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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested anterior optical coherence for evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that anterior optical coherence tomography was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Anterior optical coherence tomography is indicated for complex cases of angle closure glaucoma to elucidate the pathophysiology of the angle closure. This test can show the exact anatomic features responsible for the closure, which gonioscopy cannot show. Anterior optical coherence tomography is particularly effective for patients with plateau iris syndrome, as this testing is able to make a diagnosis after peripheral iridotomy has failed. Also, anterior optical coherence tomography is utilized to follow patients long-term to monitor the configuration of the iris root and ciliary body. All told, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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: All three reviewers are board certified in ophthalmology 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:  The parent of an enrollee has requested A1C, B12, Iron, ferritin, and vitamin D testing for evaluation of the enrollees medical condition.   Findings:  The physician reviewer found that in this clinical setting, the submitted records support the medical necessity of the requested tests.  The American Diabetes Association (ADA) has established screening criteria for testing for type 2 diabetes or pre-diabetes in asymptomatic children. However, the ADA does not provide specific criteria for screening for other types of diabetes in youth. Based on the information provided, the patient would not strictly meet ADA criteria for screening for type 2 diabetes. But, as the nature of the parents pre-diabetes is unknown, it is possible that this patients parent may have a form of MODY (monogenic diabetes) which can be inherited in an autosomal dominant fashion. Therefore, it is reasonable to obtain a screening A1C test for the patient. As to the screening for other nutritional deficiencies, the patient is noted to have poor intake of fruits, vegetables, and dairy products. Vitamin D deficiency is common in adolescents, even in sunny areas.  It is reasonable to screen the patient for this deficiency during the adolescent period of maximal bone accretion to prevent long-term sequelae of vitamin D deficiency on bone mineral density. Iron deficiency in a menstruating adolescent female who does not consume adequate iron in her diet is also common, and screening is justified based on this patients dietary history. Furthermore, folate and B12 deficiency, although much less common, may be of concern if there is inadequate intake of these nutrients in the diet or any concerns about malabsorption. For all these reasons, the requested tests are medically indicated for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested tests 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 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 continued skilled nursing facility services and stay, including rehabilitative physical therapy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. There were no identified skilled nursing needs including rehabilitative physical therapy for this patient. The patients care needs can be appropriately met at an alternate level such as with home based services or at a custodial level until her weight-bearing status is advanced. The patient is status post multi-trauma with orthopedic precautions including touchdown weight-bearing on the right which can be considered as even more restrictive than non-weight-bearing and is intended to prevent both traction and compressive forces across the limb. The patients orthopedic precautions are ongoing and will likely continue at least until the end of July. The records submitted indicate that the patient has reached a plateau at her level of function consistent with her orthopedic injuries and precautions. The expectation of significant functional progress in a reasonable and predictable time cannot be established. All told, the requested services are not medically necessary for 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 physical medicine and rehabilitation 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 medications Tafinlar 75 mg and Mekinist 2 mg for treatment of the enrollees metastatic adenocarcinoma of the cervix. Findings: Three physician reviewers found that Tafinlar in combination with Mekinist are approved for use in the treatment of metastatic melanoma who have a BRAF V600 mutation. There is very little information on the presence of BRAF mutations in cervical cancer and a lack of support for the use of these drugs in cervical cancer. These drugs are also not within National Comprehensive Cancer Network Guidelines for treatment of adenocarcinoma of the cervix. The study by Le Tourneau and colleagues indicated that choosing chemotherapeutic agents just by molecular assays is not better than conventional therapeutic decisions. Due to lack of clinical data in medical literature to support treatment of adenocarcinoma of the cervix with Tafinlar 75 mg and Mekinist 2 mg, the requested medications are not likely to offer clinical benefit when compared to conventional standard therapies.Final Result: Three reviewers determined that the requested medications 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 physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy for treatment of the enrollees medical condition. Findings:  The physician reviewers found that the patient presents with a non-length dependent small fiber sensory neuropathy as documented by skin biopsy and diffuse neuropathic pain. The patient suffers from moderate to severe pain which has partially responded to some of the medications including opiates. In this clinical setting, it is vital to determine an etiology and evaluate certain markers. Elevated spinal fluid protein and possible presence of oligoclonal banding suggests an underlying autoimmune etiology. The documentation submitted for review does not support an autoimmune etiology. The patient has not had a spinal fluid analysis. Furthermore, non-length dependent small fiber sensory neuropathy is rare and there are only small open label retrospective reports of treatment cited in the medical literature. Some patients responded to oral anticonvulsant type medications, but the patients often require a combination of three different therapies to obtain a good response. A good response to prednisone in some patients and others who did respond to IVIG. Immunotherapy be reserved for patients who have failed standard therapy and have evidence of autoimmunity. This patient has not yet tried several of the standard therapies including a combination that contains amitriptyline, and corticosteroids. Final Result: Two of three reviewers determined that the requested medication 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: Physician reviewers number one, two, and three are board certified in neurology and 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 breast tomosynthesis for evaluation of the enrollees risk for breast cancer.   Findings:  The physician reviewer found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. Final Result: Two of the 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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: A enrollee has requested reimbursement for inpatient psychiatric hospitalization for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that Although the patient denied acute suicidal ideation, treatment could not have reasonably been conducted at a less restrictive setting because less intensive treatment would have resulted in inadequate care. The patient had neither resolved the illness burden that prompted the admission nor consolidated the treatment gains necessary to successfully follow through with outpatient treatment services. The patient had a refractory affective disorder.  The patient  had an anxious-depression, the combination of which is difficult to treat and associated with poorer outcomes. The patient  was psychiatrically hospitalized two weeks prior to this admission.  The patient  had trialed many medications.  The patient  suffered from opioid misuse which further compromised her prognosis.  The patient reported increased neck pain. The patient was feeling hopeless. The patient's appetite had decreased and her sleep was poor.  It was further noted that the patient's energy level was low, mood was anxious and was depressed. The provider began considering the possibility of electroconvulsive therapy and transcranial magnetic stimulation. The patient was lethargic and depressed, mood remained irritable, with little improvement. Nursing notes indicated that the patient was anxious, isolative and restless. The acute setting remained safe, appropriate and reasonably expected to improve the patients condition while preventing a more serious episode of illness. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Specifically, the Health Plans denial should be overturned. 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 a knee scooter for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  There are very limited high-quality data published with respect to the rehabilitation of ankle fractures outside of basic interventions such as weight-bearing restrictions.  In this case, the patient sustained an ankle fracture and has non-weight-bearing restrictions on the affected limb.  Per the medical records, there are no other significant impairments.  This patients mobility-related activities of daily living can be met with the approved durable medical equipment.  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 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 Harvoni 90-400 mg tablets for 12 weeks for treatment of the enrollees 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.  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 (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage.  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: Physician reviewer number one 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 breast tomosynthesis. Findings: Three physician reviewers found that the patient had an automated whole breast sonogram exam as well as a targeted left breast sonogram. The targeted sonogram revealed a small benign appearing intra-mammary lymph node in her left breast. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. The patients breast tissues were described as being very dense. 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 (CT) 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 the dense breast.  Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there have been no changes when compared to prior studies.  In this clinical setting, the patient has dense breast tissue. It is specifically those patients who have dense breasts that can benefit most from breast 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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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: 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 medical literature supports breast tomosynthesis in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and biopsies and increase in detection of small cancers when compared to two-dimensional imaging alone.  Thus the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: Three 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: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Otezla 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.  Per the medical records, there is no documented adverse effect or contraindication to the use of methotrexate or cyclosporine.  The records do not demonstrate that the patient has tried and failed therapy with ultraviolet light treatments.  Acitretin is not a favored therapy for women of childbearing age, but there are other systemic options which have not been pursued.  Additionally, the patient does not show an intolerance or contraindication to the use of injectable biologic agents.  As there are several other therapies which are considered first-line, the requested medication Otezla is 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 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: An enrollee has requested 16 hours total of skilled nursing services per day, including eight hours of skilled nursing services previously mandated by independent medical review for treatment of her medical condition. Findings:  The physician reviewer found that the request for 16 hours total of skilled nursing services per day, including eight hours of skilled nursing services previously mandated by independent medical review has been established as medically necessary in this clinical setting. According to the documentation submitted for review, the patient presents with ALS and receives hospice care in the home setting. According to Newman and colleagues Continuous care most commonly is provided for two to three days; however, it can remain for a longer period of time if the acute medical crisis continues and the goal is for the patient to remain at home. The authors note that intensive home hospice services can be necessary to meet the goals of the patient. In this case, the patient is dependent for self-care, functional mobility, feeding and breathing. Tiirola and colleagues found that respiratory symptoms are a significant problem for ALS patients in hospice. Patient positioning is an important part of managing these symptoms as is care of the tracheostomy. In this case, there is sufficient support for the medical necessity for the requested services for treatment of the patients medical condition. 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 physical medicine and rehabilitation 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.