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 who presented for a breast examination. Findings:  The 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 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, she presented with a palpable mass.  Tomosynthesis, especially in patients with dense breast tissue, has been shown to be better able to delineate and characterize masses. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In addition to the need to evaluate the palpable mass, in patients with heterogeneously dense breast tissue, tomosynthesis offers the advantage of possibly demonstrating additional areas of concern. In sum, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Two of three reviewers determined that that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  Physician 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) for evaluation of the enrollees shoulder and upper arm pain. Findings:  The physician reviewers found that current accepted standards of care do not support an indication for the requested lower extremity MRI study for this patient on the basis that the medical records do not indicate any physical exam findings of joint looseness or tendon impingement. In addition, there is no documentation of a course of physical therapy that has been attempted and failed. Moreover, the medical records also do not document a trial of non-steroidal anti-inflammatory meds or acetaminophen for three or more weeks, which is also an accepted standard of care treatment prior to MRI study being performed. Thus, the requested lower extremity MRI is not supported as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the requested diagnostic procedure is 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:  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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for paramedic services. Findings:  The physician reviewer found in this case, the patient was experiencing pain in his mouth for three days following dental surgery. The paramedics report does not describe any difficulty breathing or swallowing. The patients symptoms were not sudden in onset or severe in nature, and do not support that the services at issue were necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. 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

An enrollee has requested authorization and coverage for Praluent 75 mg for treatment of the enrollees mixed hyperlipidemia. Findings:  The physician reviewer found that based on the records provided, the patient has known coronary disease and intolerance to high dose Lipitor, simvastatin and Zetia. However, there is no documentation provided to indicate trials of lower dose statin or a trial of lower dose rosuvastatin. Praluent is a PCSK9 inhibitor studied and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol despite of maximally tolerated statin medication. Available trials that demonstrate benefit with PCSK9 inhibitors primarily included patients with suboptimal LDL levels while receiving statin medications. Overall, there is insufficient outcomes data to support the use of PCSK9 inhibitors in place of low dose statin medication, as is the case in this patient. Thus, the requested Praluent 75 mg is not medically necessary for treatment of this 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla. Findings:  The physician reviewer found that the available medical records do not document that this patient has been treated with leflunomide for psoriatic arthritis and there are no listed contraindications to treatment with this medication. Additionally, Otezla is not approved for treatment in combination with other agents including Consentyx, as is currently the plan of care for 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 internal medicine with sub-specialty certification in rheumatology 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 100 hours per month of direct one on one applied behavioral analysis (ABA) therapy, 14 hours per month of supervision by BCBA and four hours per month of caregiver training for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the request for ABA therapy at the frequency of 100 hours per month of direct one on one therapy, 14 hours per month of supervision by BCBA and four hours per month of caregiver training has been established as medically necessary. In this case, the patient has made improvements, however he continues to have issues with noncompliance, tantrum, crying/whining and object mouthing. Therefore, based on the records submitted for review the requested services are medically necessary for treatment of the patients autism. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for thyroid gene test (Afirma gene expression classifier).Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. The patients initial biopsy report came back as indeterminate atypia of undetermined significance. Afirma testing is generally considered standard protocol on all fine needle aspirations performed on thyroid nodules in order to avoid needless surgeries. In this patients case, Afirma test results influenced the course of action for treatment of his thyroid nodule. 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 authorization and coverage for Victoza for treatment of the enrollee, who has been diagnosed with diabetes type 2.  Findings:  The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. Victoza (liraglutide) is used for weight loss management and to reduce blood sugar in patients with type 2 diabetes mellitus. The available medical studies indicate that Victoza is effective in the treatment of obesity-related risk factors and induces weight loss. From the forms provided, this patient was diagnosed with type 2 diabetes and had a body mass index of 40.88 at the time Victoza was sampled. In general, this medication has been known to lower hemoglobin A1C by about 1% point. Moreover, the Health Plan suggested that Victoza is medically necessary for treatment of type 2 diabetic patients who have an A1C of 7 or greater. This patient had an A1C of 6.5 in 2015. The provider indicated that the samples of Victoza and metformin were no longer effective in the treatment of this patient. As such, it is likely that if Victoza was discontinued, this patients A1C could rise to greater than 7. Therefore, the requested medication Victoza is medically necessary for treatment of this 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Rituxan for treatment of the enrollees relapsing multiple sclerosis (MS). Findings: The physician reviewer found that based on the current medical literature and the presented clinical records, Rituxan is medically necessary for treatment of the patients medical condition. Rituxan has been well studied in several placebo controlled trials for relapsing MS, and has been found to be highly effective. The humanized form of rituximab, ocrelizumab has two phase III studies proving the drug to be highly efficacious with safety that is better than interferon. Given that positive Rituxan studies have been reported in the peer-reviewed literature, and that this patient has tried four previous disease modifying therapies and still has active relapsing MS, Rituxan is medically necessary. In addition, the patient is JCV positive, and is not a good candidate for Tysabri. Moreover, the use of Zinbryta or Lemtrada, may have potential for serious side effects. Therefore, the requested medication is 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested for acupuncture services for treatment of the enrollees back pain.  Findings: The physician reviewer found that there is support in the medical studies for the requested services in this clinical setting. The current research supports the use of acupuncture for neck pain and also for acute pain. The standard of care for acupuncture services is not limited only for the treatment of chronic pain. In this patients case, he was also diagnosed with chronic pain. The patient sought acupuncture services for acute cervical radiculopathy and reported clinical improvement from the acupuncture services. The patient made multiple trips to his primary care and neurology providers. He also has made several trips to the emergency room for treatment of his pain. The provider was not able to schedule him with pain management in a timely manner. The submitted records indicate that this patient had exhausted available resources. Therefore, acupuncture is medically necessary for the 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 oriental 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested subcutaneous implantable cardioverter defibrillator for treatment of the enrollee, who has been diagnosed with hypertrophic cardiomyopathy.  Findings: Two physician reviewers found that there are sufficient support for the requested device in this clinical setting.  This patient has hypertrophic cardiomyopathy and risk factors for sudden cardiac arrest including unexplained syncope, family history of arrest in first-degree relative with the same condition, and non-sustained ventricular tachycardia on monitoring.  In this circumstance, defibrillator placement is considered standard accepted practice in the medical community.  Current guidelines endorsed by several national organizations consider defibrillator placement appropriate in this setting.  Both types of defibrillators (traditional endocardial lead systems and subcutaneous systems) accurately detect ventricular arrhythmias.  Per the records, placement of a subcutaneous defibrillator has potential long-term advantages in this particular circumstance.  For this young patient who will likely require a defibrillator for many decades, the risk of lead failure and lead extraction, which are associated with significant morbidity and mortality, are higher when implanted with a traditional endocardial lead device.  Subcutaneous leads are not subject to the stresses of the cardiac contraction and so should be less likely to fail or need replacement.  Also, if lead failure were to occur, then the subcutaneous lead should be easier to access and extract with lower risk of morbidity.  Furthermore, his condition of hypertrophic cardiomyopathy does not predispose him to symptomatic bradycardia that may require backup pacing only provided by a standard endocardial defibrillator lead.  Therefore, the requested subcutaneous implantable cardioverter defibrillator is likely to be more effective than other treatment options.Final Result: Two reviewers determined that the requested device 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 authorization and coverage for Lotronex (alosetron hydrochloride) and Subutex (buprenorphine) for treatment of the enrollees chronic pain and irritable bowel syndrome (IBS). Findings:  The physician reviewer found that the records provided document a diagnosis of opioid dependence. Thus, Subutex is medically appropriate for this patient. For these reasons, the requests for Lotronex and Subutex are supported as medically necessary for the patients irritable bowel syndrome and opioid dependence. Final Result: The reviewer determined that the requested medications 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 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 digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings: Two physician reviewers found that the current medical evidence supports the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists.  This tomographic method allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.Final Result: Two 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: Upheld Decision of Health Plan

An enrollee has requested reimbursement for custom molded orthotics (shoe inserts) provided. Findings:  The physician reviewer found that the current guidelines and medical literature do not provide adequate evidence to support the medical necessity of the custom made orthoses for treatment of this patients medical condition. Inserts and other shoe modifications such as arch supports are considered medically necessary if they are on a shoe that is an integral part of a necessary leg brace, if they are needed for the proper functioning of the brace. Orthopedic and podiatric literature does not substantiate the need for custom molded orthoses for this particular patient. All told, the custom molded orthotics (shoe inserts) provided were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the equipment 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 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.