Persius/hicric huggingface dataset:
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 the thoracic and lumbar spine for evaluation of her back pain. Findings:  The physician reviewer found that upon review of the submitted documentation, an MRI of the thoracic and lumbar spine is medically necessary in ruling out or describing anatomical changes such as a thoracic level intervertebral disc herniation or other acute soft tissue changes following the patient's history of pain. Studies show that an MRI has a meaningful impact on clinical decision making in cases of ongoing musculoskeletal pain and is capable of ruling out significant diagnoses. In the presence of mid back pain, thoracic disc herniation may be effectively ruled in or out by MRI imaging of the thoracic and lumbar spine (Cannada). As discussed in the article by Wood and colleagues, incidental MRI findings of structural changes at the thoracic level need to be interpreted with reference to the patient's clinical history and examination. In spite of the need to interpret the MRI in reference to documented incidental disc protrusions at the thoracic level, the study is still valuable and indicated in this patient. Also, additional diagnoses referencing soft tissue changes in the face of negative x-ray examination have the potential of being diagnosed through MRI imaging. All told, an MRI study supplementing the clinical and x-ray examinations for this patient is medically necessary for the treatment of her back pain. Final Result: The reviewer determined that the requested MRI of the thoracic and lumbar spine is medically necessary for evaluation 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 has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that review of the relevant scientific evidence demonstrates the use of mammography plus tomosynthesis in a screening environment resulted in significantly higher cancer detection rate and enabled radiologists to detect more invasive cancers. Available studies also show that double reading of 2D plus 3D significantly improves the cancer detection rate. Scientific data further indicates that integrated 2D and 3D mammography reduce false positive recalls. All told, the medical literature provides adequate data to support the addition of breast tomosynthesis to conventional mammogram due to improved cancer detection rate. Upon consideration of the submitted documentation and available peer-reviewed evidence, the service at issue was likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in radiology with sub-specialty certification 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 Harvoni for treatment of his hepatitis C virus. Findings:  The physician reviewer 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 should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline 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.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. As such, the requested treatment with Harvoni 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Aromasin (exemestane) for treatment of her breast cancer.  Findings: The physician reviewer found that women with hormone receptor positive breast cancer usually receive pharmacologic therapy to inhibit the estrogen-induced growth of the cancer. The interventions differ however for those who are premenopausal versus postmenopausal. This distinction is extensively supported by the medical literature and is also the main conclusion of guidelines recently published by the American Society of Clinical Oncology. The American Society of Clinical Oncology (ASCO) recommendations are for premenopausal women to receive 5 years of adjuvant tamoxifen therapy. The ASCO guidelines cited above provide rigorous data in support of tamoxifen. A longer trial of tamoxifen is warranted in this patient and if the drug becomes absolutely intolerable, a switch to exemestane may be appropriate after oophorectomy. However, according to randomized clinical studies cited in the U.S. Food and Drug Administration approval history of exemestane, the rate of musculoskeletal complication in postmenopausal women was about the same with exemestane or tamoxifen. All told, the medical necessity of Aromasin (exemestane) has not been established in this case.  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 medical oncology and hematology 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 inpatient mental health services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that upon review of the patients submitted documentation, the patient was not a danger to herself or others; she denied auditory or visual hallucinations; she was cooperative and easily re-directed; and her affect was bright. The records indicate that the patient showed no behavioral problems or agitation. Her level of agitation had improved and she was not hostile. The patient was observed as cooperative with her care, eating and sleeping well. Further indicated was that her medication regimen was stable. She did not experience any adverse events. Thus, the patient no longer met medical necessity criteria for inpatient mental health level of care. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients behavioral health conditions. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Mobi-C level total disc replacement for treatment of her medical condition. Findings:  Two physician reviewers found that evidence-based, peer-reviewed literature supports the use of two-level contiguous cervical artificial disc replacement as an option over anterior cervical discectomy and fusion for the treatment of symptomatic degenerative disc disease.  This patient presents with persistent severe neck and upper extremity pain and progressive weakness.  Clinical examination findings are consistent with two-level contiguous cervical degenerative disc disease with moderate to severe stenosis.  There is evidence of comprehensive non-operative treatment without sustained benefit.  The use of two-level artificial disc replacement will allow for motion preservation, which would be sacrificed with the use of fusion. Therefore, the requested Mobi-C two-level disc replacement is likely to be of greater benefit than other treatment options.  Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested bronchial thermoplasty for treatment of his medical condition.  Findings:  Two physician reviewers found that in this patients case, the medical records fail to demonstrate the superior benefits of the requested services.  This patient is on a combination inhaler and the medical record indicates that he was just started on a long-acting anti-muscarinic agent which has proven beneficial in poorly controlled asthmatics.  The effects of this additional medication have yet to be determined in the patient. Further, there is no mention of an IgE level or any consideration for omalizumab therapy, which has been shown to improve outcomes in patients with poorly controlled allergic asthma.  In sum, the superior effectiveness of bronchial thermoplasty has not been established. Final Result: Two reviewers determined that the requested services 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in pulmonary 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 the evaluation of her medical condition.   Findings:  Three physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. There is better detection of abnormalities when separating the various layers of breast tissue. This technique has been shown to be most useful in the evaluation of the dense breast.  As noted in a paper by researchers, this 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. In another study, researchers state that the addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate. In addition to evaluating dense breasts and breast masses, the same principle can be applied to evaluating calcifications. In a research study, the clarity with which calcifications were seen on digital breast tomosynthesis (DBT) was equal to or better than conventional mammography (CM) and in almost half, the clarity on DBT was judged to be better than for CM. In this particular patient, her breasts have been described as being heterogeneously dense.  It is specifically those patients with dense breasts who benefit most from tomosynthesis.  In addition, the presence of the micro calcifications would not have been noted without the use of tomosynthesis. All told, the use of tomosynthesis for this patient 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 service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in radiology with sub-specialty certification 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.  Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  The primary rationale for breast tomosynthesis is the ability to separate out overlapping tissues in patients where the overall density of the breasts makes visualization of fine detail confusing.  It is specifically in those patients with dense breasts that the greatest value of tomosynthesis is found.  Thus, breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.  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 Juvederm injections for treatment of her medical condition.  Findings:  The physician reviewer found that in this patients case, the condition constitutes an abnormal structure of the body.  The patient has evidence of lesions/changes that are consistent with chronic biting.  The patient also has some evidence of facial soft tissue atrophy.  This would be considered abnormal.  The chronic biting provides a form of trauma that has led to the lesions/condition.  However, the requested services will not be performed to improve function.  The use of Juvederm as a functional treatment of her chronic biting is not a standard therapy.  In addition, conservative management and other treatment choices have not been adequately documented.  Juvederm can be used to create a more normal appearance, if there is evidence of significant soft tissue loss of the face, which is not present in this case.  Additionally, the services are not likely to provide more than a minimal improvement in the appearance of the patient.  In this case, her facial abnormality is not well-defined to be significant enough to warrant soft-tissue augmentation and thus, one cannot determine if more than a minimal improvement would be likely.  Although the patient states that the Juvederm is being performed for functional reasons, it is not clear that soft tissue augmentation would be the treatment of choice in preventing chronic mucosal injury.  All told, the requested Juvederm injections are not reconstructive in nature and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not reconstructive in nature and 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 plastic 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Dapsone for treatment of his medical condition. Findings:  The physician reviewer found that the current medical evidence does not support the requested medication in this clinical setting.  Per the medical literature, there are numerous topical and systemic therapies which are available for the treatment of psoriasis.  Treatment modalities are chosen on the basis of disease severity, relevant comorbidities, efficacy, and evaluation of individual patient response. It is recommended that patients with mild to moderate plaque psoriasis be initially treated with topical corticosteroids and emollients. Combination regimens may be required, including localized phototherapy.  Most patients with moderate to severe plaque psoriasis should be initially treated with phototherapy if feasible. In this case, the patient has a diagnosis of psoriasis.  Dapsone is not a medication indicated in first-line treatment for this condition.  All told, Dapsone is not medically indicated for the treatment of this patient. 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 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 the LINX Reflux Management System for treatment of his medical condition.  Findings:  Three physician reviewers found that the LINX Reflux Management System has been approved for lower esophageal sphincter augmentation.  Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  However, the data to date on LINX is observational in nature and not generated from controlled, randomized trials.  Long-term efficacy and safety compared to other approaches such as traditional fundoplication or intensified medical therapy is not available.  Therefore, the requested LINX Reflux Management System is not likely to be of greater benefit than other treatment options. Final Result: Three reviewers determined that the requested services 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: 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.