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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a panniculectomy for treatment of ventral hernia and morbid obesity. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The records document a complicated case of recurrent ventral hernia in association with a severely enlarged symptomatic pannus.  The patient is well-documented to have signs and symptoms that are likely associated with her severe abdominal pannus.  This includes chronic back pain, abdominal pain, recurrent rashes and open wounds.  The patient has indications for both procedures, as she has a symptomatic severely enlarged abdominal pannus that has failed reasonable conservative management. The panniculectomy approach can provide adequate exposure for the repair of the complex recurrent ventral hernia.  The current medical evidence supports the recommended combined procedure which includes treatment of her complex hernia. 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the gene test, molecular pathology (mopath) procedure level 7 (CPT code 81406) for evaluation of her malignant neoplasm of pleura.  Findings:  Two physician reviewers found that There are no therapeutic implications for the diagnosis of CADASIL. This patient has diabetes, which is considered a vascular risk factor, and her MRI findings are consistent with vascular changes associated with her specific risk profile. In the absence of a family history of CADASIL and specific MRI changes in the temporal lobes there is a low clinical suspicion of CADASIL. In addition, the yield under these circumstances for CADASIL is not considered to be effective. Final Result: The reviewers determined that the requested testing is 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: Reviewers 1, 2, and 3 are board certified in internal medicine and neurology 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services provided on 10/15/14 and 10/21/14.Findings:  The physician reviewer found that the urgent care services provided on 10/15/14 and 10/21/14 were not necessary for treatment of an emergency medical condition. On 10/15/14, the patient presented with a headache for two days. She denied any other neurologic symptoms. She was not febrile. Her neurologic exam was normal. Her symptoms on this date were not acute in onset. On 10/21/14, the patient presented with complaints of headache and dysuria. She denied any focal neurologic complaints. Her exam was unremarkable. The patient was evaluated the day prior by her primary care provider and a urinalysis had been ordered. Additionally, the patient had been referred for a neurology evaluation. Since this patient had already been examined and treated for these symptoms the day prior, and no acute deterioration had been documented, her symptoms were not necessary for treatment of an emergency medical condition. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospitalization services.   Findings:  The physician reviewer found that the inpatient hospitalization services provided was necessary for treatment of an emergency medical condition. The patient was diagnosed with active labor on her presentation to the local out-of-network hospital. Labor progresses a variable rates and transfer from one hospital to another in the active phase of labor is not advised. On average, iparous women progress from 4 to 10 cm in 5.5 hours, indicating that many women will progress more rapidly than this. Given that the second stage of labor, which includes pushing, typically takes two to three hours, this patient had progressed more rapidly. In addition, epidural analgesia, which this patient received, has been associated with slower progress in labor. Had this patient been transferred to another hospital, she would not have received the epidural analgesia and may have delivered sooner. In addition to the risk of delivery en route, fetal monitoring is required in labor and this cannot be accomplished during transport. For the reasons provided, transfer once active labor has been diagnosed is not recommended unless the initial hospital does not have obstetric facilities. Since the hospital was capable of providing the necessary care, transfer was contraindicated. Accordingly, the services at issue were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal and fetal 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 hyaluronan derivative Hyalgan/Supartz IA injections for treatment of his bilateral knee pain. Findings:  The physician reviewer found that There is support in the medical literature for the requested services in this clinical setting. One study concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Guidelines stated that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high quality scientific evidence. Another study concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. As such, evidence based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. In this patients case, he has a history of bilateral knee osteoarthritis. He reports knee pain and functional impairment in mobility that has failed to respond adequately to other conservative treatment, including corticosteroid injections. Clinical examination findings are consistent with the diagnosis of arthropathy (arthritis). Final Result: The reviewer determined that the services at issue were 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the inpatient psychiatric hospitalization services for treatment of his social anxiety and depression. Findings:  The physician reviewer found that the records document that this patient was not in withdrawals. He was not a danger to himself or others, and he was not gravely disabled. He was cognitively intact and attending to his ADLs. His appetite and sleep were moderate to good. He was medically stable. Psychiatrically he could have been treated at a lower level of care. The patients social interaction was improving, engagement in his treatment plan was improving, and he was cooperative and compliant with his medication regimen, albeit in a perseverative and ruminative fashion. He did not demonstrate impulsive behavior on any level. There was no evidence of imminent risk requiring inpatient stay. Discharge plan was for PHP in his area. He no longer required the structure of inpatient level of care and he could have continued treatment on an ambulatory basis. 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 with sub-specialty certification in addiction 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  The physician reviewer found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. 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: Reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg, one tablet daily for 12 weeksFindings: The physician reviewer found that  according to the recent 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 limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, the requested treatment with Harvoni 90-400 mg, one tablet daily 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for a breast examination. Findings:  The physician reviewer 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.  But in terms of surveillance in patients who have had breast cancer, studies have demonstrated that when digital breast tomosynthesis was applied in a study, screening sensitivity had improved. Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings by proving either a definite benign or malignant diagnosis. Moreover, this study indicated that digital breast tomosynthesis avoided unnecessary biopsies. 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: Reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a power wheelchair for treatment of her contracture of the left knee. Findings:  The physician reviewer found that the requested power wheelchair is not medically necessary for treatment of the patients medical condition. Although power mobility can benefit specific individuals, it is not likely to be of benefit in this clinical setting. In this case, the patient has a personal mobility deficit that has been treated with an ankle foot orthosis and manual wheelchair. The medical records show she has not been walking due to left leg pain, with a return to walking a possibility. The medical records do not show the manual wheelchair to be inadequate for her current mobility deficits. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 reimbursement for continuous positive airway pressure (CPAP) device, along with the following CPAP device supplies: full face mask, tubing, filters, and replacement mask seal for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that there is sufficient support in the medical literature for the device and supplies at issue in this clinical setting. The patient has a diagnosis of OSA and has been on CPAP for several years.  The medical records provided for review have shown that the patient has used his CPAP consistently on a daily basis. The patient has surpassed the minimum standards for compliance as defined in the literature and in the standard guidelines. A portion of the ongoing management of patients with OSA is the replacement of consumable supplies which may include the mask, filters, and tubing, on a periodic basis. In this case, the patient was compliant with therapy and the provision of supplies was consistent with the generally accepted standards of practice and was clinically appropriate.  Final Result: The reviewer determined that the equipment 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 in neurology with sub-specialty certification in sleep 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 authorization and coverage for Cialis and Viagra for treatment of the enrollees malignant neoplasm of the bladder with erectile dysfunction.Findings:  The physician reviewer found that patients who undergo radical cystoprostatectomy are at high risk of developing erectile dysfunction secondary to damage to the nerves associated with erectile function. Therefore, these patients do have organic basis for erectile dysfunction. The treatment of erectile dysfunction is multimodal. Recovery of sexual function can take up to 12 months. Medical therapy for erectile dysfunction including PDE 5 inhibitors can be beneficial. Cialis daily at a lower dose at 5 mg is approved for treatment of patients with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms. However, this patients records do not document a diagnosis of BPH and his complaints focus on urinary retention. He has undergone a bladder replacement therapy. Thus, his urinary symptoms are related to poorly functioning neobladder rather than bladder outlet obstruction. Final Result: The reviewer determined that the requested medications 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 urology 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 reimbursement for residential mental health and substance use treatment program services for treatment of his polysubstance abuse and anxiety. Findings:  The physician reviewer found that the progress notes indicate the patient did not have recent intensive treatment prior to the RTC services at issue. The progress notes report that he did not have any suicidal ideation, psychosis or homicidal ideation. He was cooperative in treatment and was progressing in the residential treatment plan. According to the American Society of Addiction Medicine (ASAM) criteria for level of placement, this patient was a candidate for intensive outpatient program (IOP) services. The patients emotional/behavioral or cognitive conditions and complications suggest the patient had a risk rating score of 1 indicating mild issues that are stable. In addition, the patients recovery/living environment suggest the patient had a risk rating of 1 due to a sober living environment. Overall, the patients presentation suggests risk rating scores in the 0 to 2 range. This overall risk rating recommends the patient be treated with IOP services for nine or more hours of service per week. IOPs allow individuals to remain in their own homes and communities, which may improve their adjustment to community life. Researchers noted that IOPs are an important part of the continuum of care for alcohol and drug use disorders. They are as effective as inpatient treatment for most individuals seeking care. Public and commercial health plans should consider IOP treatment as a covered health benefit. Standardization of the elements included in IOPs may improve their quality and effectiveness. 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.