Persius/hicric huggingface dataset:
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 physician reviewer s 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 breast.  In this patients case, her breast tissue was described as extremely dense.  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.  Therefore, digital breast tomosynthesis was likely to have been more efficacious than other methods of evaluating this patient.   Final Result: Three 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90-400 mg tablet 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 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). The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the patient should be treated with Harvoni 90-400 mg tablet for 12 weeks, which is supported as medically necessary.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential treatment center services for evaluation of the enrollees behavioral health conditions. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious addiction and comorbid mental illness.  In this patients case, she was unable to maintain sobriety in the outpatient setting.  Drug use, heroin and benzodiazepines in particular, dominated her daily routine, permeated functional domains and jeopardized her well-being.  Her peer group, social interactions and family dynamics were not conducive to clean and sober living.  She was deemed to be high risk for relapse.  She had significant psychiatric comorbidity and a poorly defined self-concept.  She was malnourished and unhealthy upon presentation.  She had failed less restrictive treatment interventions.  Per the records, the dates in dispute were aimed at both consolidating the gains made in treatment and facilitating a successful transition to a less restrictive setting.  Based on the longitudinal history and medical documentation, the patient would have likely promptly relapsed and required re-admission in the absence of the disputed residential programming.  Both the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment, considering the extent of her illnesses and suboptimal outcomes of previous treatments, aligned with community standards.  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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the prenatal genetic testing (gene panel testing) for evaluation of the enrollees pregnancy. Findings:  Three physician reviewers found that genetic testing is becoming more widely available and now offers expanded carrier screening panels for ethnicity based and general population carrier screening. Use of this technology provides information regarding more conditions than the currently recommended screening guidelines. Of note, the professional practice guidelines recommend offering carrier screening for individual conditions based on condition severity, race or ethnicity, prevalence, carrier frequency, detection rates, and residual risks. At present, the American College of Obstetrics and Gynecology (ACOG), the American College of Medical Genetics and Genomics (ACMG), and the National Society of Genetic Counselors recommend panethnic screening for cystic fibrosis. The ACOG and ACMG also recommend Fragile X syndrome carrier screening for patients with a family history suggestive of Fragile X syndrome. However, advanced maternal age alone is not an indication for expanded carrier screening. Final Result: Three reviewers determined that the testing at issue was 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 physician reviewers are board certified in obstetrics and gynecology 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 medical condition. Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has extremely dense breasts. 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: 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 104 hours of applied behavioral analysis (ABA) therapy, 10 hours per month of supervision and 4 hours per month of home care training for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the request for 104 hours ABA therapy, 10 hours per month of supervision and four hours per month of home care training are medically necessary for treatment of the patients medical condition. Mohammadzaheri and colleagues found that ABA is effective in helping with maladaptive behaviors in school age children with autism. In this case, the patient presents with maladaptive deficits that include aggression, destruction of property and elopement. Moreover, the best medical practice dictates that if the patient responds to ABA therapy, then continuation with services should be implemented. In this case, there is documentation supporting that the patient has benefited from ABA services. 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 neurology with special qualification in child 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: An enrollee has requested authorization and coverage for gastric sleeve surgery for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records do not document a body mass index of 40 or greater, or a body mass index of 35 or greater with serious comorbid conditions such as diabetes, hypertension or sleep apnea.  This patients body mass index is 32.73.  Bariatric surgery is not standard treatment in this clinical setting.  Additionally, there is a lack of documentation of dietary efforts, dietary evaluation or behavioral evaluation specifically regarding bariatric surgery.  The medical evidence does not support the requested services in this patients case. 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 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 the digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that 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 it brings radiologists interpreting mammograms. This tomographic method often allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in biopsies and callbacks and increase in diagnostic accuracy and detection of small cancers compared to 2D imaging alone. Thus, the addition of tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery to remove cysts for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a variety of complaints that anatomically localize to a variety of nerve root distributions. These distributions encompass lower lumbar and sacral dermatomal distributions, and some of these symptoms are inconsistent and vague.  Her complaints of urinary incontinence did not yield diagnostically aberrant findings with urological work-up.  The low back and hip pain could correlate with a variety of findings, such as her dysmenorrhea.  Her right leg pain is not isolated to a sacral nerve root distribution and involves at least L5 and possibly L4.  In addition, she has a normal ankle jerk on the right which does not correlate with compression of the S1 nerve root, although its presence does not refute some amount of S1 dysfunction. There is a lack of objective physical findings that point specifically to a right S1, S2 distribution; only subjective findings that involve a capacious amount of dermatomes.  The fact that her symptoms improved somewhat with a selective S2 cyst injection does not necessarily provide significantly useful diagnostic information.  Given the inconsistent, widespread and vague nature of this patients complaints, and the fairly weak support in the literature for specific surgical intervention for Tarlov cysts, the requested surgery to remove cysts is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurological 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the computed tomography (CT) scans of the head and cervical spine on an emergent or urgent basis. Findings:  The physician reviewer found the patient presented to the ER due to a closed head injury. Thus, the patient met prudent layperson criteria for immediate medical attention. However, the patient did not have symptoms of significant head injury such as loss of consciousness, vomiting, or neurologic deficit. Thus, there was no medical indication for a head CT scan. Additionally, the patient denied any neck pain and no cervical spine tenderness to palpation was present. Therefore, there was no indication for a CT scan of the patients cervical spine. In sum, the CT scans of the head and neck were not required on an emergent basis to screen and stabilize the patients medical condition. Moreover, the CT scans of the head and cervical spine were not required on an urgent basis. The patient presented without symptoms of significant head injury such as loss of consciousness, vomiting, or neurologic deficit, there was no medical indication for an urgent head CT scan. In addition, the patient denied neck pain and there was no evidence of cervical spine tenderness to palpation. Final Result: The reviewer determined that the services at issue were not required on an emergent or urgent basis to screen and stabilize the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a compounded medication. Findings:  The physician reviewer found that the optimum duration of supplementation has not been established; it has been given until a positive or negative pregnancy test was obtained or as long as the end of the first trimester. Intramuscular progesterone (progesterone in oil) and the various vaginal progesterone preparations (suppositories, tablets, gel, or ring) are equally effective; oral progesterone appears to be less effective. These progesterone preparations and doses are not associated with birth defects or virilization. Intramuscular progesterone is more painful for the patient.  However, in this patients case, the provided records did not demonstrate that she required the compounded injectable form of progesterone in addition to the other routes, nor is there any documentation in the records for this approach. The meta-analysis by Polyzos and colleagues similarly concluded, This meta-analysis provides solid evidence that no significant difference exists between vaginal gel and all other vaginal progesterone forms in terms of clinical pregnancy rates. Final Result: The reviewer determined that the medications 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 obstetrics and gynecology 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 bilateral procedure (CPT code 19340) and bilateral procedure (CPT code 19316) in addition to the already approved CPT code 19371. Findings:  The physician reviewer found that the patient has a symptomatic, painful capsular contracture of both breast implants. As the initial surgery was deemed medically necessary from the documentation provided, reasonable surgical intervention is medically necessary as well.  Standard treatment for significant capsular contracture is implant replacement (or removal) and capsulectomy. Thus, the request for bilateral procedure (CPT code 19340) is considered medically necessary. However, the requested mastopexy, bilateral procedure (CPT code 19316) is not medically necessary and reconstructive in nature for treatment of the patients medical condition. The medical documentation does not support that a functional deficit is related to any skin to skin overlap that would be corrected with this procedure. There is a lack of sufficient documentation supporting bilateral procedure (CPT code 19316) as medically necessary or reconstructive in nature. Final Result: The reviewer determined that a portion of the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer number one is board certified in plastic 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: An enrollee has requested acute hospitalization services for treatment of the enrollees pulmonary embolism, status post tracheostomy, asthma, atrial fibrillation, chronic kidney disease, and possible cerebrovascular accident (CVA).  Findings: The physician reviewer found that based on the records provided the patient has a history of multiple comorbid medical conditions. She presented with congestive heart failure requiring intravenous diuretics. Though the patients left ventricular ejection fraction (LVEF) was reported to be only mildly reduced, there is a poor correlation between ejection fraction and severity of heart failure since diastolic dysfunction, atrial fibrillation, valvular heart disease and other factors can be contributory. Moreover, given her documented frequent emergency department visits, aggressive diuresis is indicated to help reduce the risk of recurrent congestive heart failure and hospital readmission. Given the need for intravenous diuresis and the patients several comorbid conditions, the requested acute hospitalization services are appropriate and considered standard accepted practice in the medical community. The patient management in this case cannot be safely or effectively provided at a lower level of care. For these reasons, the requested acute hospitalization services are medically necessary for treatment of this 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 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.