that the requested medication is 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 reviewers are board certified in internal medicine with sub-specialty certification in pulmonary 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested proton beam radiation therapy and full body positron emission tomography/computed tomography (PET/CT) using choline C-11 for treatment of his medical condition.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  The standard treatment for patients who have a rising PSA following radiation therapy is with hormone therapy or chemotherapy. In patients requiring palliative radiation to the spine for bone metastases, there is a lack of evidence to suggest that proton radiation therapy will improve outcomes. Standard radiation in patients with metastatic disease is with standard photon techniques.  Furthermore, there is a lack of medical literature to suggest that volume based radiation planning based on a C-11 choline PET/CT scan improves outcomes. Therefore, the requested services are not likely to be more efficacious for treatment of the patients medical condition than other treatment options. Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in radiation oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested residential treatment services with specific patient/physician ratios for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that while the medical literature regarding staff to patient ratios for adolescents who are receiving residential treatment services is somewhat limited, studies clearly show that higher staff to patient ratios are overall much more effective. Studies have shown that retention rates were greater in facilities that reported a higher staff to patient ratio and that individual consultation and high staffing levels were both associated with retention. These studies also indicated that the amount of programming implemented at these facilities was directly correlated with the number of staff available to run the groups or programs. Although the absolute number of staff was not delineated as a measure of effective mental health treatment, it is clear that the amount of direct attention provided by staff members to patients was strongly correlated with better patient outcomes and reduction in recidivism.  Additionally, there are ample studies suggesting, and it is well established from the literature, that medication management alongside therapy is consistently much more effective. A program which includes a team based approach including a prescriber as well as highly trained therapist will be more effective. This patient has strong documented history of suicidal ideation and behavior (SIB) as well as severe anxiety and post-traumatic stress disorder (PTSD).  Moreover, the records indicate that the patient continues to be suicidal. Therefore, the requested services are medically necessary for treatment of this patients SIB; severe anxiety and panic disorder; and PTSD.   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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This new method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her exam been done using two-dimensional imaging alone.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies and callbacks and increase in detection of small cancers.  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: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: 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 reviewers found that this technique often 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, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the 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. 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 Repatha for treatment of her medical condition.  Findings: The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  There is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia.  Familial hypercholesterolemia usually manifests by a combination of physical examination findings that are not documented in this case and low-density lipoprotein cholesterol levels that are at minimum above 180 mg/dl and usually significantly higher.  Repatha is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein cholesterol.  PCSK9 inhibitors have not been studied in other patient populations such as this patient for primary prevention.  Finally, Zetia has been shown to improve outcome and appears to be tolerated by the patient and there are other statin medications such as pitavastatin and fluvastatin that have lower side effect profiles and have not been documented to be tried or not tolerated in this patient.  In sum, Repatha 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 physician reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 heart computed tomography (CT) scan for evaluation of his medical condition.  Findings: Two physician reviewers found that based on the documentation submitted for review, the patient has significant coronary risk but no evidence of coronary ischemia on recent stress testing. In this circumstance, guidelines to manage coronary risk are available and endorsed by several national organizations. The guidelines currently do not recommend the routine performance of coronary CT scanning to assess coronary risk. Treatment change or addition based on coronary CT scan results in this patient population with high risk has not been demonstrated to improve cardiac outcome incremental to that achievable based on standard clinical profile and basic lipid analysis alone. Therefore, the requested heart CT scan was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The 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 physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested anterior optical coherence tomography (OCT) for evaluation of her medical condition. Findings: Two physician reviewers found that an anterior segment OCT is a technology that has been used in assessing the status of the angle of the eye. It provides information that cannot be obtained from gonioscopy, especially the status of the angle in light versus dark. However, OCT is not indicated to check the angles of a patient who has been diagnosed with narrow angles. Gonioscopy is the standard of care and that has been already performed. Further, the patient has already undergone peripheral iridotomy, which will prevent angle closure from occurring. An OCT evaluation does not add any clinically significant value towards management of this patient. Thus, the requested anterior OCT was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the diagnostic procedure at issue was 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 physician reviewers are board certified in ophthalmology and are actively practicing. All three reviewers are an experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a cold therapy device for treatment of his medical condition. Findings: Three physician reviewers found that upon review of the operative note, some form of cryotherapy was appropriate in view of the extent of the surgical procedure. A further issue to be decided is whether cryotherapy has increased efficacy when administered through a mechanized pump versus the simplest form of cryotherapy in the form of icepacks and ice bags. In this case, medical evidence has not established the superior efficacy of the device at issue compared to simpler applications of cold.  The article by Martimbianco and colleagues provides support for reduction in pain levels at 48 hours, but does not provide sufficient evidence for efficacy of cryotherapy for other outcomes such as analgesic medication use, range of motion, blood loss, hospital stay or quality of life.  The authors concluded that there is a need for additional studies with randomized trials before the ambiguity as to the efficacy of cryotherapy can be resolved. In the study authored by Raynor and colleagues, a meta-analysis of the use of cryotherapy following anterior cruciate ligament reconstruction was published; six studies were reviewed. Some individual studies reported significant benefit but a pooled analysis did not support a significant impact compared to traditional methods of delivering cold, such as icepacks. In summary, while cryotherapy was indicated and likely to have been beneficial for this patient, simpler applications of cold would have been equally efficacious. Therefore, the cooling device was not likely to be more beneficial than simpler applications and so, the superior effectiveness of the equipment at issue has not been established. 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 physician reviewers are board certified in orthopedic surgery 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Three physician 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. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that  there is sufficient support for the services at issue in this patients case. Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This new method often allows the reader to separate dense glandular elements from underlying mass/architectural disorder, resulting in a decrease in callbacks and biopsies and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done using two-dimensional imaging alone.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. Al 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.