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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a hospital grade electric breast pump for treatment of her medical condition.  Findings:  The physician reviewer found that upon review of the submitted documents as well as the relevant literature, a hospital grade electric pump is medically necessary in ensuring that this patient is able to feed her infant. The American College of Obstetricians and Gynecologists Committee (ACOG) have weighed in on this issue as it relates to breast pumps and advocating for removal of barriers to the process of breast feeding. There is growing support for delivery of breast pumps as part of womens preventative health services. It is prevailing opinion that there should be a mechanism to support and help achieve the successful process of providing human breast milk to infants during the first year of life. Also, the majority of womens and infant care organizations agree that all efforts to assist the infant and nursing mother through the process should be supported. Major medical association guidelines do not require that the nursing mother show a need for a breast pump; but instead, these associations base their recommendations on the more global process of supplying a newborn breastmilk in whatever means that can be best achieved. For these reasons, the requested hospital grade electric breast pump is medically necessary to ensure the patient is able to nurse her infant.  Final Result: The reviewer determined that the requested device 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 obstetrics and gynecology 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 magnetic resonance imaging (MRI) of the back for evaluation of his medical condition. Findings: The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. The physician emphasized the importance of a focused history and thorough physical examination before any imaging is ordered. In addition, for patients with acute lower back pain and without any risk factor for serious spine abnormalities, imaging within the initial weeks should not be performed. The American College of Radiology (ACR) has established appropriateness criteria for the evaluation of low back pain and has defined several variants of low back pain. The ACR states that an MRI is not warranted in the acute setting. In the setting of low back pain in which the patient is a candidate for surgery or other intervention, then the ACR considers an MRI to be the most appropriate study, with no stipulation about delaying the MRI. In this case, the submitted records do not indicate that he is a potential candidate for surgery or that he is a candidate for intervention. Current research supports that prior to an intervention, it is recommended to attempt a trial of conservative treatment such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs. All told, given the current guidelines and submitted records, the requested MRI of the back is not indicated for this patient.  Final Result: The reviewer determined that the requested services are 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials.  For these reasons, 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 anesthesia services administered during an endoscopy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that upon review of the submitted records, this patient presents without comorbidities that would require the services of an anesthesiologist during an endoscopy procedure. The guidelines set by the American Society for Gastrointestinal Endoscopy (ASGE) guidelines and the American Society of Anesthesiologists (ASA) set forth the following: The assistance of an anesthesia specialist should be considered for ASA physical status III, IV, and V patients. Other possible indications for involvement of an anesthesia professional during sedation include emergency endoscopic procedures, complex endoscopic procedures, and patients with a history of (1) adverse reaction to sedation, (2) inadequate response to moderate sedation, (3) anticipated intolerance of standard sedatives (e.g. alcohol or substance abuse), and (4) those at increased risk for sedation-related complications, such as patients with severe comorbidities or with anatomic variants predictive of increased risk for airway obstruction or difficult intubation (e.g. morbid obesity or sleep apnea). In this case, the patient did not present with a significant history that would require the services of an anesthesiologist for the procedure performed. As such, anesthesia services administered during an endoscopy was not medically necessary in this clinical setting.  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 anesthesiology with sub-specialty certification in pain 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Xifaxan for treatment of her medical condition.  Findings:  The physician reviewer found that Xifaxan is U.S. Food and Drug (FDA) approved for the treatment of irritable bowel syndrome with diarrhea. The patient is requesting for Xifaxan to treat small intestinal bacterial overgrowth (SIBO). In this clinical setting there are multiple other antibiotics, alone or in combination, which can be used rather than Xifaxan. These antibiotics, while not compared directly to Xifaxan, are of equal efficacy. In sum, the patients request for Xifaxan for the treatment SIBO has not been established 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/Qualification:  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 and Daklinza for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. In non-cirrhotic genotype 3 patients who have failed peg-interferon and ribavirin, therapy is recommended with Sovaldi and Daklinza for 12 weeks (regardless of interferon eligibility). This is based on the ALLY-3 study, which showed a high cure rate. This patient is ineligible for alternative interferon or ribavirin-containing regimens due to a medical condition which can be exacerbated by interferon or ribavirin. The guidelines cite study data reporting that delay in treatment may result in decreased survival. For these reasons, the requested treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection. 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: 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: 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 the current medical evidence supports the superior efficacy of the patients initial three-dimensional breast tomosynthesis.  However, the follow-up three-dimensional breast tomosynthesis was not likely to have been of greater benefit than other modalities.  Breast tomosynthesis has been associated with a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the two-dimensional images on the initial screening exam was of greater benefit to the patient than had the exam been done with the two-dimensional technique only.  There is a lack of support for the addition of bilateral tomosynthesis as part of the follow-up diagnostic study as it would not have provided additional information not already available.  Final Result: Two reviewers determined that a portion 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 partially 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested genetic testing Decision Dx melanoma assay for evaluation of his medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Decision Dx melanoma assay is utilized to help predict future metastatic risk of his invasive melanoma. In this case, the patient was diagnosed with an invasive melanoma, which requires excision for definitive treatment. Subsequent follow-up is aimed at identifying recurrences or the development of distant metastases. Once metastatic, treatment of melanoma is very challenging and not very successful. The Decision Dx melanoma assay identifies the molecular fingerprint of the melanoma and tests for the expression of genes which have a higher or lower risk of future metastasis.  The patients Decision Dx result showed a pattern of gene expression which is associated with an increased risk of the development of metastatic disease. This information, in conjunction with the diagnosis of invasive melanoma changes the patients treatment course. For instance, with this information, the patient may pursue a more aggressive treatment course with therapy that may otherwise be considered controversial, such as interferon injections or shorten the interval between imaging studies to identify metastatic lesions at an earlier time. All told, the Decision Dx melanoma testing was clinically indicated for treatment of this patients invasive melanoma. Final Result: The reviewer 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:   The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested growth hormone therapy, Genotropin (somatropin) injection, for treatment of the enrollees short stature. Findings:  The physician reviewer found that review of the submitted documentation reveals the patient has extreme short stature with normal weight for height ratio, poor growth velocity, low IGF-1 level, and a delayed bone age. Although her peak GH response on provocative GH testing was normal, she meets standard criteria, as established by the Pediatric Endocrinology Society for treatment with GH. Provocative GH testing has poor sensitivity and specificity for the diagnosis of GH deficiency. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity < 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets at least three of the above criteria and for these reasons, growth hormone, Genotropin (somatropin injection) is 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested transcranial magnetic stimulation therapy for treatment of his behavioral health conditions.  Findings:  The physician reviewer found that transcranial magnetic stimulation is a novel, non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population. A typical treatment course for transcranial magnetic stimulation typically includes 30 to 40 sessions delivered over a course of four to six weeks.  It appears that the patient had a positive response and was tapered from the intervention.  However, there was no recent clinical documentation submitted for review. In sum, the medical evidence does not support continuing transcranial magnetic stimulation therapy while the medical records do not illustrate that standard therapies have been exhausted.  Thus, the requested transcranial magnetic stimulation therapy 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 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 Rituxan infusions for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The provided medical records do not indicate any information regarding the status of multiple sclerosis, symptoms, impact, attack frequency, or prior medication trials.  There is mixed data regarding the effectiveness of Rituxan.  There is a lack of justification in the submitted records to use Rituxan compared to proven, multiple sclerosis disease modification therapies.  All told, the requested Rituxan infusions are 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an endoscopic bilateral lumbar sympathectomy for treatment of her medical condition. Findings:  Two physician reviewers found that the patient has been diagnosed with plantar hyperhidrosis; however there is a lack of verification and quantitation of this diagnosis. There is a lack of verification that the patient has failed tannic acid, glutaraldehyde, anticholinergics, tranquilizers, or certain nonsteroidal anti-inflammatory drugs (NSAID) which are required before considering surgical treatment of plantar hyperhidrosis. Moreover, a medication list for this patient has not been provided to establish that she does not suffer from secondary hyperhidrosis, which can contribute and/or cause plantar hyperhidrosis. There is some promising literature supporting the requested surgery. However, at this time there is a lack of large, prospective, randomized studies showing the long-term safety and effectiveness of surgical lumbar sympathectomy. The studies that are available are of small numbers, short-term, have a high complication rate, a recurrence rate, and have not shown long term safety and effectiveness of this procedure. Thus, in accordance with accepted standards of medical practice, the request for endoscopic bilateral lumbar sympathectomy 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 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 neurological 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested durable medical equipment in the form of an electric wheelchair for her musculoskeletal condition. Findings:  The physician reviewer found that she has not been able to effectively and functionally propel herself for a number of years.  She is dependent upon caregivers to help her navigate her surroundings via her manual chair.  The patient is not able to propel herself in her wheelchair as her body structure, impaired upper body strength, and the supporting surfaces on her wheelchair make it difficult.  With her current wheelchair, she is not able to perform certain activities of daily living.  Further, her social interactions have been negatively impacted by her difficulties with functional mobility. The current medical evidence supports the requested equipment in this clinical setting.  All told, the requested power wheelchair is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 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.