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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty for treatment of the enrollee, who has been diagnosed with severe persistent asthma. Findings:  Three physician reviewers found that based on the submitted documentation, this patient is a good candidate for bronchial thermoplasty. She is still symptomatic despite maximal medical therapy. She reportedly has been compliant with her treatment and does not have another condition that can explain her symptoms. She has no other condition that contraindicates or increases the risk of bronchial thermoplasty. Multiple studies have shown that although bronchial thermoplasty is not curative, it does decrease symptoms, improve the quality of life, and decrease the use of medications and frequency of exacerbations.  Bronchial thermoplasty has been found to be safe in follow-up studies up to five years following the procedure. Thus, bronchial thermoplasty is likely to be more efficacious than other modalities for treating this patients condition. Final Result: The 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 reviewers are board certified in internal medicine with sub-specialty certification in pulmonary 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 Xifaxan 1600 mg medication for 10 days or more for treatment of the enrollees small intestinal bacterial overgrowth. Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested medication in this clinical setting. The records indicate that this patient has small intestinal bacterial overgrowth. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. For bacterial overgrowth, eradication was demonstrated in 80% versus 54% for placebo. The medication had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones. The results were sustained for several weeks after treatment. One more recent study has corroborated this finding. A prospective trial of patients with irritable bowel syndrome and a positive breath test found that 86% responded to Xifaxan, and symptoms were reduced as well. The patient had a serum sickness syndrome with tetracycline, in the past.  For these reasons, Xifaxan 1600 mg for 10 days or more is supported as medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for obinutuzumab (Gazyva) therapy for treatment of the enrollees end stage renal disease (ESRD) secondary to C1q nephropathy. Findings:  Three physician reviewers found that an alternative to murine anti-CD20 antibody is justified by this patients side effects to treatment with rituximab. Humanized anti-CD20 has been used in antibody mediated rejection by the same transplant team and their experience has been published. Since the patients providers have recommended against another round of rituximab and he faces possible organ failure, treatment with Gazyva is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 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 physician reviewers are board certified in nephrology and re 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 reimbursement for Afirma Gene Expression Classifier testing.Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  The initial biopsy report noted follicular lesion of undetermined significance.  The genetic testing performed was beneficial in avoiding an unnecessary surgical procedure.  Genetic testing is generally considered standard protocol on fine needle aspirations done on thyroid nodules.  There is sufficient literature demonstrating that this test can be easily performed to avoid needless surgeries.  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 physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 reimbursement for bilateral digital breast tomosynthesis performed for evaluation of the enrollee, who was asymptomatic. 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 (CT) 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 patients case, the records noted dense breast tissue.  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.  Thus, bilateral digital breast tomosynthesis performed was likely to have been more effective 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bilateral digital breast tomosynthesis for evaluation of the enrollees breast exam. Findings:  2/3 of the physician reviewers found that there is sufficient support in the peer-reviewed literature for the diagnostic procedure at issue in the routine screening population. According to the study by colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. In addition, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Given the support above, the bilateral digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of 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: 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Three physician reviewers found that the 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 (CT) 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 patients case, the records documented dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from breast 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 superior over 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: 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 reviewer found that tomosynthesis is a technique that was developed 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. In this case, tomosynthesis was indicated due to the presence of a breast lump, in the clinical setting of nipple discharge. It is important to be as sure as possible that an occult mass is not being missed. Tomosynthesis is a valuable tool in separating overlapping breast tissue and delineating any masses that may be palpable. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 28 day starter pack for treatment of the enrollees guttate psoriasis. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  This patient has tried and failed treatment with several topical steroid creams.  She is unwilling to take the known associated risks of malignancy and infection associated with injectable biologic agents.  Otezla is an oral U.S. Food and Drug Administration (FDA) approved medication for the treatment of psoriasis and psoriatic arthritis.  No clinical monitoring is necessary for patients using Otezla, as it has an excellent safety record and is not considered to be immunosuppressive.  The patient also complains of an aversion to injectable agents.  Given the associated risks of biologic therapy, Otezla is a medically appropriate treatment.  It is not reasonable to require a patient to submit to known risks of alternative therapy when FDA approved, safer treatments are available.  All told, Otezla 28 day starter pack 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that the request for Otezla is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has not had a trial of treatment with a conventional disease-modifying antirheumatic drug (DMARD) such as methotrexate or leflunomide. In addition, there is a lack of documentation demonstrating that conventional medications have been exhausted. Based on the medical records and peer-reviewed guidelines for the treatment of psoriatic arthritis, the request for Otezla is not medically necessary for treatment of the patients psoriatic arthritis. 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 internal medicine with sub-specialty certification 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 authorization and coverage for Cialis (tadalafil) 5 mg. Findings:  The physician reviewer found that in review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. Cialis is one of the most extensively investigated phosphodiesterase type 5 inhibitors for the indication of lower urinary tract symptoms suggestive of benign prostatic hyperplasia and erectile dysfunction. The peer-reviewed literature supports Cialis 5 mg once daily as a safe and effective treatment option for both lower urinary tract obstructive and erectile dysfunction. Moreover, Cialis has a distinct mechanism of action that works in improving both erectile dysfunction and obstruction prostatic hyperplasia which is not possible with other drugs that are used for these diagnoses. 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 urology 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 Synvisc One injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  The peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and is more effective than corticosteroid injections.  In this case, the patient has been diagnosed with osteoarthritis of both knees.  She had been treated with corticosteroid injections, bracing, physical therapy, exercise, medications, and activity modification, without sustained relief.  She has undergone prior series of Synvisc One injections for five years, with reported significant sustained pain relief allowing improved mobility. Therefore, the requested Synvisc One injections are medically indicated for the treatment of this patient. 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 physician reviewer is board certified in orthopedic 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization mental health treatment provided from 7/11/16 through 7/19/16.  Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious addiction and comorbid mental illness.  In this case, the patient had a serious addiction to alcohol which contributed to occupational problems, interpersonal discord, depression and dangerous behaviors such as operating a motor vehicle while intoxicated.  He had a history of alcohol withdrawal seizure activity.  He abused substances other than alcohol as well.  Upon presentation, he was depressed and irritable, and diagnosed with a mood disorder.  He failed two previous residential placements which suggested the need for a more conservative treatment course.  Thus, the partial hospital placement was indicated.  Per the records, the patient had not consolidated the treatment gains necessary to succeed in the outpatient setting by 7/11/16.  On 7/11/16, the patient was in the contemplative stage of change.  He was not active in all programmatic elements.  He was still craving alcohol.  He had not yet resumed naltrexone, an anti-craving medication.  Additionally, he had not yet established a sober network in the community.  Considering the patients clinical presentation, partial hospitalization was a safe, appropriate disposition consistent with good medical practice while the duration of services provided aligned with community standards of a case of this severity.  Final Result: The reviewers 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 physician 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.