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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for Aranesp 60 mcg/0.3 ml syringe for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the standard practice for treatment of anemia is to try and correct iron deficiency prior to starting Aranesp therapy. Treatment of anemia with Aranesp does not reduce mortality. The main benefit of treatment is an improvement in the quality of life. The provided records indicate that the patient failed oral iron therapy but there is no evidence that a more aggressive treatment for iron deficiency was attempted. Moreover, the patients anemia could be multifactorial. There may be components of anemia related to her CKD but the evidence is lacking to indicate if she is symptomatic from the anemia. Therefore, for the reasons stated above, the medication at issue was not medically indicated for treatment of this patients anemia. Final Result: The reviewer determined that the medication at issue was 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 internal medicine with sub-specialty certification in nephrology 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 treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation demonstrates that the patient reported a high level of motivation and commitment. He had decreased panic and handwashing episodes.  He was using the tools he had learned to self-comfort his anxiety and he applied those towards recovery efforts as well.  He denied suicidal or homicidal ideation.  He was future oriented and planning to return to school to complete an advanced degree. The patients mood ranged from stable to depressed, with appropriate affect. His thoughts were linear and goal directed. The patient lived with family members. His family was involved in his recovery. There were no reported withdrawal symptoms.  He was medically and psychiatrically stable. The patient was not a danger to himself or others.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential treatment services.  He was motivated and was working the program.  The submitted documentation show that the patient had improved.  There was no evidence to indicate that returning him to his environment would lead to destabilization.  He had a sponsor. The patient was engaged in all aspects of his treatment plan. Although he continued to struggle with his emotions and OCD symptoms, and required treatment to further develop and solidify coping skills, these issues did not require the structured environment of a residential care treatment setting. The patient could have been stepped down to an ambulatory level of care. For these reasons, the residential treatment center services were not medically necessary for treatment of the patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for pelvic magnetic resonance imaging (MRI) for evaluation of the enrollees medical condition. Findings:  Three physician reviewers found the role of MRI in men with rising PSA and prior negative biopsies has been increasingly studied over the last few years. However, the value of performing MRIs and conducting MRI guided biopsy in men without previous biopsy, such as in this patients case, is under evaluation. Multi-parametric magnetic resonance imaging (MP-MRI) and transrectal ultrasound-guided (MRI/TRUS) fusion-guided prostate biopsy improve the cancer detection in patients with low apical lesions, anterior lesions, enlarged prostates, and even disease outside the prostate. The medical literature have shown these procedures have been especially useful in patients with an elevated PSA despite negative TRUS biopsy where MRI has proven potential. Of 195 men with prior negative TRUS biopsy, 73 (37%) were found to have cancer on subsequent fusion biopsy. Although prospective trials showed improved detection rate of prostate cancer and high-risk prostate cancer in patients who underwent MRI guided biopsy, recent randomized controlled trials do not suggest the same benefit for biopsy naive patients. Final Result: The reviewer determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in urology and are actively practicing. The reviewers is 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 right knee replacement surgery for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the peer-reviewed literature indicated that the safety of corticosteroid injections in patients who were candidates for total knee arthroplasty has been questioned, as they may increase infection rates in subsequent arthroplasty.  Studies have consistently recommended further research to evaluate the safety of these injections prior to total knee replacement.  This patient presented with right knee pain and associated functional limitations in walking.  Clinical examination findings have been consistent with imaging evidence of advanced right knee osteoarthritis, greatest in the medial compartment.  This patient has been treated conservatively with exercise, swimming, anti-inflammatory medications, weight loss, and corticosteroid injections.  She requested a right total knee replacement, but requested a one month delay.  A corticosteroid injection was provided for pain management.  There is a lack of consistent, large volume, long-term studies evidencing a conclusive relationship between date/quantity of dosages of corticosteroid injections and infection risk to support the health plan's proposed seven month surgical delay. Therefore, the requested right knee replacement surgery, prior to the health plan's proposed surgery date, is medically necessary 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 physician 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 a power operated vehicle (POV for treatment of the enrollees idiopathic aseptic necrosis of head and neck of femur.  Findings: The physician reviewer found that the requested equipment has not been established as medically necessary for treatment of the patients medical condition. The documentation submitted for review does not demonstrate that the patient is unable to safely use a manual wheelchair or other walking aid such as a walker, crutches or cane. In addition, the documentation submitted for review does not reveal a thorough gait assessment. There are no physical therapy documents evaluating the patients gait or ability to use a manual wheelchair or other walking aid. Moreover, there is no clear physician evaluation of the upper extremities that specifically examine range of motion, strength, deformity, endurance or coordination or objective documentation on physical examination or electro diagnostic testing of carpal tunnel syndrome that would reveal that the patient has deficiencies in the upper extremities that would prohibit a manually operated device. There is also no evidence that a modification to a manual wheelchair hand rim was attempted that would enable the patient to safely operate a manual wheelchair. For the aforementioned reasons, the request for a power operated vehicle is not medically necessary for treatment of the patients medical condition.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: The parent of an enrollee has requested in-home private duty nursing services for treatment of the enrollees medical condition.  Findings: The physician reviewer found that according to the American Academy of Pediatrics (AAP) guidelines for home care of infants, children, and adolescents with chronic disease, the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities. In this case, the patient presents with multiple medical problems that include subdural fluid, gastroesophageal reflux, and feeding intolerance. The requested in-home private duty nursing services are not custodial in nature because it requires experienced observation, appropriate expertise to determine when intervention is necessary and constant management of his gastrointestinal issues. Therefore, in-home private duty nursing services have been established as medically necessary 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 pediatrics and pediatric critical care 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 the medication Avastin for treatment of the enrollees vaginal cancer, stage II.  Findings: The physician reviewer found that there is very little data concerning Avastin plus chemotherapy for treatment of vaginal cancer. Avastin is an inhibitor of endothelial growth. There is some medical literature to support Avastin in combination with chemotherapy for treatment of certain cancers, particularly colon and lung cancer. There are also studies that support Avastins usefulness in treating ovarian cancer. However, there is a lack of substantial data to support its use, along with chemotherapy, for treatment of vaginal cancer. Rajagopalan and colleagues reviewed concurrent chemoradiation therapy for the treatment of vaginal cancer and concluded that combining radiation with chemotherapy was reasonable. However, the authors did not mention Avastin in combination with chemotherapy. While there is reasonable support to include chemotherapy in the treatment of vaginal cancer, there is a lack of evidence based studies to support the additional use of Avastin. As such, the requested Avastin for treatment of the patients vaginal cancer is not medically necessary.  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: Physician reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Two 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 (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 dense breasts.  In this patients case, her breasts were described as heterogeneously dense.  It is specifically those 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.  Additionally, the area of asymmetry was an appropriate indication for breast tomosynthesis.  In sum, digital breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are 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 Harvoni 90-400 mg for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a 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 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Zepatier for 12 weeks is also a recommended regimen, and the guidelines recommend either as acceptable therapy.  Thus, the Health Plans alternative Zepatier is medically appropriate for the treatment of this patient. Therefore, the medical necessity of Harvoni 90-400 mg is not supported for treatment of this patients hepatitis C infection.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 physician 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 authorization and coverage for Humatrope 12 mg cartridge for treatment of the enrollees medical condition.Findings:  Two physician reviewers found that Williams syndrome is a genetic disorder resulting from microdeletion of chromosome 7q11.23.  Common characteristics include dysmorphic facial features, global cognitive impairment, supravalvular aortic stenosis, and renal/urinary tract abnormalities. Endocrine abnormalities include short stature, precocious puberty, hypothyroidism, and hypercalcemia.  This patient has been diagnosed with idiopathic short stature, with anticipated adult height significantly below mid-parental height predictions.  Prior to a trial of growth hormone therapy, his height velocity was 4 cm, and increased to 9.27 cm with growth hormone administration.  Williams syndrome is a rare condition, and not all affected patients suffer from short stature, making research on the effects of growth hormone difficult.  This patient has short stature with precocious puberty and advanced bone age.  Despite treatment with Lupron, his growth velocity was very slow. Administration of growth hormone has increased his growth velocity, with possibility that he will achieve a reasonable adult height based on mid-parental height.  Final Result: Two reviewers determined that the requested medication is 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: One reviewer is board certified in pediatrics and is actively practicing. Two reviewers are board certified in pediatrics with sub-specialty certification in pediatric endocrinology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Three reviewers found that the breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. 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: 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 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 digital breast tomosynthesis for evaluation of the enrollees medical condition.Findings:  Two physician reviewers found that 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 biopsies and callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. 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 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.