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

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for advanced lipoprotein for evaluation of her medical condition.  Findings:  Three physician reviewers found that based on the records provided the patient has been diagnosed with hyperlipidemia but no documented coronary disease. In this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine (Greenland, et al; Stone, et al). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. All told, the advanced lipoprotein 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a computed tomography (CT) angiogram with three-dimensional imaging for evaluation of her medical condition.   Findings:   Two reviewers found that per the documentation submitted for review, it appears this patient had a previous coronary angiogram which did not reveal any significant abnormalities. Hence, pursuing a coronary CT angiogram in the absence of any symptoms is not indicated in this patient. However, she does have a history of abdominal pain and was previously found to have celiac artery stenosis and renal vein stenosis. The CT angiogram of her coronary arteries seems unlikely to be beneficial for her medical condition given a prior coronary angiogram did not show coronary anomalies. However, a CT angiogram of her mesenteric and renal arteries is likely to be beneficial for her medical condition as she has a documented history of mesenteric artery stenosis and renal vein stenosis. Given the above, a portion of the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result:  Two reviewers determined that a portion of the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: All three 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: 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 breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The advantage of tomosynthesis relates to the ability often afforded the reader in being able to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers.  For this reason the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the exam been done with two-dimensional technique 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. 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 Sovaldi and Daklinza for treatment of his medical condition.  Findings:  The physician reviewer found that a according to the 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 comorbid conditions. Per the guidelines, patients with cirrhosis are high priority for therapy. The guidelines recommend that cirrhotic interferon-ineligible patients with genotype 2 hepatitis C who have failed Sovaldi and ribavirin regimens should be treated with Sovaldi and Daklinza and ribavirin for 24 weeks. This is based partially on the results of two clinical trials (Sulkowski, et al; Wyles, et al). Sovaldi and peg-interferon with ribavirin is also recommended, but this patient is interferon-ineligible due to thrombocytopenia, and also has depression and anxiety which can be worsened by ribavirin (Dusheiko, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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 Viekira Pak for treatment of her medical condition. Findings: The physician reviewer found that according to the 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 comorbid conditions. Per the guidelines, treatment-naive genotype 1b patients should be treated with Viekira Pak for 12 weeks. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and the medication is U.S. Food and Drug Administration-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Viekira Pak 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 physician 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 mental health inpatient hospitalization for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient was diagnosed with a serious mental illness that impacts mood and cognition and is associated with functional impairment across multiple domains, poor clinical outcomes and heightened risk of suicide.  Despite good family support, efforts to engage in age-appropriate community activities while consolidating the gravity of her psychiatric diagnosis, and treatment with complex pharmacotherapy, one of which is delivered via long-acting injection, the patient was clinically depressed and endorsing suicidality.  The patient was engaged in active treatment during the entire hospital stay including aggressive medication management, discharge planning and aftercare involving family, group and milieu therapies, and other standard interventions afforded by the inpatient setting.  During the disputed timeframe, the acute inpatient setting remained reasonably expected to improve the patients condition while preventing a more serious episode of illness.  All told, mental health inpatient hospitalization  was medically indicated for the treatment of this patient.  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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus (HCV).   Findings:  The physician reviewer found that according to the recommended joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), the recommended regimen for genotype 6 treatment-naive patients with and without cirrhosis is daily fixed-dose combination of ledipasvir/sofobuvir for 12 weeks. However, in this case, there is a lack of documentation demonstrating that the patient has persistent or active HCV infection. The RNA (ribonucleic acid) quantitation provided showed a relative low viral load that had not been confirmed by retesting for a considerable period of time. Therefore, treatment with Harvoni has not been established as medically necessary for treatment of the patients medical condition. 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 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 total cervical disc arthroplasty for treatment of her medical condition. Findings:  Two physician reviewers found that total cervical disc arthroplasty was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient had evidence of chronic right upper extremity radiculopathy with associated MRI findings of stenosis, particularly in the foraminal area. Progressive neurologic deficit was documented. She had exhausted conservative measures including facet rhizotomies and epidural steroid injections.  Surgery was therefore indicated. Based upon the imaging studies, the degenerative changes at other levels were not significant.  As such, the services at issue were likely to be more beneficial for treatment of the 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 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: 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 the current medical evidence supports the services at issue in this patients case.  According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  The medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  Therefore, breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.  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 Orthovisc injections to the bilateral knees for treatment of her knee pain.  Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. This has been found to be safe and effective and allows for delay of total knee replacement. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronan were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has been diagnosed with severe osteoarthritis of both knees. The patient has been diagnosed with bilateral knee end-stage degenerative joint disease. She has undergone two prior viscosupplementation series with long-term pain reduction documented and has had the ability to avoid surgery. She has failed to respond to other conservative treatment including anti-inflammatory medications, physical therapy, activity modification, and corticosteroid injections. For all these reasons stated above, the requested Orthovisc injections for both knees are medically necessary for treatment of the patients bilateral knee pain. Final Result: The reviewer determined that the requested therapy 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Medical studies and peer reviewed literature support the use of tomosynthesis in this clinical setting.  For these reasons, tomosynthesis was likely to be more beneficial 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:   An enrollee has requested an office consultation for treatment of her medical condition. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. Although there is a lack of standard guidelines for the criteria for office consultation for weight loss surgery, the requested consultation is indicated for this patient. An evaluation for possible weight loss surgery is medically necessary for this patient to explore weight loss treatments available for her morbid obesity. For the reasons stated, the requested services are 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 general 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:  The parent of an enrollee has requested group social skills therapy for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. There is evidence that social skills groups are effective for children with autism spectrum disorders (ASD) to improve social skills and friendship quality. However, most of the peer-reviewed literature in regards to social skills groups does not include children who are also receiving applied behavior analysis (ABA). Social skills groups are designed to refine communication and work on conversational reciprocity and staying on conversational target. In this case, the patient has good communication skills, but limitations in his reciprocity with conversation. This is likely a social skills group goal that should be addressed in a group social skills therapy. In this clinical setting, a social skills group therapy in addition to ABA services is indicated for this patient.  For the reasons stated, group social skills 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.