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

Nature of Statutory Criteria/Case Summary: An enrollee has request for Matched Unrelated Donor Search for treatment of the enrollees medical condition.  Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  This patient has a very aggressive case of acute myeloid leukemia (AML). AML of this subtype is highly chemotherapy-resistant.  Thus, allogeneic hematopoietic stem cell transplantation (allo-HSCT) is being considered.  This patients age makes the allo-HSCT procedure a very toxic procedure that must be weighed with the potential benefit of long-term remission.  On the other hand, allo-HSCT has the best prognosis and chance for disease-free survival.  Recent data on reduced intensity conditioning shows some favorable outcomes for older patients.  At this point, there is a lack of alternatives in this setting.  The patients functional age should be taken into account when assessing her as a candidate for an allo-HSCT.  Pursuing a suitable match at this point is medically reasonable and necessary.  All told, the requested Matched Unrelated Donor Search is medically indicated for the treatment of 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 internal medicine with sub-specialty certification in medical oncology and hematology 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 surgical procedure of upper airway stimulation (UAS) of the hypoglossal nerve for treatment of the enrollees obstructive sleep apnea (OSA). Findings:  The 3 physician reviewers found that there is a lack of sufficient support in the peer-reviewed literature showing UAS is superior to CPAP treatment. According to colleagues, UAS is a potential therapy for continuous positive airway pressure (CPAP)-refractory obstructive sleep apnea by hypoglossal stimulation using an implantable, programmable neurostimulator. In this case, the records submitted for review do not demonstrate that the patient has tried and failed an adequate trial of CPAP. Given the lack of support showing the patient has failed CPAP treatment, the UAS of the hypoglossal nerve has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested procedure 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 reviewer number one is board certified in otolaryngology 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.Physician reviewer number two is board certified in otolaryngology 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.Physician reviewer number three is board certified in otolaryngology 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 the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that the patient is a female who had a digital breast tomosynthesis performed as part of her routine screening mammography. At issue is whether digital breast tomosynthesis is superior to two dimensional digital mammography in the detection of breast cancer in a routine screening population. The patient has several additional risk factors for developing cancer, including a personal history of breast cancer. The patient has requested reimbursement for the digital breast tomosynthesis performed.  The Health Plan has denied the reimbursement. Per the Health Plan, digital breast tomosynthesis was investigational/experimental for evaluation of this patient. The digital breast tomosynthesis performed was likely to be more beneficial for this patient than other available standard modalities. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening. Final Result: 2/3 of the reviewers have 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 retroactive authorization and coverage and continuation of skilled nursing facility services for treatment of the enrollee, who had a below the knee amputation performed to the right leg. Findings: The physician reviewer found that the patient underwent a transtibial (below knee) amputation, and has a history of a contralateral transtibial amputation. Her functional status upon transfer to a skilled nursing facility was below her baseline. Initiation of inpatient rehabilitation was appropriate, with a goal of improving her functional status towards independence and healing her residual limb wound (Esquenazi; Goldberg; Klarich and Brueckner). The patient has had a dehiscence at the lateral margin of the surgical closure site in the right residual lower limb that has been slow to heal. The wound was granulating. It had stabilized sufficiently for the patient to have been transitioned off of intravenous antibiotics.  However, there was a local trauma, and the wound had enlarged in size. There was enlargement of the sinus tract, which was now questionably exposing bone. While x-rays did not reveal evidence of recurrent osteomyelitis, additional inpatient care for another week, for close medical and nursing evaluation, is clinically appropriate. Moreover, an additional week was necessary to confirm overall wound stability and to minimize risk of worsening wound status and need for further surgery, such as revision amputation, including a more proximal level amputation. In addition, the patient was making some modest functional progress with respect to her transfers and self-care. One additional week to work on transfers and self-care in conjunction with her wound care was and is medically indicated. Therefore, the continuation of skilled nursing facility services prior to wound stability was medically necessary for treatment of this patient. However, continuation of skilled nursing facility services post wound stability being achieved was and is not medically necessary.Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested transcranial magnetic stimulation (TMS for treatment of the enrollees major depression.  Findings: The physician reviewer found that based on peer-reviewed medical literature, TMS is a non-invasive brain stimulating procedure utilized in the treatment of patients with major depressive disorder. The procedure has been approved by the U.S. Food and Drug Administration (FDA). In addition, TMS tends to be well tolerated with fewer barriers and side effects than electroconvulsive therapy. TMS is likely to prevent the need for treatment in a more restrictive setting to address suboptimal treatment of clinical depression. Further, the American Psychiatric Association (APA) has endorsed use of TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. All told, the requested TMS is supported as medically necessary for treatment of this patients major depressive disorder.Final Result: The reviewer determined that the requested service 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 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 Xolair (omalizumab) for treatment of the enrollees asthma. Findings: The physician reviewer found that the requested medication has not been established as medically necessary for treatment of the patients medical condition. According to Hendeles and colleagues Omalizumab therapy is an alternative for patients with more severe poorly controlled asthma in whom adherence does not improve with conventional interventions. In addition, the highlights of prescribing information state that Xolair is indicated for patients where other medications are ineffective. Thus, Xolair is not supported for use to replace medications that are beneficial. In this case, the patient is well controlled on her present medication and there is no documented steroid side effects other than the feeling of puffiness. Based on the clinical documentation submitted and peer-reviewed literature, the request for Xolair is not medically necessary for treatment of the patients medical condition.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 otolaryngology 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 retroactive authorization and coverage of digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. 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 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. Accordingly, the breast tomosynthesis was was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two 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: All three physician 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: 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 3 physician reviewers 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. Accordingly, the breast tomosynthesis that was performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 naltrexone injections for treatment of the enrollees opiate dependence.  Findings: The physician reviewer found that the naltrexone injections provided were medically necessary for treatment of the patients opiate dependence. Naltrexone is a promising pharmacotherapy in the treatment of opioid use disorder. Naltrexone blocks opioid receptors and thus removes the reward of getting high. The medication is available as an oral preparation taken every day or a microsphere formulation delivered monthly via intramuscular injection. Use via injection avoids the first-pass effect, and the bodys monthly exposure to the medication is much less (1500 mg orally versus just 380 mg intramuscularly), resulting in fewer side effects, while the delivery system ensures medication adherence improving outcomes. In this case, the patient has had a three-year intravenous heroin addiction. Further, she had significant psychiatric co-morbid diagnoses. It appears that she was prescribed oral naltrexone but was non-adherent resulting in relapse. The medication was recommended by the patients treating provider who knows the patients illness burden, characterological organization, support system and living environment. Thus, the U.S. Food and Drug Administration (FDA) approved intramuscular naltrexone was and is reasonably expected to improve the patients condition and prevent a worsening of her condition. Further, the use of the particular medication via injection is safe, appropriate and consistent with good medical practice. Therefore, the naltrexone injections provided was medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the medication at issue was and 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 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 Synvisc I for treatment of the enrollees left knee pain. Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use of viscosupplementation (Synvisc) injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective. Moreover, this may allow for delay of total knee replacement, and these injections are more effective than corticosteroid injections. In this case, the patient has been diagnosed with osteoarthritis of the left knee. She has worsening left knee pain and functional impairment in mobility that have failed to respond adequately to other conservative treatments. Therefore, the requested Synvisc I injections to the left knee are medically necessary for treatment of 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested authorization and coverage for 20 hours per week of direct applied behavioral analysis (ABA) therapy, nine hours per month of supervision and two hours per month of parent training. Findings:  The physician reviewer found that ABA therapy at the frequency of 20 hours per week of direct, nine hours per month of supervision and two hours per month of parent training are medically necessary for treatment of the patients ASD. The study showed that ABA is effective for addressing disruptive behaviors in school aged children. The patient has made some gains with ABA therapy, however he continues to have aggression. In addition, the most recent progress report shows an increase in inappropriate attention gaining behavior and insistence on routine behavior. 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-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.