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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the 3D x-ray breast tomosynthesis for evaluation of her palpable finding and heaviness in the right upper quadrant.  Three physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard mammography alone is limited due to breast density. For these reasons, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone. 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 reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested mental health residential treatment center services for treatment of the enrollees behavioral health condition. The physician reviewer found that the mental health residential treatment center services were medically necessary for treatment of the patients medical condition. Based on the documentation provided, this patient does meet the American Society for Addiction Medicine (ASAM) adolescent criteria for continued stay in the residential treatment level of care. In this case, the patient remained at moderate risk of harm and needed a stable living environment for safety. Her home environment presents moderate to severe interference with recovery. She exhibits evidence of moderate impairment in her social functioning and she has a history of prolonged use and poor response to stress. In addition, the patient requires moderate to intensive motivating in a 24-hour structured environment to promote or sustain progress. She is unable to control use and avoid serious impairment without a 24-hour structured program as she is unable to overcome environmental triggers or cravings and has insufficient supervision at home. Finally, her home environment poses a risk to her recovery such that she requires residential treatment center services support. In sum, the services in dispute were medically necessary and reasonably expected to improve the patients condition and prevent a more serious episode of illness. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bilateral breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that in this patients case, the services at issue were likely to have been superior over other available modalities.  The current medical evidence supports the services at issue in this clinical setting.  Per the literature, the addition of digital breast tomosynthesis to mammography has proven to be very useful to radiologists interpreting mammography.  Breast tomosynthesis has been associated with a decrease in callbacks and increase in detection of small cancers.  All told, bilateral breast tomosynthesis was likely to have been more effective than other methods of evaluation.  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 reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing (81210, 81275, 81301, 81350, 81401, 81404, 81479, 88291, 88313, 88323, 88368, and 88381) for evaluation of her adenocarcinoma of the sigmoid metastatic to the liver. Two physician reviewers found that relying on guidelines issued by the National Comprehensive Cancer Network (NCCN), in newly diagnosed metastatic colon cancer, testing for BRAF, KRAS, and NRAS genetic mutations was indicated in this patients case. Further, because the patient is younger than age 70 with a diagnosis of colon cancer, she was an appropriate candidate for screening for Lynch syndrome. This is achieved with performance of an assay for microsatellite instability (MSI). Thus, testing for BRAF (81210), KRAS (81275), MSI (81301), and NRAS (81404) were clinically indicated. Based on the foregoing discussion, CPT codes 81210, 81275, 81301 and 81404 were likely to have been more beneficial in evaluating this patients medical condition than any available standard therapy. Final Result: Two reviewers determined that a portion of 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 partially overturned.  Credentials/Qualifications: One reviewer is board certified in clinical biochemical genetics and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Thus, the recommendation is not deny patients treatment if the patient has early stage disease, but to provide treatment to avoid complications from advanced disease, including liver failure and extrahepatic complications. In addition, AASLD/IDSA guidelines recommend Harvoni for patients with hepatitis C genotype 1a.  As such, the patients request for Harvoni is medically necessary.  Final Result:   Two reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested passive chiropractic manipulation and/or physical therapy modalities/procedures for treatment of his neck muscle strain. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. According to Walker and colleagues there is currently no evidence that supports or refutes these interventions, provided clinically meaningful difference for pain or disability in people with low back pain when compared to other interventions.  Additionally, Eriksen and colleagues report that no prospective study has examined the incidence of adverse reactions following spinal adjustments using upper cervical techniques and the impact of this care on clinical outcomes. According to the documentation submitted for review, there is a lack of documentation of objective functional deficits to support the medical necessity for therapy. Based on the medical literature cited above and the documentation submitted for review, the request for passive chiropractic manipulation and/or physical therapy modalities/procedures is not medically necessary for treatment of the patients medical condition.  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 physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested transcranial magnetic stimulation (TMS) for treatment of his depression, obsessive compulsive disorder (OCD), and anxiety.   Findings:  The physician reviewer found that the records indicate that this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have not successfully brought on remission. The medical literature reported that TMS had a moderate effect on treatment resistant depression. Moreover, TMS has been approved by the U.S. Food and Drug Administration (FDA) for patients with treatment resistant major depressive disorder. Thus, TMS is supported as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested therapy 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for evaluation of her risk for breast cancer. Two physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited due to breast density. For these reasons, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of your medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Nutropin AQ Nuspin for treatment of the enrollees medical condition.   The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. According to the documentation submitted for review, the patient is of normal stature with his height at the 20th percentile. His adult predicted height, based on his bone age and height measurement, is over 69 inches, normal for an adult male. A complete longitudinal growth chart was not provided for review, and there is no documentation of fall-off in height or poor growth velocity, as measured on the same stadiometer on at least two measurements one year apart. The patients screening growth factors were normal, and there is no known morphological abnormality of the pituitary gland. Thus, the patient does not have clinical evidence of GH deficiency, and he is not short enough to warrant an empiric trial of GH for idiopathic short stature. Although the patient underwent provocative GH testing with two agents, clonidine and L-dopa, there are a total of four GH measurements documented over a period of 90 minutes after administration of both provocative agents, and typically two separate provocative tests, with serial measurements for 2-3 hours after each test are necessary to assess peak GH response to provocative agents. In addition, provocative GH testing has poor sensitivity and specificity for the diagnosis of GH deficiency in the setting of a low prior probability of an abnormality in a patient without auxological evidence of poor growth. Based on the medical literature cited above and the documentation submitted for review, the request for Nutropin AQ Nuspin is not 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 pediatric endocrinology 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 Harvoni for treatment of her chronic hepatitis C virus genotype 6.  Three physician reviewers found that data on treatment of hepatitis C virus genotype 6 are limited. The interferon-free option for genotype 6 infection is the fixed-dose combination of ledipasvir-sofosbuvir (Harvoni) given once daily for 12 weeks. In a study of 25 genotype 6 infected patients, this regimen resulted in a sustained virologic response rate of 96%. A less desirable alternative is a 12 week regimen of sofosbuvir plus peginterferon and weight-based ribavirin. This is also expected to be highly effective in the treatment-naive. The NEUTRINO trial, which evaluated this regimen in treatment-naive patients, included six genotype 6 patients, all of whom achieved sustained virologic response. Given that this option for genotype 6 infection includes interferon, which is associated with significant adverse effects, is not the preferred regimen. Consistent with these findings, the requested Harvoni is supported as medically necessary. Final Result: Three reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested acute inpatient psychiatric care for treatment of his behavioral health condition.   The physician reviewer found that acute inpatient psychiatric care was not medically necessary for treatment of the patients medical condition. There is a lack of documentation demonstrating that the patient was a danger to himself or others during the dates in dispute. The discharge summary indicates that the main goal of the treatment was to obtain the patients compliance with his medication regimen. Based on the documentation submitted for review, the services in dispute could have been provided at a lower level of care where the patient could have received education about his medication and could have been monitored as well. Therefore, 24-hour level of care was not medically necessary in this clinical setting. Based on the documentation provided,  acute inpatient psychiatric care was not medically necessary for treatment of the patients behavioral health condition.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities.  Digital breast tomosynthesis with [three-dimensional] 3D images might overcome some of the limitations of conventional [two-dimensional] 2D mammography for detection of breast cancer. Ciatto and colleagues investigated the effect of integrated 2D and 3D mammography in population breast cancer screening. The authors concluded that Integrated 2D and 3D mammography improves breast-cancer detection and has the potential to reduce false positive recalls. As such, the digital breast tomosynthesis performed was likely to be more beneficial for breast cancer screening than standard modalities. Final Result: Two reviewers determined that the diagnostic procedure 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 reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Despite the lack of long term studies supporting increased survival rates using digital breast tomosynthesis, the addition of the technique to screening digital mammography has gained worldwide popularity due to the associated decreased callback rates and increased detection of small cancers. Thus, the addition of tomosynthesis to standard digital mammography is more beneficial than using digital mammography alone. Therefore, breast tomosynthesis was likely to be more beneficial for evaluation of this patient than standard modalities. Final Result: Two reviewers determined that the diagnostic procedure 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 reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for treatment of his hepatitis C.  Three physician reviewers found that there is sufficient support for the requested medication in this clinical setting.  According to the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver related comorbid conditions.  It is advantageous to treat patients before they progress to F3 or F4 fibrosis.  Based on published evidence of safety and efficacy, Sovaldi is medically indicated for the treatment of this patient.  Final Result: Three reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.