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.  Three physician reviewers found that there is sufficient support for the use digital breast tomosynthesis in this patients case.  Per the current medical evidence, using digital breast tomosynthesis in addition to mammography may result in improvement in the detection of small cancers.  In this patients case, the addition of digital breast tomosynthesis to screening mammogram was likely to have been more efficacious than mammographic views alone.  Therefore, breast tomosynthesis was likely to have been superior over other modalities.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 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 available modalities.  The addition of breast tomosynthesis to screening mammography has been associated with a decreased call back rate and increased detection of small cancers.  Thus, there is support for the addition of breast tomosynthesis to digital screening mammography views in this clinical setting.  All told, the records support the superior efficacy of breast tomosynthesis.  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:  An enrollee has requested residential treatment services for treatment of his binge eating disorder.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Although the patient has a significant eating disorder with psychiatric comorbidity and concerning medical sequelae, the clinical documentation provided simply does not support the medical necessity of residential treatment services.  This patients pathological eating habits and subsequent obesity have been dominating his routine and impacting his sense of self and physical health.  However, he has reasonable insight and concern for his health.  The records indicate that the patient has good family support.  He successfully lost significant weight in the past when he was adherent to a meal plan.  He has not failed coordinated, multi-disciplinary specialty programming in an intermediate setting.  Finally, the record was inconsistent with an impairing psychiatric illness burden that would necessitate residential treatment.  All told, the requested residential treatment services are not medically necessary for the treatment of this patient.  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 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 a power wheelchair (K0822, E2365, E1028, E0973, K0195, K0108 and E2607) for treatment of her medical condition.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The available records do not establish that the patient would be bed or chair confined without a power mobility device.  She does not have neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using assistive devices or an optimally configured manual wheelchair to accomplish her mobility-related activities of daily living.  Physical activity, moreover, is generally appropriate for conditions such as chronic obstructive pulmonary disease and chronic widespread pain, as well as for general musculoskeletal health.  All told, the requested power wheelchair is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that equipment 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a pelvic floor stimulation home unit (CPT code E0740) for treatment of his fecal incontinence.  Two physician reviewers found that in multiple trials, patients with intact sphincter musculature benefit most from dietary modification and biofeedback. There is a lack of trials showing additional benefit with pelvic floor stimulation. In this patients case, the radiation has caused decreased compliance, thus there will be smaller volumes and a shorter time interval between sensation and the need to defecate. There is also evidence of pudendal neuropathy, which may have multiple etiologies. All told, the requested pelvic floor stimulation home unit (CPT code E0740) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: One reviewer is board certified in general surgery and is actively practicing. One reviewer is board certified in urology and is actively practicing.  One reviewer is board certified in general surgery with sub-specialty certification in colorectal surgery and is 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 24-hour skilled nursing facility care for treatment of his back pain. The physician review found that based on the clinical documentation submitted for review, the medical necessity for 24-hour skilled nursing facility care has not been established. In this case, the patient has had years of low back pain and reduced level of social functioning. Based on his physical examination, he does not have any significant impairment of functional mobility or self-care. The documentation submitted for review does not demonstrate that intensive inpatient level physical or occupational therapy is clinically indicated. Moreover, the records submitted do not establish the medical necessity for 24-hour nursing. The patient has assistance for transportation, meals, and laundry. There is no evidence to support inpatient rehabilitation, inpatient medical care, or 24-hour custodial care. For the reasons provided, 24-hour skilled nursing facility care is not medically necessary for treatment of the patients medical condition. 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 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 a sleep study for evaluation of her chronic insomnia. The physician reviewer found that the services at issue were not medically necessary for evaluation of the patients medical condition. According to the documentation submitted for review, the patient presented with sleep onset insomnia which is not an indication for a sleep study. Patients with clinically significant sleep apnea have decreased sleep latency. Also, there is a difference between fatigue and hypersomnia. The patient had a normal Epworth Sleepiness score and did not have hypersomnia. Hypersomnia is a cornerstone for a diagnosis of sleep apnea. In addition, the patients AHI was normal. She did not have sleep apnea and there was no indication for the sleep study performed. Based on the medical literature and documentation submitted for review, a sleep study was not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 internal medicine with sub-specialty certification in pulmonary 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 digital breast tomosynthesis for evaluation of her risk for breast cancer.  Two physician reviewers found that the addition of digital breast tomosynthesis to standard digital mammography has been shown to increase the detection of small cancers, particularly in dense or heterogeneously dense breast tissue. This patient was noted to have heterogeneously dense tissue on her mammograms. Currently, there is a lack of long-term studies showing increased survival rates using digital breast tomosynthesis. However, the addition of digital breast tomosynthesis to screening mammogram imaging is becoming more common due to the data demonstrating its advantages. Therefore, breast tomosynthesis was likely to have been more beneficial for evaluation of this patients medical condition than any available technique. Final Result:  Two reviewers determined that the services at issue were medically necessary for evaluation of the patients medical condition. 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:  An enrollee has requested Viibryd for treatment of his major depressive disorder and attention deficit disorder.  The physician reviewer found that this patient has a hypercoagulability syndrome and is at risk for thrombotic rather than hemorrhagic stroke. Plavix and aspirin help reduce that risk and thereby place him at risk for hemorrhagic stroke if his doses are too high. The prescribing information for Viibryd notes that the drug may increase your chance of bleeding or bruising. However, there is a lack of evidence that the bleeding risk that Viibryd poses or any other association with bleeding or stroke is any different from any other antidepressant with serotonergic activity. Song and colleagues reported that Lexapro has more significant decrease in platelet count than venlafaxine, but that bupropion, which boosts dopamine and norepinephrine, does not decrease platelet count. According to these findings, bupropion appears to have the lowest risk for bleeding. All told, the requested Viibryd for management of this patients depression is not supported as medically necessary. 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 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 growth hormone treatment with Nutropin for treatment of his idiopathic short stature.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. According to the documentation submitted for review, an evaluation indicates that he measures 56, has normal growth hormone and measurement, and normal IGF-I and testosterone. Accordingly, his genetic target is 57.5, +/- 4 inches. This implies that any male height above 53.5 would be normal for this family.  Thus, he has essentially reached his adult height and growth hormone supplementation would not lead to any increased discernible height gain. Based on the medical literature cited above and the documentation submitted for review, the request for growth hormone treatment with Nutropin is not 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 pediatric endocrinology 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 fetal aneuploidy trisomy risk test for evaluation of her pregnancy.  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Per the American College of Obstetricians and Gynecologists (ACOG), indications for use of cell-free DNA testing include maternal age 35 years or older at delivery, fetal ultrasonographic findings indicating an increased risk of aneuploidy, positive test result for aneuploidy, history of prior pregnancy with a trisomy and parental balanced robertsonian translocation with increased risk of fetal trisomy 13 or trisomy 21.  This patient is under the age of 35 and meets none of the ACOG approved indications for the use of cell-free fetal DNA.  All told, a fetal aneuploidy trisomy risk test was not likely to be superior over other methods of evaluating this patient.  Final Result: Three reviewers determined that 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 obstetrics and gynecology 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 Saizen for treatment of the enrollees medical condition.   The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The records document short stature and an abnormal growth hormone response test to stimulation tests.  The current medical evidence supports the requested medication in this clinical setting.  All told, the requested Saizen 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 reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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.  Three physician reviewers found that the current medical evidence supports the addition of digital breast tomosynthesis to the standard screening digital breast mammography due to the decreased call back rate as well as the earlier detection of small cancers.  Per the medical literature, breast tomosynthesis may be of particular benefit in women with dense or heterogeneously dense breast tissue.  Based upon the medical records, this patients breast tissue was described as heterogeneously dense on her mammogram report.  In this clinical setting, breast tomosynthesis offers advantages when compared to screening mammography alone.  All told, breast tomosynthesis was likely to have been superior over other modalities for evaluating this patient.  Final Result: Three reviewers determined that 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 Botox injections for treatment of her migraine headaches. Three physician reviewers found that the Botox injections were not and are not likely to be more effective for this patient than other available options. Khalil and colleagues studied patients with chronic migraine treated with Botox injections and found that Botox significantly, reduced the number of headache and migraine days, and increased the number of headache free days. However, in this case, there is a lack of documentation provided regarding the frequency and duration of the patients headaches. Moreover, there is a lack of documentation of pain and functional improvement with the use of Botox. For the reasons provided, the Botox injections at issue were not and are not likely to be more effective than other modalities. Final Result: Three reviewers determined that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: One reviewer is board certified in neurology and is actively practicing. Two reviewers are board certified in neurology with sub-specialty certification in headache 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested clomiphene citrate for treatment of his hypogonadism.  Three physician reviewers found that clomiphene citrate as evidenced by case reports will increase testosterone and has been shown to have equal short-term efficacy to topical androgen therapy. Clomiphene citrate is almost exclusively recommended for infertility and considered off-label for young men with decreased testosterone and there is little long-term evidence for its effectiveness. As such, there is a lack of evidence that clomiphene citrate would have greater efficacy in this patients case than topical testosterone replacement. For the reasons provided, the requested medication is not likely to be more effective than other modalities.  Final Result: Three reviewers determined that the requested medication 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 urology 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.