Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Daklinza 60 mg tablets and Sovaldi 400 mg tablets for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that The American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) treatment guidelines specific to the patients circumstance, genotype 3, treatment-naive patients without cirrhosis recommends the following treatment regimen: Daily daclatasvir 60 mg plus sofosbuvir 400 mg for 12 weeks. While this patients records may not support advanced fibrosis, the AASLD/IDSA guidelines support the medical necessity and medical appropriateness of HCV treatment. Per the guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The patients available record supports that her life expectancy exceeds this limit. 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: Physician reviewer number one 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 reimbursement for a digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Tomosynthesis was also approved by Centers for Medicare and Medicaid Services (CMS) for reimbursement in 2014. The American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. Final Result: Two of the 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: Physician reviewers number one, two and three are board certified in diagnostic radiology and are actively practicing. The 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 a nine-year-old enrollee has requested intensive outpatient rehabilitation program for treatment of the enrollees stroke with left-sided hemiplegia. Findings: The physician reviewer found that based on the documentation submitted for review, the patient has a history of an ischemic stroke of hemispheric subcortical origin. Intensive rehabilitation therapy as an outpatient to stabilize and recover neurologic function is medically necessary. Intensive physical and occupational therapies are the standard of care in this clinical setting. The specific treatment provided by the Kennedy Krieger Institute that includes pediatric rehabilitation, physical therapy, occupational therapy, neuropsychology, is medically necessary to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes. All told, the requested intensive outpatient rehabilitation program at the frequency of five days per week for four weeks has been established as medically necessary for treatment of the patients medical condition.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 neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
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 medical condition. Findings: Two physician reviewers found that the breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. In addition, there is support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, as in this case.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. The 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 biventricular pacemaker for cardiac resynchronization therapy for treatment of the enrollees medical condition.  Findings: Two physician reviewers found that based on the records provided, the patient has high rate atrial fibrillation not controlled on medication. She has Class III New York Heart Association (NYHA) congestive heart failure and cardiomyopathy. However her left ventricular ejection fraction was not documented. In this circumstance, if the ejection fraction remains less than 35%, the usual accepted criteria for a biventricular pacemaker are met. Per the providers note dated 7/12/16, the patients ejection fraction is greater than 35%. Given that the patients ejection fraction is not less than 35%, biventricular pacemaker for cardiac resynchronization therapy is not likely to be more beneficial for treatment of the patient's medical condition than any alternative therapy.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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The 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 panniculectomy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical documentation does not support that the patient has evidence of a significantly overlapping abdominal pannus.  The photographs do not show evidence of a significantly overhanging abdominal pannus that would be addressed with a panniculectomy.  He does not have a well-defined functional deficit that would likely be treated with a panniculectomy.  Although the records note chronic back pain, abdominal examination and submitted photographs do not provide evidence that a panniculectomy would likely improve his condition.  Therefore, the requested panniculectomy is not medically indicated 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 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 Restasis for treatment of the enrollees medical condition. Findings: The physician reviewer found that according to the documentation submitted for review, treatment with Restasis for this patient has not been established medically necessary. There is scant evidence in the medical literature that supports Restasis for the treatment of peripheral ulcerative keratitis that is resistant to other forms of treatment. In addition, there is a lack of evidence linking Restasis as a preventive or prophylactic treatment for peripheral ulcerative keratitis or Terrien marginal degeneration. In sum, the requested Restasis 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 ophthalmology 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 residential treatment services for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was not reporting post-acute withdrawal symptoms.  The patient had not received a detoxification protocol.  The patient did report ongoing cravings, depression, and anxiety.  The patient was medically and psychiatrically stable.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  There were no reported attempts to treat her at a lower level of care, such as intensive outpatient programming.   Although she continued to struggle with her emotions and required further treatment to help her develop and solidify coping skills, she no longer required the structured environment of a residential setting and could have continued at a lower level of care.  Therefore, residential treatment services were not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested computed axial tomography (CAT) scan for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that based on the records provided, this patient has significant coronary risk but no documented symptoms or findings of coronary disease.  In this circumstance, guidelines for the evaluation and management of coronary risk are available, periodically updated and endorsed by several national organizations.  These guidelines currently do not recommend routine screening with cardiac CAT scan for calcification scoring.  Cardiac outcomes have not been demonstrated to improve with the routine use of cardiac CAT scanning incremental to that achievable based on therapy guided by a combination of clinical profile and basic lipid analysis.  Routine screening cardiac CAT scanning is not considered standard accepted practice in the medical community in this setting.  Therefore, the requested CAT scan is not likely to be superior over other methods of evaluating this patient.Final Result: Two 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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The 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 autologous chondrocyte implantation for treatment of the enrollees medical condition.  Findings: Three physician reviewers found that the current medical evidence supports the requested services in this patients case.  The peer-reviewed literature supports autologous chondrocyte implantation for large patellar lesions in patients who failed operative and nonoperative treatment.  This patient presents with persistent and worsening right knee pain that significantly limits her activities of daily living.  There is imaging evidence of full thickness chondral loss of the medial facet of the patella.  She has failed long-term comprehensive operative and nonoperative treatment.  Detailed evidence of long-term comprehensive treatment and failure has been submitted.  In sum, the requested autologous chondrocyte implantation is likely to be more efficacious than other treatment options.Final Result: Three 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 physician reviewers are board certified in orthopedic surgery and are actively practicing. The 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 risk for breast cancer. Findings: Three physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, the breast tomosynthesis that 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 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: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The 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 Otezla tablets for treatment of the enrollees chronic plaque psoriasis.  Findings: The physician reviewer found that the requested medication is medically necessary in this clinical setting.  In accordance with professionally recognized standards of care, Otezla is prescribed for treatment of chronic plaque psoriasis. In a letter, the provider stated that the patient has tried and failed other therapies but did well with the Otezla samples. Per the provider, the patient has tried Clobetasol and failed. Moreover, this patient is at child bearing age so treatment with methotrexate, cyclosporine, and acitretin are not recommended because of the serious complications these medications may cause with pregnancy. Otezla is a medication that is standard therapy for treatment of chronic plaque psoriasis. All told, the requested medication is medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The physician 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 reimbursement for the genetic test for evaluation of the enrollees risk for cancer. Findings:  The physician reviewers found although this patient does not have a personal history of cancer the patient has an ovarian cyst and a strong family history of cancer, especially on paternal side where they are diagnosed at a young age. The patient also has family members on mothers side with cancer. Thus, The patient meets criteria per the National Comprehensive Cancer Network (NCCN) guidelines for testing for BRCA1 and BRCA2. Final Result: Two of three reviewers determined that a portion of the testing 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 partially overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and actively practicing. The 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 reimbursement for acute level of care services for treatment of the enrollees behavioral problems. Findings:  The physician reviewer found that the patient did not demonstrate suicidal or homicidal ideation. The patient was no longer significantly aggressive or impulsive in behavior, nor was a danger to self or others, and was ready to resume in what was a highly contained environment with full time caregivers. The patient was cooperative and medically tolerated her medication regimen. In addition, a highly developed discharge plan was in place including multiple full time caregivers. The patient's care became custodial in nature. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hypoglossal nerve stimulator for treatment of the enrollees medical condition. Findings:  The physician reviewers found that The patient has nasal obstruction and erythema of the hypopharynx on examination which is likely due to his reflux and/or smoking. Nasal obstruction worsens OSA. Treatment of the nasal obstruction with medication or surgery is indicated. In addition, the patient likely suffers from laryngopharyngeal reflux (LPR). Treatment of LPR and the nasal obstruction can help the patient tolerate the CPAP device. Furthermore, there is a lack of evidence showing that the patient has tried other treatment options such as bi-level positive airway pressure (BiPAP) or automatic positive airway pressure (APAP) devices which are generally more tolerated than CPAP. Final Result: The reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in otolaryngology and actively practicing. The 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.