Persius/hicric huggingface dataset:
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 the enrollee, who presented with right breast nodule.  Findings: Two physician reviewers found that the patient was diagnosed with a right breast nodule.  It is unclear whether this was found on a mammogram or whether this was a palpable nodule.  The patient had a right sided mammogram consisting of both two dimensional images as well as tomosynthesis.  A prior sonogram had identified a 6 mm lobulated nodule in the right breast.  The mammogram images were compared to the prior study as well as additional older mammograms.  The study, no masses, areas of suspicious calcifications, or areas of architectural distortion were identified.  The patients right breast was described as being heterogeneously dense. Following that negative study, it was recommended that she return for a six month follow-up sonogram. The patient requested reimbursement for breast tomosynthesis. The Health Plan has denied reimbursement of the service at issue noting that the service at issue was investigational for the evaluation of this patient. 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 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.  In this particular patient, she has apparently been found to have a right breast nodule.  It is unclear if this was a mammographic/sonographic finding or whether this was a clinically palpable lump.  A prior sonogram did demonstrate a small lobulated nodule.  Regardless, once a nodule has been found, it is imperative to fully evaluate the suspected abnormality.  In addition, the patients breast tissue was described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Therefore, the digital breast tomosynthesis rendered was likely to have been more effective than the available standard methods for evaluating this patient.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested MyRisk gene testing for evaluation of the enrollees breast cancer. Findings: Two physician reviewers found that according to the National Comprehensive Cancer Network (NCCN) guidelines, this patient is a candidate for genetic testing due to the age of diagnosis. Algorithms exist that may focus the genetic testing, but these rely upon a detailed family history. Thus, these algorithms or guidelines do not help patients with de novo mutations or patients with uninformative family histories. The most common candidates are BRCA1, BRCA2, and the genes involved in mismatch repair that are causal in Lynch syndrome. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers). BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers). In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. These are the Amsterdam criteria and the Bethesda consensus guidelines. Notably, the Amsterdam criteria have low sensitivity in HNPCC detection, however, these guidelines are highly focused on patients with colorectal cancer who have microsatellite instability although the occurrence of microsatellite instability in other Lynch syndrome associated tumors was discussed. The MyRisk panel is appropriate since the patients current clinical situation may be caused by several potential cancer-causing genes. All told, the MyRisk gene testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that 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 overturned.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and is 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: The parent of a male enrollee has requested authorization and coverage for speech therapy at the frequency of one hour per week for treatment of the enrollees autism spectrum disorder and pragmatic language disorder. Findings:  The physician reviewer found that review of the submitted documentation fails to demonstrate the medical necessity of speech therapy. The review by colleagues provided analysis of the effectiveness of commonly used interventions for social pragmatic interventions for children with autism and social communication disorders. The authors found that several evidence-based social skills interventions are emerging, including peer mentoring, social skills groups, and video modeling. According to the documentation submitted for review, this patient has age appropriate expressive, receptive and articulation skills on standardized testing. Given the patients normal receptive and expressive language skills confirmed on testing and mild pragmatic language delay, a social skills group or play group is indicated to address his social interaction challenges. In addition, ABA treatment is likely to be more beneficial than speech therapy for treatment of his lack of eye contact and repetitive behaviors. For the reasons stated, the request for speech therapy at the frequency of one hour per week is not medically necessary in this clinical setting. 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 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 authorization and coverage Tanzeum for treatment of the enrollees type 2 diabetes. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. Albiglutide is a long-acting glucagon-like peptide-1 (GLP-1) receptor agonist (RA) that lowers glycosylated HbA1c and reduces weight by stimulating glucose-dependent insulin secretion, suppressing glucagon secretion, delaying gastric emptying, and promoting satiety. One study performed a large meta-analysis of the efficacy of GLP-1 receptor agonists and found that compared with other antidiabetic agents, once-weekly GLP-1 RAs outperformed sitagliptin, daily exenatide and insulin glargine in terms of HbA1c-lowering. Another study showed that Weekly albiglutide is a simpler therapeutic option than thrice-daily lispro for advancing basal insulin glargine therapy, resulting in comparable HbA1c reduction with weight loss and lower hypoglycemia risk. In addition, the American Diabetes Association support the addition of the weekly GLP-1 receptor analog Tanzeum to patients regimen of basal insulin and Jardiance. In this case, treatment with Tanzeum is likely the best option for this patient with uncontrolled diabetes. Tanzeum will promote the release of insulin from pancreas in patients with diabetes type 2, and will also decrease gastric emptying causing early satiety and weight loss. This effect is a key for the management of this patient with morbid obesity and other comorbidities. Increasing insulin, may promote weight loss and or make weight loss efforts more difficult. In addition, it is well know that insulin increases fluid retention which could be dangerous for this patient with cardiomyopathy. Treatment with Tanzeum samples have helped the patient to improve her diabetes control as her HbA1c has fallen under 10%, and her glucose levels are close to goal. As such, Tanzeum has been established as medically necessary for treatment of the 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 reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 celiac plexus nerve block for treatment of the enrollees chronic abdominal pain. Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Celiac disease can be a cause of abdominal pain (Mahadov, et al).  Celiac plexus block is an effective therapy for chronic abdominal pain due to a number of causes, as the plexus provides sensation information from the liver, pancreas, spleen, omentum, alimentary tract to the mid-transverse colon, adrenal glands, and kidney.  It can decrease the need for opioid medications, which have risks (Rana, et al; Fields, et al).  Celiac plexus block is a relatively safe method to control abdominal pain that is unresponsive to medical treatments in patients with benign disease (Soweid, et al).  As such, celiac plexus block has demonstrated efficacy in this case.  For these reasons, celiac plexus block is supported as medically necessary for the treatment of the patients chronic abdominal pain.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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi for treatment of the enrollees chronic hepatitis C virus genotype 3.  Findings: The physician reviewer found that according to guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions. Patients with cirrhosis are high priority for therapy. The AASLD/IDSA guidelines cite data showing decreased survival with delay in therapy (Jezequel, et al). The ALLY-3 study demonstrated 71% cure rates in Sovaldi-experienced patients after 12 weeks of Sovaldi/Daklinza therapy (Nelson, et al). The AASLD/IDSA guidelines use this evidence to make a Class IIa, Level C recommendation to treat Sovaldi-experienced patients with 24 weeks of Sovaldi, Daklinza, and ribavirin. The use of PEG-interferon and ribavirin with Sovaldi is not recommended. Therefore, the requested therapy with Sovaldi for 24 weeks (to be used with Daklinza and ribavirin) 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 mental health residential treatment program for treatment of the enrollees major depressive disorder.  Findings: The physician reviewer found that the request for a 30-day mental health residential treatment program is not medically necessary for treatment of the patients medical condition. Although episodic placement at higher levels of care is often necessary, modern psychiatric practice aims to place patients in the least restrictive treatment setting to optimize treatment gains and foster autonomous resilience. In this case, the record does not support the medical necessity of placement in a structured and contained residential treatment setting. Despite the diagnoses of depression and anxiety, the patient does not have psychosis, suicidality, or substance use. He is cooperative, engaged in treatment and well-supported by family. He has made modest progress in treatment thus far. The documentation provided for review does not detail prior interventions tried and failed such as a psychiatric/psychological evaluation, serial progress notes, mental status evaluations, clinical rating scales and clinician assessments would be useful in demonstrating the longitudinal illness burden, and its refractoriness. Moreover, it does not appear that standard therapies have been exhausted in this case. The application of cognitive behavioral therapy is an evidence-based intervention for major depressive disorder, however, other therapies such psychodynamic therapy and interpersonal therapy share similar endorsement and may represent reasonable alternatives. Further, the there is no mention of wellness- and community-based interventions, such as exercise, support groups, mindfulness and meditation, which can capitalize on therapeutic gains and meaningfully address at least some impairing symptoms. Although treated with psychotropic medication, there is no report of past trials which introduces the possibility that an alternative standard pharmacologic regimen may be effective. In addition, there is a lack of evidence that specialty services provided in an intermediate setting would be inadequate, inappropriate or unsuccessful based on the patients condition and reported clinical progress with outpatient services. In sum, residential treatment is not medically necessary for the 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 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 acupuncture services treatment of the enrollee who has been diagnosed with malignant stage 4 glioblastoma. Findings: The physician reviewer found that there is a lack of evidence based studies supporting acupuncture as an effective analgesic adjunctive method for cancer patients or for chemotherapy induced peripheral neuropathy. The medical literature suggests that more research needs to be performed as to the efficacy of acupuncture in the treatment of cancer patients. In addition, the submitted documentation, in this patients case, does not support an objective improvement in the use of acupuncture. Therefore, the acupuncture services rendered were not and are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were not and 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 oriental 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for one-on-one applied behavioral analysis (ABA) support to be provided at school for treatment of the enrollees autism.  Findings:  The physician reviewer found that the request for one-on-one ABA support to be provided at school has been established as medically necessary for treatment of the patients autism. ABA is medically indicated for the treatment of children with autism. Studies shows that ABA started at a younger age provides improvements in cognitive skills, adaptive skills and language skills. In addition, the American Academy of Pediatrics state that for the management of children with autism spectrum disorder, a comprehensive program is important and that the program should be done in natural settings such as home and community as well as structured settings such as school. In this case, the patient has issues with non-compliance. In this clinical setting, one-on-one ABA support is appropriate in the school setting. However, the one-on-one ABA support should continue through the current school with the plan to transition the behavioral plan to the school team over the course of this school year. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested for a real-time remote 30 day heart monitor for treatment of the enrollees no sustained ventricular tachycardia (NSVT). Findings: Two physician reviewers found that in this circumstance if evaluation for recurrent no sustained ventricular tachycardia or other dysrhythmia is thought to be necessary then Holter monitoring for frequent symptoms or exertional symptoms or off-line self-activated event monitoring for less frequent symptoms should be sufficient in recording cardiac rhythm during palpitations. In addition, off line auto-triggered event recorders should be effective in identifying asymptomatic paroxysmal dysrhythmias. There is no documentation to indicate the patient is not able to effectively manage these types of devices or that these devices have already been tried and failed. Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and/or patient-activated or auto-triggered event recorders appropriate initial tests and standard of care for evaluation of dysrhythmias (Blomstrom-Lundqvist, et al; Crawford, et al). Continuous real-time monitoring by telemetry services is not indicated in this case, since off-line analysis of a patient-activated or auto-triggered event recorder should be sufficient in the identification of dysrhythmias without jeopardizing patient safety. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry has not been shown to improve health outcome compared to standard monitoring techniques. Thus, the use of a real-time 30 day heart monitor is not likely to be more beneficial for treatment of the patients medical condition than available standard therapy.Final Result: Two 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and is 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.