Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral digital breast tomosynthesis  for the enrollees breast cancer screening. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography 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, her breast tissue was described as very dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: The reviewers determined that the service at issue was likely to have been 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 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

An enrollee has requested authorization and coverage for the weight loss medication Saxenda.  Findings:  The physician reviewer found that Saxenda is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index of 30 or greater or 27 or greater in the presence of at least one weight-related comorbid condition.  The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention: a combination of diet, exercise, and behavioral modification.  The patient had been tolerating Saxenda and had lost 16 pounds while on the medication.  Given the documentation that supports the patient has obesity with a body mass index of 40.75, has had previous treatment with diet and exercise without successful weight loss, and has had success with weight loss while taking Saxenda. Final Result: the physician reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. The physician reviewer is board certified in internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for ultraviolet B (UVB) phototherapy treatment twice per week. Findings:  The physician reviewer found that it is unreasonable for the patient to be changed to an alternative systemic therapy with increased potential of side effects rather than continuing a therapy that has been effective for the patient. The request for coverage of narrow band UVB should be approved for this patient, as it has been a proven treatment and is one with fewer potential side effects than the other systemic therapies available for treatment of her plaque psoriasis. Final Result: The reviewer determined that the 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent 75 mg every two weeks for treatment of the enrollees hypertension, hyperlipidemia and an elevated coronary calcium score.  Findings:  The physician reviewer found that Tte request for Praluent 75 mg every two weeks has not been established as medically necessary for treatment of the patients medical condition. Based on the records provided for review, the patient is a 62-year-old female with hyperlipidemia, intolerance to statins and Zetia and no documented significant obstructive coronary or carotid disease.  Praluent is a PCSK9 inhibitor studied and approved for patients with heterozygous familial hypercholesterolemia or patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol. This patient does not meet any of those conditions based on the documentation provided. Specifically, there is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. These diagnoses require not only elevated LDL- cholesterol levels that significantly exceed 180 mg/dL but also a combination of physical exam findings, a strong family history of coronary disease and documented genetic defects related to cholesterol metabolism. PCSK9 inhibitors have not been studied in other patient populations such as this patient. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 authorization and coverage for Ativan for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The records indicate that the patient has been taking the disputed medication.  This makes the overall duration of the medication use approximately 10 months.  During this time, the patient has been documented to have escalated his dose against physician advice.  He has recently requested numerous refills of the medication.  His providers have advised him against long-term use of this medication and advised him against use of this medication with other benzodiazepine medications that he has been taking. The treatment center he has been going to has advised him to continue psychotherapy along with medication management.  The patient was noted to have not been in psychotherapy.  The disputed medication is not medically appropriate for long-term use.  The documentation indicates that his providers have discussed adverse effects of this medication as well.  The current medical evidence does not support the requested medication in this clinical setting.  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 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 authorization and coverage for residential treatment 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 requested services. This patient presented to her provider reporting depression and anxiety.  However, her insight, judgment, and impulse control were all good on mental status examination.  The patient was aware of her deficits and indicated that she could grow up more.  She denied suicidal or homicidal ideation, she was not manic or psychotic, and she was not gravely disabled.  While she did endorse being under a great deal of stress due to finances and poor grades at school, these are not reasons for residential level of care. The records indicate that she was medically stable. She was an active participant in her groups, and she was being seen in individual and medication management appointments.  Final Result: The reviewers 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50 mg/100 mg, one per day for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that there is sufficient support for the requested medication regimen in this clinical setting.  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 (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This recommendation applies regardless of fibrosis score. The guidelines recommend that treatment-naive, genotype 1b patients should be treated with Zepatier for 12 weeks, regardless of NS5A resistance testing results. These guideline recommendations are based on high-quality clinical trial data. The current guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom foot orthotics for treatment of bilateral plantar fasciitis.  Findings:  The physician reviewer found that the submitted documentation supports the requested equipment in this clinical setting.  Evidence-based guidelines generally recommend orthotics devices for plantar fasciitis foot pain in rheumatoid arthritis, and plantar heel pain.  Guidelines state that outcomes from using a custom orthosis are highly variable and dependent on the skill of the fabricator and the material used.  A trial of a prefabricated orthosis is recommended in the acute phase, but due to diverse anatomical differences, many patients will require a custom orthosis for long-term pain control.  This patient presents with a diagnosis of bilateral plantar fasciitis.  Clinical examination findings documented a cavus foot with restricted range of motion and bilateral hallux valgus.  The records document a history of custom orthotic wear to treat her bilateral plantar fasciitis and high arches.  There is evidence-based medical guideline support for custom orthotic use for long-term pain control for plantar fasciitis foot pain.  All told, the requested custom foot orthotics are 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for biofeedback and rectal sensation testing. Findings:  Three physician reviewers found that, based on the records provided, there is a lack of support for biofeedback and rectal sensation testing.  There is a significant amount of important information to be gained from a careful rectal examination as well as examination of the perineum during attempted defecation.  In many cases, anal manometry is not necessary.  In addition, many patients can have good continence with solid or semi-solid stool.  Controlling the diarrhea can obviate the need for biofeedback.  In sum, the superior efficacy of the requested biofeedback and rectal sensation testing has not been established. Final Result: 2 of 3 reviewers determined that the requested services are not likely to be more beneficial for evaluation and 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 gastroenterology 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 authorization and coverage for genetic testing, CADASIL Lab Test. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The documented neurologic examination is unremarkable, and the medical record does not adequately develop the clinical suspicion of autosomal dominant stroke in the family history in a relatively young person with or without migraine or dementia.  This patients MRI lacks abnormalities in the temporal lobe more specific for CADASIL.  Since there is no adequately documented family history and similar vascular changes can occur in chronic migraine, the medical necessity of the requested services has not been established. Final Result: The reviewers 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 physician 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Xeljanz 10 mg, twice per day for treatment of the enrollees alopecia universalis. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested medication regimen.  The patient has a history of alopecia universalis, with initial positive response to Xeljanz 5 mg, twice daily.  She is requesting coverage for the higher dosage of this medication, as her current dosage has lost its effectiveness.  Recent studies have identified a better success rate of hair regrowth using Xeljanz 10 mg, twice per day.  The Health Plan has previously approved the request for Xeljanz 5 mg, twice daily.  As there has been a loss of efficacy at the current lower dosage, it is medically appropriate to increase the dose to levels shown in the literature to be most effective in treating this condition.  All told, the requested Xeljanz 10 mg, twice per day is medically indicated for the treatment of this patient. Final Result: The reviewers determined that the requested medication regimen is 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for single photon emission computed tomography (SPECT) scan for evaluation of the enrollees behavioral health conditions. Findings:  Three physician reviewers found that SPECT scanning is a sophisticated nuclear medicine study that examines blood flow in the brain with the assistance of a radioactive tracer that is introduced to the patients body.  Brain activity demands blood flow, so it is postulated that SPECT can provide information regarding hyperactive, suboptimal or normal functionality of specific brain structures and regions.  Advances in neuroimaging techniques, such as SPECT, present an exciting, and potentially useful, expansion of the collective knowledge base.  However, the technology is still in its infancy, and meaningful correlation between clinical presentation and specific brain activity patterns does not yet exist.  Per the records, the patient was prescribed a trio of activating medications including noradrenergic enhancers and a stimulant. This regimen could have contributed to his anxiousness and irritability.  Further, there was no evidence that the patient had failed evidence-based, non-pharmacologic interventions, such as cognitive behavioral therapy, psychodynamic psychotherapy or interpersonal therapy.  Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 are board certified in psychiatry 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 reimbursement for digital breast tomosynthesis who presented for a breast examination. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography 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 breasts that have been described as being extremely dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: The 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: Physician reviewers 1, 2, and 3 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 reimbursement and prospective authorization and coverage of PTNS (percutaneous tibial nerve stimulation) treatments from 11/14/14 forward.Findings:  Two physician reviewers found that the patient has a history of intractable overactive bladder. This patient has tried numerous medications, including anticholinergics, but severe side effects were noted. Prior treatments were not tolerated. Subsequently, the patient tried beta agonist therapy without any improvement in her symptoms. She did have significant relief from percutaneous tibial nerve stimulation therapy. Her symptoms have almost completely subsided. The patient has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) provided from 11/14/14 forward. There is sufficient support for the services at issue in this patients case.  Intractable lower urinary tract symptoms related to overactive bladder can be clinically difficult to treat. Treatment options often have significant side effects and are not tolerable. Therefore, most often this is a multimodal treatment with proceeding to secondary and tertiary treatment options. PTNS is considered as a tertiary treatment option for intractable overactive bladder with urgency frequency syndrome. Furthermore, the records show that this patient has responded positively with this treatment.Final Result: Two reviewers determined that the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in urology 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.