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

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for digital breast tomosynthesis performed. 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 (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, there was a reported abnormality in the right axilla.  In this clinical setting, with a mass that needs to be explained (or biopsied), tomosynthesis is of particular value.  By separating out overlapping structures, in combination with sonography, her palpable abnormality was shown to represent accessory breast tissue as opposed to a more significant abnormality.  It is specifically those patients with heterogeneously dense breast tissue that can benefit most from tomosynthesis.  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: the 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xanax or Valium for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications in this clinical setting.  Benzodiazepines possess an array of potential side effects.  Disinhibition, cognitive dulling, perceptual disturbances and exacerbation of depression are common, while a connection with Alzheimers disease later in life has been suggested in the peer-reviewed literature.  Additionally, there is growing concern of misuse, tolerance and dependence issues with this medication class.  Contemporary practice standards aim to minimize benzodiazepine therapy and optimize treatment alternatives.  Per the records, the risks of benzodiazepine therapy outweigh the potential benefits in this patients case.  The patient is prescribed an opioid analgesic.  Benzodiazepines should be avoided in patients treated with opioid therapy.  Further, the patient reportedly has a history of addiction.  Benzodiazepines should be avoided in patients with history of addictive illness.  In terms of medication alternatives, the patient has not failed an adequate trial of pro-serotonergic medicines, which represent first-line interventions for generalized anxiety and depression, some of which, the serotonin-norepinephrine reuptake inhibitors (SSRIs), can also help with pain.  The record illustrates that the patient has been presented reasonable somatic alternatives but declined those treatments.  Finally, it does not appear that the patient has pursued a structured course of dialectical behavior therapy or cognitive behavioral therapy for pain, anxiety and/or depression.  Thus, Xanax or Valium are not medically indicated for the treatment of this patient. 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 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 Harvoni 90 mg-400 mg tablets. Findings:  The physician reviewer found that 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), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. For treatment naive patients with hepatitis C, genotype 6 infection, the guidelines recommend Harvoni for 12 weeks. This is based on both in vitro data and clinical trial results showing 96% sustained virologic response after 12 weeks of therapy. AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, Harvoni 90 mg - 400 mg tablets 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the neck. Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI of the neck. The records demonstrate a CT scan of the spine was normal following the patient's automobile accident and there are no new physical exam findings that would indicate a new imaging study is medically necessary. In addition, the patient has not yet completed a physical therapy treatment program. In sum, there is a lack of clinical documentation supporting MRI in this clinical setting. All told, the requested MRI of the neck is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer 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: The parent an enrollee has requested reimbursement for continued psychiatric residential treatment provided for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient meets clinical criteria for continued stay at the residential level of care. Although the patient was not a serious risk of harm to herself or others during the dates in dispute, this is not the only criterion for continued treatment at the residential level of care. An important consideration for discharge is the ability of the patient to transition to a lower level of treatment without risk of regression and readmission. In this case, the notes show that even in the secure environment of the residential treatment center, the patient experienced regression during treatment. In addition, she had continued intermittent suicidal thoughts expressed to her provider on multiple occasions. The records demonstrate that the patient was not psychologically stable enough to be discharged to a lower level of care without a serious concern that she would regress and harm herself. 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 physician reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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 Harvoni 90/400 mg tablets for treatment of the enrollees chronic hepatitis C virus genotype 1a. Findings:  The physician reviewer found that according to the most 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 (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: 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 the digital breast tomosynthesis for evaluation of the enrollees breast cancer examinationFindings:  All three reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has heterogeneously dense breasts. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: All 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for IgG food sensitivity testing for evaluation of the enrollee, who has a history of gastrointestinal symptoms. Findings:  Three physician reviewers found that the patient has a history of diarrhea, bloating and weight gain. She was noted to have eliminated wheat from her diet and was doing better with less bloating and diarrhea. The patient had comprehensive metabolic panel, celiac panel, and immunoglobulin G (IgG) test. Her celiac panel was normal and her IgG to wheat was positive.  The patient requests reimbursement for the IgG food sensitivity testing. The Health Plan denied reimbursement for the services at issue. The Health Plan deemed the services at issue as investigational for the evaluation of this patients medical condition. Multiple evidence based studies have demonstrated that IgG testing to foods is an unproven method of testing for food intolerances as well as food allergies. The Guidelines for the Diagnosis and Management of Food Allergy, published by the National Institute of Allergy and Infectious Diseases (NIAID) specifically lists tests that are unproven and non-standardized. IgG food sensitivity testing is not recommended for the diagnosis of food allergy. IgG antibodies are proteins produced by the immune system in response to exposure to external triggers, like pollens, foods or insect venoms. Their presence reflects exposure to these triggers, not the disease that results from exposure. IgG antibodies to food are commonly detectable in healthy adult patients and children, whether food-related symptoms are present or not. There is a lack of credible evidence that measuring IgG antibodies is useful for diagnosing food allergy or food intolerance. Moreover, there has been a lack of evidence to support that IgG antibodies cause symptoms. All told, testing for wheat IgG is not a standardized or recommended method of evaluating and treating patients who are suspected of having food allergy or food intolerance.  Therefore, the IgG food sensitivity testing performed was not likely to be more efficacious than the standard modalities of evaluating this patients medical condition. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in allergy and immunology 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: A female enrollee has requested authorization and coverage for anterior cervical discectomy/decompression and fusion (ACDF) surgery and two days of hospital stay for treatment of the enrollees cervical stenosis.  Findings:  The physician reviewer found that The request for ACDF surgery and two days of hospital stay have not been established as medically necessary for treatment of the patients medical condition. In this case, the patient presents with chronic neck pain. However, she has no symptoms or signs of a cervical radiculopathy or cervical myelopathy (Corey, et al). In addition, her physical examination was normal. There are no localizing features to her pain to implicate the C5-6 nor the C6-7 levels. Thus, her pain generator has not been identified. Moreover, there is no documentation that she has failed conservative management for six weeks. All told, the proposed surgery is not in accordance with the standard of care in this clinical setting. Accordingly, the requested surgery and related services are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery and related services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Final Result: The reviewer determined that the requested surgery and related services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for continued residential treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the patient was attending, participating and benefitting from the residential programming, which included family involvement, psychiatric services, individual therapy and an array of chemical dependency non-pharmacologic interventions.  Thus, the treatment was appropriate and reasonably expected to further the patients improvement at the time while minimizing the chance of relapse.  Further, the duration of treatment was well within community practice standards and facilitated a seamless transition to a sober living environment with community services and aftercare programming.  All told, continued residential treatment was medically indicated for the treatment of this patient.  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 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: The parent of a 15-year-old female enrollee has requested reimbursement and prospective authorization and coverage for continued residential treatment center services provided for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that Based on the documentation submitted for review, RTC services provided and forward were not and are not medically necessary for treatment of the patients medical condition. The patients treatment team states that the patient does not have insight into her mood and behavior problems and does not have coping skills for day-to-day functioning. However, the provider notes that the patient is generally cooperative and she feels that the structure is helping her. She has no suicidal ideation and is not harming herself, other than picking on her face. Prior to admission, she was aggressive toward her family for taking away her phone. However, the provider noted that she had learned to tolerate being without her phone during the admission. Her functional scale ratings showed that she had improved in performing her hygiene and dressing most days and engaging in physical activities. Based on the documentation provided, there is a lack of rationale supporting continued RTC level of care. In this clinical setting the patient could safely transition to a lower level of care such as a partial hospitalization program (PHP). The structure of a PHP daily routine will allow for the patient to continue to work on transferring learned skills to the home environment, and she would be able to continue an intensive therapy schedule while receiving weekly psychiatric treatment. For the reasons provided, the services at issue were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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 Epclusa for treatment of the enrollees chronic hepatitis C virus genotype 2. Findings:  The physician reviewer found that According to 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 life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is ot medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for eight weeks. 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.  This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment.  Per the guidelines, treatment-naive, genotype 1 patients should be treated with Harvoni.  Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks.  These guideline recommendations are based on multiple randomized clinical trials.  The current guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.