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 for evaluation of the enrollee, who was asymptomatic. Findings:  2/3 of the physician reviewers found that the current medical literature supports the service at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often 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 tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done using two-dimensional imaging alone. Final Result: 2/3 of the reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bilateral digital breast tomosynthesis screening mammogram performed for evaluation of the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that there is sufficient support in the peer-reviewed literature for the procedure at issue in this clinical setting. According to the study by colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. In addition, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. All told, the breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the 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: Physician reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for One Touch Verio test strips for treatment of the enrollees type 2 diabetes. Findings:  The physician reviewer found that self-monitoring of blood glucose is an important component of modern therapy for diabetes which has been recommended for diabetic patients in order to improve their glycemic control and to prevent hypoglycemia.  There are numerous glucose monitors which are available for personal use at the present time. The U.S. Food and Drug Administration (FDA) requires that manufacturers demonstrate that their test system provides acceptable accuracy and consistency of results. While the OneTouch Verio is a reliable meter, there are other meters which are available which are of equal reliability.  It is medically appropriate that the patient use a meter which is preferred by the Health Plan.  All told, the requested OneTouch Verio test strips are not medically necessary for the treatment of this patient.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 physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cymbalta for treatment of the enrollees depression and back pain. Findings:  The physician reviewer found that the request for brand name Cymbalta is not medically necessary for treatment of the patients medical condition. A study compared patients initiating antidepressant therapy with a brand versus generic medication, found no significant difference in the likelihood of discontinuation of the initially dispensed medication during the first 180 days of SSRI [selective serotonin reuptake inhibitors] or SNRI [selective norepinephrine reuptake inhibitors] therapy. In addition, Cymbalta is well known to have significant side effects that include nausea. There is a lack of adequate studies to support the use of brand name versus generic in this clinical setting. Therefore, Cymbalta 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 physician reviewer number is board certified in anesthesiology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed for evaluation of the enrollee, who was asymptomatic. Findings:  Two physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often 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. Final Result: Two reviewers determined that the services 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 authorization and coverage for treatment at a National Cancer Institute designated cancer center. Findings:  The physician reviewer found that Acute leukemia and their treatment are major emergencies in internal medicine. B-cell ALL is an aggressive disease where the standard of care is multi-agent chemotherapy followed by allogeneic hematopoietic stem cell transplant (allo-HSCT) for those with matched bone marrow. In this case, the patient was treated with hyper-CVAD and rituximab, which involves remission induction, intensification, followed by maintenance. At this time, he is a candidate for an allo-HSCT. Allo-HSCT eligibility depends upon human leukocyte antigen (HLA) match and social infrastructure. The social infrastructure is an essential component to determining eligibility since the post-transplant period requires almost daily evaluation for graft versus host disease and infectious complications. The patient has expressed a preference for treatment at the City of Hope since he lives 68 miles away from that facility versus over 100 miles from UCLA. However, the patients residence to UCLA consists of a commute of approximately one hour and 38 minutes, while his commute to the City of Hope showed is about one hour and six minutes. 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 internal medicine with sub-specialty certification in oncology and hematology 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 modafinil for treatment of the enrollee, who has a history of obstructive sleep apneal. Findings:  The physician reviewer found that current practice guidelines from the American Academy of Sleep Medicine indicate that modafinil is only used in OSA patients when the underlying OSA has been addressed, Modafinil is recommended for the treatment of residual excessive daytime sleepiness in OSA patients who have sleepiness despite effective PAP treatment and who are lacking any other identifiable cause for their sleepiness. This statement was reaffirmed in subsequent guidelines. In this case, the patient reported that he uses the CPAP less than one hour per night.  It is unknown if his OSA has been successfully treated by another methodology (e.g. oral appliance therapy). The clinical studies that were conducted on modafinil for OSA only evaluated this medication in patients with treated OSA. While modafinil is known to have wake-promoting properties, current medical literature does not permit conclusions on its overall efficacy in untreated OSA, at this time. Consequently, given the lack of documented adequate treatment of this patients OSA, the medical necessity for the requested medication has not been established. Therefore, modafinil is not medically necessary 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 in neurology with sub-specialty certification in sleep 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 authorization and coverage for prescription refills of oxycodone IR 5 mg and morphine ER 15 mg for treatment of the enrollees chronic pain syndrome, thoracic vertebral fracture, and back pain with radiculopathy. Findings:  The physician reviewer found that as noted in the medical literature, chronic pain that has no hope for a cure is considered palliative in nature. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, given the documentation of this patients known history of psychiatric conditions, any continuation of such medication should be under the direct guidance of a mental health professional. It is also appropriate for the provider to consider alternatives to opioids and to wean the patient to a lower dose of opioids or even off opioids. All told, the requested prescription refills of oxycodone IR 5 mg and morphine ER 15 mg are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology 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 has requested reimbursement for the residential treatment level of care behavioral services for treatment of the enrollees polysubstance abuse, depression, and anxiety. Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) guidelines, residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. For these individuals, residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse. As in the case of hospital-based programs, residential treatment programs frequently provide psychosocial, occupational, and family assessment; psychoeducation; an introduction to self-help groups; and referral for social or vocational rehabilitative services where necessary. The duration of residential treatment should be dictated by the length of time necessary for the patient to meet specific criteria that would predict his or her successful transition to a less structured, less restrictive treatment setting (e.g., outpatient care). In this case, the patient has demonstrated severe problems related to substance use involving several different classes of substances such as heroin, amphetamines, anxiolytics, cannabis, and alcohol, which could be potentially dangerous if mixed together. He has been in psychotherapy treatment which has not been substantially beneficial as therapeutic rapport cannot be formed with him due to his drug use. His treating provider has expressed concern regarding the patients behaviors and it has been identified that he lacks motivation and has significant cravings and access to drugs. It is to be noted that he was not a candidate for lower level of care based on significant risk associated with his extensive drug use, poor motivation, and availability of drugs when he is being treated in outpatient settings as well as poor response to outpatient therapy. For these reasons, the residential treatment level of care was medically necessary for treatment of the patients polysubstance abuse, depression, and anxiety. 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 Botox injection provided for treatment of the enrollee, who was diagnosed with vocal process granuloma. Findings:  2/3 of the physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Some authors have found positive results, but numbers are small.  The 2012 study done at Massachusetts Eye and Ear Infirmary resulted in the conclusion that there was significant recurrence of vocal granuloma after injection of the thyroarytenoid muscle with botulinum toxin, but that better results were obtained with injection into the inter-arytenoid musculature. This evaluation was done with small population study and as a retrospective review.  There is currently an efficacy study underway to further evaluate this method of injection and compare recurrence rates with those found to occur with the use of anti-reflux therapy alone.  At this time, the superior efficacy of Botox injection provided has not been established.  Final Result: 2/3 of the reviewers determined that the services at issue were 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: Physician reviewer number one is board certified in otolaryngology 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.Physician reviewer number two is board certified in otolaryngology 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.Physician reviewer number three is board certified in otolaryngology 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 and prospective authorization and coverage for 50 hours per month of applied behavioral analysis (ABA) therapy, five hours per month of supervision and one hour per month of individual parent training services provided for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the despite more than six years of ABA therapy, the patient continues to have language deficits and aggressive outbursts. The request for 50 hours per month of ABA therapy is not likely to improve his medical condition. In this clinical setting, the Health Plans authorization of one hour per month of parent training, two hours per month of supervision, and 20 hours per month of one-on-one ABA is medically appropriate for this patient.  Final Result: The reviewers determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the quantitative sensory testing.Findings:  Two physician reviewers found that although quantitative sensory testing is not  frequently utilized, there is sufficient support in the peer-reviewed literature supporting this testing in this clinical setting. Quantitative sensory testing was indicated for this patient due to findings on examination that were not consistent with usual findings of neuropathy. Given the patients presentation of possible non-organic features, the quantitative sensory testing was helpful in coming to diagnostic conclusions that will potentially guide his treating physicians. Final Result: Tworeviewers determined that the testing 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 neurology 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.