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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections.Findings:  The physician reviewer found that evidence-based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allows for delay of total knee replacement. A meta-analysis conducted by a study found that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Another study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Moreover, a study concluded that repeated cycles of intra-articular sodium hyaluronate treatment, to delay time for total knee replacement in patients with knee osteoarthritis and who have failed conservative treatment, was found efficacious during a 54-month follow-up period. In this patients case, she has been diagnosed with osteoarthritis of both knees. She has undergone prior left knee arthroscopic surgery. She has undergone multiple prior viscosupplementation injections for over 10 years in an attempt to delay total knee replacements. Prior injections have resulted in pain reduction and improvement in function ability. She has worsening bilateral knee pain and functional impairment that has failed to respond adequately to other conservative treatments. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis. Findings:  Three physician reviewers found that the patient has a history of having had bilateral breast cancer.  The malignancies were in 1996 on the right, and 2002 on the left. The submitted records noted that the malignancies were treated with lumpectomies, radiation therapy, and chemotherapy. In addition, the patient reported that her mother and sister were also diagnosed with breast cancer.  The patient underwent a routine screening mammogram with breast tomosynthesis. The current images were compared to prior mammograms and no interval changes were noted. There were no masses or areas of new suspicious calcifications.  In the upper outer quadrant of her right breast, an area of scarring and dystrophic calcifications was seen. 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 particular patient, on the basis of breast density, one could not justify the superior effectiveness of tomosynthesis. But in terms of surveillance in a patient who has had breast cancer, studies have demonstrated that specificity increased from 20.7% to 74% when digital breast tomosynthesis (DBT) was applied in a study. Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings by proving either a definite benign or malignant diagnosis. DBT allowed unnecessary biopsy to be avoided in 37.3% of patients. Final Result: Three 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: 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for calcitonin-salmon 200 unit spray (once daily x indefinitely). Findings:  The physician reviewer found that even though this patient has concerns for side effects from bisphosphonates, they are the therapy of choice in osteoporosis associated to HIV disease. Calcitonin has not been demonstrated to be very effective to decrease the risk of non-vertebral fractures. In addition, the patient should be evaluated to rule out secondary correctable causes of osteoporosis. The patient has a known history of a pathological fracture of ankle, thus, the treatment of choice is a bisphosphonate given monthly, like residronate, or annual intravenous zoledronic acid, which significantly decreases non-vertebral fractures. Final Result: The reviewer determined that the medication at issue was not and 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 internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism 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 coverage for wireless capsule endoscopy. Findings:  Two physician reviewers found that , the patient has iron deficiency anemia and is symptomatic with fatigue. The American Gastroenterological Association guidelines recommend video capsule endoscopy to investigate patients with iron deficiency anemia and/or evidence of gastrointestinal bleeding when EGD and colonoscopy do not provide an explanation. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines also recommend capsule endoscopy for investigation of gastrointestinal bleeding or iron deficiency anemia. Compared with the enteroscopy for detecting a small intestinal bleeding source, capsule endoscopy has sensitivity of 95%. In comparison with computed tomography angiography (CTA) and standard angiography, capsule endoscopy detects more bleeding source lesions. Based on the records submitted for review, the source for anemia is not conclusive, thus the clinical literature supports the use of wireless capsule endoscopy. Final Result: Two reviewers determined that the requested service is 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 internal medicine with sub-specialty certification in gastroenterology 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 and prospective authorization and coverage for sclerotherapy for the enrollees varicose veins. Findings:  Three physician reviewers found that this patient is diagnosed with bilateral varicose veins that were associated with aching, heaviness and edema in both lower extremities.  The records do not document a history of complications with varicose veins.  Varicose veins and reticular veins were identified.  There were no venous duplex to evaluate reflux, so it is not known if this patient has axial reflux or previous deep vein thrombosis symptoms in either leg. The treating provider performed both sclerotherapy and cutaneous laser therapy. The patient requested reimbursement for the sclerotherapy treatments performed. The patient is also requesting prospective authorization and coverage for future sclerotherapy treatments. The Health Plan has denied the services at issue as investigational for treatment of this patients medical condition. This denial is the subject of this appeal and determination. The medical literature suggests that both direct and ultrasound guided primary venous sclerotherapy are limited to the treatment of accessory recurrent varicose veins following surgery and thread veins. In this patients case, the submitted documentation fails to demonstrate that this patient had appropriate work-up prior to the sclerotherapy treatments performed. Therefore, these interventions were experimental as to the treatment of this patient. Moreover, without documentation of appropriate work-up, future sclerotherapy would also be investigational.  As such, the sclerotherapy treatments performed on were not and are not likely to be more effective than other methods of therapy for this patient. Final Result: The reviewers have determined that the services at issue were not and 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 vascular surgery 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 16 hours per month of applied behavioral analysis (ABA) therapy (CPT H2019) and 16 hours per month of supervision (CPT H0032) for treatment of the enrollees medical condition. Findings:  The physician reviewer found that in review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. In this case, the patient presents with the diagnosis of autism spectrum disorder and co-occurring anxiety and depressive disorders. About one-third of individuals diagnosed with autism spectrum disorder are prescribed a serotonin-enhancing medication, which are first-line medicines for anxiety and depression. The records do not show utilization of pharmacotherapy. In addition, there is a lack of an objective assessment, via a standardized measure such as the Vineland or Adaptive Behavior Assessment System, to assess for maladaptive behaviors across multiple domains of functionality. The data from such testing is useful in developing quantifiable objectives as part of a larger multidisciplinary treatment plan.  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 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 for brand name Axert for treatment of the enrollee, who has been diagnosed with migraine without aura and chronic daily headache. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting.  There is a lack of evidence of a difference of bioavailability of generic medications compared to brand name products.  It is likely that the patient experienced nausea and vomiting related to the migraine itself, as opposed to a side effect of the generic product.  Additionally, pharyngitis is not a reported side effect of this medication.  There is a lack of support for the brand name medication in this patients case.  All told, the requested brand name Axert 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 neurology 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 pre-adolescent enrollee has requested shoe inserts for treatment of the enrollees bilateral pes planus.  Findings: The physician reviewer found that after a review of the medical literature on this issue, the requested custom made orthotics are not medically necessary. The patient has a congenital flatfoot condition that is symptomatic, causing her foot, leg, and hip discomfort, as well as problems with balance. Her BMI of 19.3, which classifies her as overweight as well. On examination by her podiatrist, she is also noted to have an equinus bilaterally, which often accompanies a flexible flatfoot in children and contributes to her painful symptoms. Symptomatic flatfoot in children, particularly those accompanied by an equinus, require treatment consisting of proper shoe gear with a supportive arch, daily stretching exercises of the posterior leg muscles to reduce the equinus, weight management, and arch supports. However, the current peer-reviewed medical literature does not support the exclusive use of custom made orthotic devices and suggests that over the counter or pre-fabricated arch supports are just as effective as custom made devices in the treatment of this condition. Overall, there is a lack of significant evidence in the scientific data to support the use of custom orthotics over appropriate over the counter devices, or pre-fabricated orthotics for the treatment of this patients condition. Thus, the requested shoe inserts are not medically necessary for treatment of this 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 podiatry 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 Retin-A for treatment of the enrollees adult acne. Findings: The physician reviwer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. In the treatment of acne, topical retinoids, such as Retin-A, are standard of care. Retinoids are the core of topical therapy for acne according to the guidelines of care of the American Academy of Dermatology. In this case, treatment with the topical medication Retin-A is indicated for treatment of the patients acne. Accordingly, the request for Retin-A has been established as medically necessary for treatment of the patients medical condition.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested prescription medication, Repatha for treatment of the enrollees hypertension.  Findings: The physician reviewer found that Repatha is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. In this case, the documentation provided for review does not support either of these criteria.  PCSK9 inhibitors have not been studied in other patient populations such as the patient in this case. Also current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting (Stone, et al). Therefore, the prescription medication, Repatha has not been established as 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 internal medicine with sub-specialty certification in cardiovascular disease 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 the enrollees routine breast cancer screening. Findings: Two physician reviewers found that the report revealed no evidence of cancer. The Health Plan has denied reimbursement for digital breast tomosynthesis as investigational for the evaluation of this patient. There is evidence-based support for the service at issue in this clinical setting. 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 an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocols was likely to be more effective to the patient than had her examination been performed using two dimensional imaging alone.Final Result: Two 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: 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An male enrollee has requested authorization and coverage for one hour of occupational therapy (OT) at the frequency of three sessions per week for treatment of the enrollees autism. Findings:  The physician reviewer found that the request for one hour of OT at the frequency of three sessions per week has not been established as medically necessary for treatment of the patients medical condition. There is evidence in the peer-reviewed literature that supports occupational therapy as effective for addressing sensory processing issues for children with ASD. However, there is a lack of research indicating how many hours of OT are needed. In this case, per the OT assessment, 30 minute sessions at the frequency of three sessions per week was recommended due to the patients attention span. Given the patients limited attention span, the request for one hour sessions of OT is not clinically indicated. Moreover, the treatment plan notes that once the patients attention span has increased, then longer treatment sessions may be indicated. Accordingly, the request for one hour of OT at the frequency of three sessions per week is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested duration of therapy 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 pediatrics with sub-specialty certification in developmental and 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.