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

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested residential behavioral health treatment services for the 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.  The patient was cooperative and actively participated in all aspects of his treatment program.  He became more positive in his outlook, his mood stabilized, and he was getting along with his parents.  He had improved and no longer required the structured setting of a 24-hour residential center.  His living environment would not have undermined ongoing treatment at a lower level of care.  His parents were supportive and actively involved in treatment.  The current medical evidence does not support the services at issue in this clinical setting.  All told, residential behavioral health treatment services at issue 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 a water circulating cold pad with pump for treatment of her medical condition.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the equipment at issue.  Researchers concluded that the potential benefits of cryotherapy on blood loss, postoperative pain, and range of motion may be too small to justify its use, and the quality of the evidence was very low or low for all main outcomes.  The authors noted that well-designed randomized trials were needed.  Based upon a review of the recent literature, the routine use of continuous flow cryotherapy after a total knee arthroplasty is not indicated.  The equipment at issue was not and is not likely to be more beneficial for treatment of the patients medical condition than standard cold packs.  Final Result: Three reviewers determined that the equipment at issue was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in 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 testing for level of infliximab as well as antibodies to infliximab for treatment of her Crohns disease.  Findings:  Three physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available options. Monitoring patients on infliximab with measurement of infliximab levels and antibodies to infliximab remains an area of intense investigation. There is a lack of high quality data to support drug level monitoring. Although there is some retrospective data demonstrating that drug levels correlate inversely with disease activity, it has yet to be shown that a strategy of following drug levels is superior to optimal clinical care. Therefore, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the testing at issue was 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: Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. One reviewer is board certified in gastroenterology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with HCV genotype 2 and is expected to prevent further damage of the liver. According to the joint guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) daily sofosbuvir (Sovaldi) and weight-based ribavirin for 12 weeks is recommended for treatment-naive patients with hepatitis C genotype 2. As such, the requested treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C genotype 2. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested intravenous immune globulin (IVIG) therapy. Findings:  The physician reviewer found that PANDAS is a disorder with early and abrupt onset of obsessive-compulsive disorder (OCD) and/or tic disorders subsequent to streptococcal infections. PANDAS is a clinical diagnosis and is suspected in children with an abrupt onset of neuropsychiatric symptoms, recent group A streptococcal (GAS) infection, and remission of neuropsychiatric symptoms with antibiotic therapy. In this case, the clinical evidence submitted for review supports the treatment of IVIG for this patient. Perlmutter and colleagues performed a randomized control trial. The potential benefits of treatment with plasma exchange or IVIG was compared with placebo in 29 children who met PANDAS criteria and were severely affected. Symptom severity was rated at baseline, and at 1 and 12 months after treatment. Significant improvement in symptoms from baseline was noted in the treatment groups at one month and improvements were maintained at one year. In conclusion, the IVIG therapy at issue was medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the therapy at issue was 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 allergy and immunology 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 plasmapheresis for treatment of her medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  First-line treatment for this patients condition consists of systemic immunosuppression with systemic glucocorticoids with or without adjuvant immunosuppressive medications.  Per the medical evidence, patients who do not respond to first-line therapies may benefit from additional interventions.  Treatment regimens which include rituximab, cyclophosphamide, intravenous immunoglobulin, or plasmapheresis may lead to clinical improvement in these patients.  In this case, the documentation does not support that the patient has failed treatment with first-line therapies.  There is no documentation of refractory disease that would require alternative treatment with plasmapheresis.  Thus, plasmapheresis performed was not likely to have been more effective than other alternatives. Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.   Credentials/Qualifications: One reviewer is board certified in internal medicine and is actively practicing.  Two reviewers are board certified in dermatology 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 genetic testing for inherited thrombophilia for treatment of her medical condition. Three physician reviewers found that according to the American Congress of Obstetricians and Gynecologists (ACOG) practice recommendation, testing for inherited thrombophilias in women who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence. There is insufficient clinical evidence that antepartum prophylaxis with unfractionated heparin or low molecular weight heparin (LMWH) prevents recurrence in these patients. In addition, there is insufficient evidence of an association and, therefore, insufficient evidence to either screen for or treat women with inherited thrombophilias and obstetric histories that include complications such as fetal growth restriction or preeclampsia. The only superseding issue would be if the patient had a personal history of venous thromboembolism or a first degree relative with a history of high risk thrombophilia, which was not presented in this case. Therefore, the genetic testing for inherited thrombophilia was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in obstetrics and gynecology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested BRAF genetic testing for evaluation of his medical condition.  Findings: Two physician reviewers found that there is support for the services at issue in this clinical setting.  There is published data from a large retrospective trial that the presence of the BRAF mutation provides additional prognostic information with regards to cetuximab treatment.  The testing performed in this case was standard care.  Therefore, BRAF genetic testing performed was likely to have been more effective than other modalities for evaluating this patient.   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:   One reviewer is board certified in internal medicine and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 the breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The addition of tomosynthesis has gained worldwide popularity among providers due to an associated decrease in callbacks and increase in detection of small cancers. This advantage is particularly evident in patients with heterogeneously dense tissue, such as in this case. Tomosynthesis gives providers the ability to sort out dense glandular tissue from underlying mass or architectural distortion. Thus, the addition of the tomosynthesis is likely of more benefit to the patient than digital two-dimensional mammography without tomosynthesis. For the reasons provided, the breast tomosynthesis 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested group speech therapy for social skills for treatment of the enrollees pervasive developmental disorder. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. Social skills groups are effective for teaching social skills and pragmatic language skills to children with autism. In this case, the speech therapy evaluations indicated that the patients pragmatic language skills are not behind enough to require speech therapy. However, the patients overall autism symptoms indicate that she does need intervention. For the reasons stated, group speech therapy for social skills is medically necessary in this clinical setting.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested MRI. An MRI, at this time, will not likely change the patients options for treatment.  The fact that she had a recent episode of trauma is not an adequate reason to have another MRI. If plain x-rays had demonstrated a significant fracture, then an MRI may be indicated. However, even if she had a microfracture or minor compression, an immediate MRI would not be of significant prognostic value. As stated in the literature All of the guidelines emphasize the importance of a focused history and thorough physical examination before any imaging is ordered. In addition, all agree that for patients with acute [lower back pain] LBP and without any risk factor for serious spine abnormalities, imaging within the initial 4-8 weeks should not be performed. In this case, there is a lack of rationale supporting an MRI of the lumbar spine as it would not likely change her treatment options. All told, the requested services are not medically necessary in this clinical setting.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 podiatry services for treatment of her toe pain.  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. In this case, the request for a podiatry referral for this patients right foot pain is medically reasonable and necessary. The progress note from the primary care physician documents a hallux valgus and hammertoe deformity of the right foot along with pain to the area. X-rays revealed a hallux valgus deformity with osteoarthritic changes to the first MPJ. The physical findings of pain to the right foot first MPJ area coupled with the x-ray findings of hallux valgus and osteoarthritis changes of the first MPJ together establish the medical necessity for a podiatry referral for treatment. For these reasons, podiatry services are medically necessary for this patient.  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 podiatry 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 a bone mineral density scan for evaluation of her medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  The diagnosis of osteoporosis is made when the patient experiences a non-traumatic fracture regardless of the T-score.  In this case, the patient had a bone density study that indicated osteopenia.  At a later date she presented with an acute compression fracture, apparently not associated to trauma.  A bone mineral density study at this time might be useful to determine whether the patient has experienced significant bone loss in a short period of time, which should prompt the investigation and management of secondary causes for osteoporosis.  All told, the requested bone mineral density scan is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are 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 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 a 12-week course of 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, non-cirrhotic genotype 1 patients who have failed therapy with peg-interferon and ribavirin should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials. For these reasons, the requested treatment with Harvoni for 12 weeks 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.