Persius/hicric huggingface dataset:
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 there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in patients with extremely dense tissue.  This technique often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in biopsies, 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 with two-dimensional technique 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for drug metabolizers and advanced lipoprotein testing for evaluation of her medical condition.   Findings:  Three physician reviewers found that the available medical records do not support a specific indication of the requested laboratory testing for this patient. Further, there is a paucity of peer-reviewed medical literature supporting the utility of drug metabolizer status testing and advanced lipoprotein testing in this clinical setting. Accordingly, the genetic testing for drug metabolizers and advanced lipoprotein testing was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the testing 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 reviewers are board certified in internal medicine and cardiology 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 Lyrica for treatment of her fibromyalgia. Findings:  The physician reviewer found that there is medical support for the requested medication in this clinical setting. The U.S. Food and Drug Administration has approved Lyrica (pregabalin) for treatment of fibromyalgia.  Pauer and colleagues note that pregabalin demonstrated modest efficacy in pain, global assessment, and function in patients with fibromyalgia, and the study also showed improved sleep across all dose levels. Early onset of pain relief was seen, with separation from placebo detected by week one in all pregabalin groups. All pregabalin doses demonstrated superiority to placebo on the Medical Outcomes Study-Sleep Scale Sleep Disturbance subscale and the Sleep Quality diary.  Pregabalin was generally well tolerated for the treatment of fibromyalgia. A study by Mease and colleagues also notes that patients in all pregabalin groups showed statistically significant improvement in endpoint mean pain score and patient impression of global change (PGIC) patient response when compared with placebo. Compared with placebo, all pregabalin treatment groups showed statistically significant improvement in assessments of sleep and in patients' impressions of their global improvement. In this patient, the submitted medical records support a condition of fibromyalgia. As such, Lyrica is medically necessary for treatment of the patients medical condition. 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 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 breast tomosynthesis for evaluation of her medical condition.   Findings:  Two 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. Accordingly, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.  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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested inpatient mental health services for treatment of her psychosis with mood disturbance.   Findings:  The physician reviewer found that although the patients illness was chronic, the record indicates a well-defined episode of symptom exacerbation. The patient endorsed vague suicidal ideation to the nursing staff because she believed she was possessed.  She noted a decreased need for sleep and a more powerful controlling entity. Her antipsychotic medication was changed and thereafter, she remained symptomatic, but evidenced a slow, yet incomplete recovery. The clinical documentation addressed the level of care needed to treat the patient and demonstrated the presence of an acute psychiatric syndrome during the entire hospital stay. Overall, the admission facilitated active treatment for a health related issue that was reasonably expected to improve the patients quality of life and functionality. Moreover, this treatment necessitated the expertise of well-trained mental health professionals. Both the clinical care and treatment setting were safe, appropriate and consistent with current American Psychiatric Association (APA) treatment guidelines. Thus, the inpatient mental health services were medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a Senza High Frequency spinal cord stimulator for treatment of his medical condition. Findings:  Three physician reviewers found that there is a lack of support for the requested device in this clinical setting.  High frequency spinal cord stimulation is a new approach to providing analgesia in failed back surgery syndrome.  This modality is currently undergoing a clinical trial in various chronic pain states.  Although some research presents promising data, the studies to date are small and have been funded by the company.  In sum, the current medical evidence has not established the superior efficacy of the requested device. Final Result: Three reviewers determined that the requested device is 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 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 a Botox injection for treatment of her medical condition. Three physician reviewers found that the requested Botox injection is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patient has a diagnosis of chronic migraine. The submitted records confirm a substantial benefit with Botox treatment with an estimated 18 fewer headache days. Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic migraine. Given the support in the peer-reviewed literature and clinical documentation submitted for review, the requested Botox injection 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 services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in neurology 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 inpatient psychiatric and substance abuse hospitalization for the treatment of his behavioral health conditions. Findings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting.  The patient was not at risk for imminent severe withdrawals.  His suicidal ideation was passive in nature, and no plan was endorsed.  He denied homicidal ideation.  The patient was medically and psychiatrically stable.  He was not gravely disabled.  He was at his baseline level of mood and affect initially, while towards the end expressing some lessening of negativity of thoughts.   The current medical evidence does not support the services at issue in this clinical setting.  All told, inpatient psychiatric and substance abuse hospitalization were 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 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: The parent of an enrollee has requested comprehensive orthodontic treatment of adolescent dentition for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates the dental necessity for the requested services. The patient presents with a Class III malocclusion and crowding. The recommendation for interceptive treatment, while she is in the mixed dentition phase can help to improve her bite, anteroposterior position of the incisors, vertical positioning of the incisors, correction of the posterior crossbite (with expansion of the maxillary arch) which will improve intercuspation of the posterior teeth, help to correct the spacing issues which will lead to less crowding as the permanent teeth begin to erupt, as well as helping to prevent deleterious occlusion which could lead to periodontal issues. Early treatment in children with prognathnic lower jaw can also minimize the potential need for future orthognathic surgery. Based on the clinical documentation submitted for review, comprehensive orthodontic treatment of adolescent dentition is dentally necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are dentally necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   The reviewer is board certified in pediatric dentistry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging (MRI) of both knees for evaluation of her medical condition.  Findings:  The physician reviewer found that current medical evidence supports the requested services in this patients case.  There is no evidence of fracture on a recent x-ray series, and there are no clinical signs of infection.  However, the patient complains of severe pain in both knees, and the radiographs indicate the presence of a joint effusion.  The presence of such fluid indicates increased intra-articular pressure, and current guidelines support MRI in this clinical setting.  All told, the requested MRI of both knees is medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The physician 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 magnetic resonance imaging (MRI) for evaluation of her medical condition.  Findings:  The physician reviewer found that in this patients case, an MRI is not medically necessary for evaluation of the patients medical condition. Medical literature supports obtaining an MRI in anticipation of some sort of intervention such as surgery or facet injections. Prior to an intervention, standard medical practice is to attempt a trial of conservative treatments such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs. The submitted documentation does not support the use of an MRI, at this time. As stated by Roudsari and Jarvik, `All of the guidelines emphasize the importance of a focused history and thorough physical examination before any imaging is ordered. In addition, all agree that for patients with acute LBP [low back pain] and without any risk factor for serious spine abnormalities, imaging within the initial 48 weeks should not be performed.` Moreover, The American College of Radiology (ACR) has established appropriateness criteria for the evaluation of back pain. The ACR agrees that MRI is not warranted in the acute setting. In the setting of back pain in which the patient is a candidate for surgery or other intervention, the ACR considers an MRI to be the most appropriate study, with no stipulation about delaying the MRI. Thus, a strong recommendation against the routine use of MRI for chronic low back pain (CLBP) evaluation is made. Chou and colleagues make the specific recommendation that, There is insufficient evidence to support the routine use of MRI in patients with CLBP.  For the reasons stated above, the medical necessity of the requested MRI has not been established.  Final Result: The reviewer determined that the requested service 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 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 Sovaldi and Ribapak for treatment of his 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 should be treated except those with life expectancy due to non-liver-related conditions.  Per the guidelines, Sovaldi/ribavirin is not a recommended treatment for a genotype 3 unless there is a contraindication to both peg-interferon and Daklinza. In treatment-naive genotype 3 patients who can tolerate peg-interferon, therapy is recommended with Sovaldi, peg-interferon, and ribavirin for 12 weeks.  This patient is reported to have no medical contraindications to peg-interferon.  Additionally, there is no reported contraindication to ribavirin tablets or capsules to support use of RibaPak.  For these reasons, the requested treatment with Sovaldi and RibaPak is not supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications 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 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 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 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:  The parent of an enrollee has requested a wheelchair for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity for the requested wheelchair. Lennox-Gastaut syndrome is an epileptic encephalopathy with a diverse set of etiologies, all of which converge on a clinical phenotype that is characterized by profoundly impaired cognitive development, and the requirement for a variety of mobility assisted devices. In this case, the patient presents with Lennox-Gastaut syndrome with frequent seizures, including head drops and flexor spasms involving her head and arms. Hence the need for specialized wheelchairs, and other adaptive devices are indicated to foster mobility and prevent injury. In addition, patients with Lennox-Gastaut syndrome continue to grow and develop, both physically and mentally. Thus, modifying the patients current seat of the wheelchair does not provide a long-term solution as the patient continues to grow. All told, the requested wheelchair is medically necessary for this patient as it will likely improve her physical well-being, and increase mobility.  Final Result: The reviewer determined that the requested equipment 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 with special qualification in child 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.