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.  Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The medical literature supports the services at issue in this clinical setting. Mammography plays a key role in early breast cancer detection. Single-institution studies have shown that adding tomosynthesis to mammography increases cancer detection and reduces false-positive results. As such, the addition of tomosynthesis to mammogram views has gained wide popularity among radiologists due to the associated decrease in callbacks and increased detection of small cancer particularly in patients with very dense or heterogeneously dense breast tissue as described in this patient. Therefore, the addition of breast tomosynthesis in this clinical setting was likely to be more beneficial for evaluation of this patient than any other technique. Final Result: Two 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: One reviewer is board certified in radiology and is actively practicing. Two 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 Harvoni for treatment of his hepatitis C.  Three physician reviewers found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The records do not document discontinuation of alcohol use.  There is a lack of support for treatment with antiviral agents in the setting of continued alcohol use. Alcohol and hepatitis C virus appear to act synergistically in promoting progression to cirrhosis and increasing the risk of hepatocellular carcinoma.  Additionally, available data suggests that ongoing alcohol consumption significantly impairs the efficacy of therapy for hepatitis C virus elimination. All told, the requested medication Harvoni is not medically necessary for the treatment of this patient.  Final Result: Three reviewers 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his chronic hepatitis C virus genotype 1a.  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection.  Final Result:  Two reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 methadone and Tylenol with codeine #4 for treatment of her migraine headaches.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  This patient has chronic migraine.  She has been receiving chronic opiate treatment for headache.  Per the medical records, she has had treatment with numerous preventives, and with current regimen reports improvement from Botox.  The medical literature indicates that opiates are generally not advised for migraine, as they can contribute to transformation to chronic migraine, and can provoke opiate-induced hyperalgesia.  The medical evidence does not support the requested medications in this clinical setting.  All told, the requested methadone and Tylenol with codeine #4 are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C. Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except for those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The medical evidence supports Harvoni in this clinical setting.  Based on published evidence of safety and efficacy, the requested  Harvoni is medically indicated for the treatment of this patient.  Final Result: Three reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 for physical therapy for treatment of her diastasis recti.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  Diastasis recti abdominis is common following pregnancy.  Antenatal and postnatal exercises, including in the formal physical therapy setting, are commonly recommended.  However, there is a dearth of high-quality published research to inform the medical literature.  A recent meta-analysis by Benjamin and colleagues noted that the literature was of poor quality and concluded that nonspecific exercise may or may not help to prevent or reduce [diastasis recti abdominis] during the ante- and postnatal periods.  There is a lack of high-grade evidence that formal physical therapy improves the clinical course or outcomes for this condition.  All told, the requested physical therapy is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested therapy 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 physical medicine and rehabilitation 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 brachytherapy for treatment of her basal cell carcinoma on the face.  The physician reviewer found that basal cell carcinoma is the most common form of non-melanoma skin cancers in the Caucasian population representing approximately 75%. The standard of care for basal cell carcinoma is typically local destruction or surgical removal, including electrodessication and curettage, elliptical excision, or Mohs micrographic surgery. In selected patients, radiation, including external beam radiation or brachytherapy, is an appropriate and effective option. With the advent of precise surgical treatments, such as Mohs micrographic surgery, which offers tissue-sparing tumor removal, the use of radiation for basal cell carcinoma has declined. There are significant limitations in the use of brachytherapy for treatment of basal cell carcinoma. Specifically, the tumors that respond best with the lowest recurrence rates are primary, superficial less than 2 mm deep, and small less than 2 cm in diameter. Most studies have found that adequate radiation dosage with brachytherapy cannot be delivered at depths much greater than 2 mm, making the treatment of infiltrative tumors impractical. All told, the requested brachytherapy is not medically necessary for treatment of this patients basal cell carcinoma. Final Result: The reviewer determined that the requested services 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that in this patients case, the services at issue were likely to have been of greater benefit than other modalities.  The use of breast tomosynthesis with digital mammography has been associated with an increase in detection of small cancers.  In addition, the post lumpectomy breast is very challenging to evaluate and the addition of tomosynthesis helps the radiologist discern between normal post lumpectomy scar and post radiation changes and possible tumor recurrence/residual.  All told, the superior efficacy of digital breast tomosynthesis has been established.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested speech therapy for treatment of the enrollees mixed expressive/receptive language delay.  The physician review found that review of the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested services. The patients most recent speech therapy evaluation evaluated expressive and receptive language, but did not include pragmatic language testing. An earlier speech therapy evaluation revealed the patient has deficits in pragmatic or social language skills. Many children with ADHD have social and communication deficits. The study by Cordier and colleagues examined pragmatic language exhibited in children with ADHD and found that a play-based intervention did help improve pragmatic skills. This patient has pragmatic language deficits, but her expressive and receptive language has improved and she no longer requires individual speech therapy. Many of her speech therapy goals that have not been met are social or pragmatic language goals and should be addressed in a group with her peers than in individual interventions with an adult. For the reasons stated, speech therapy is not medically necessary in this clinical setting.  Final Result: The reviewer determined that the requested services 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his bipolar disorder and major depression.  The physician reviewer found that this patients depression is treatment resistant since multiple antidepressants and augmentation strategies had not successfully brought on remission. The American Psychiatric Association (APA) practice guidelines for treatment of depression state that the acute phase treatment may include TMS. Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Avery and colleagues provided evidence that TMS is a safe and effective treatment for major depressive disorder. All told, TMS is medically necessary for treatment of this patients medical condition. 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 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 breast tomosynthesis for evaluation of her risk for breast cancer.  Two physician reviewers found that 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 the dense breast. Helvie noted that breast tomosynthesis technology has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies. Rafferty and colleagues concluded that, addition of tomosynthesis to digital mammography offers the dual benefit of significantly increased diagnostic accuracy and significantly reduced recall rates for noncancer cases. However, in this particular patient, there were no indications for the additional imaging with digital breast tomosynthesis. Specifically, the patient did not have dense breasts, a mass, or a palpable lump, and she did not have calcifications. Given the extra exposure to radiation, tomosynthesis is not routinely performed in all patients. Thus, the breast tomosynthesis was not likely to have been more beneficial for evaluation of this patients medical condition than any available modality including standard mammogram.  Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in 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 the enrollees palpable breast mass.  Three physician reviewers found that the records indicate that this patient presented for screening mammogram with complaints of a palpable lump in the left breast. Thus, the breast tomosynthesis was indicated to help differentiate the right breast and left breast findings and improve detection of early cancer. Given the patients palpable mass, the 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 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 a positron emission tomography (PET) scan for evaluation of his medical condition. Three physician reviewers found that the medical records note a history of cognitive impairment post-concussion and acute myocardial infarction with hypotension. There is no recorded history of progressive cognitive decline, hallucinations, or extrapyramidal features.  The described clinical features do not suggest Alzheimers disease or frontotemporal dementia.  Cognitive impairment following cardiac events and hypotension may be permanent, and is not typically progressive.  In this patients case, there is no indication for a PET scan, and a lack of evidence indicating that findings from a PET scan would alter therapy.  All told, the requested PET scan is not likely to be more effective than other methods of evaluating this patient.  Final Result:  Three reviewers determined that the requested services are 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 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: 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.  Three physician reviewers found that in this patients case, the services at issue were likely to have been superior over other modalities.  There have been several studies that have supported the use of breast tomosynthesis as a more accurate study than routine screening mammography.  As noted by 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.  Rafferty and colleagues noted that the addition of breast tomosynthesis to digital mammography increased diagnostic accuracy.  In this case, a mass was noted on routine mammography.  Breast tomosynthesis provided even better delineation and revealed that the nodule was one-half the size that was expected.  All told, digital breast tomosynthesis  was likely to have been of greater benefit than other available alternatives.  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.