Persius/hicric huggingface dataset:
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.  Findings: Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Skaane and colleagues, 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. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. Moreover, there is sufficient support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, such as in this case. Therefore, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  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 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: An enrollee has requested endovenous ablation of the left leg for treatment of her medical condition. Findings: The physician reviewer found that the documentation provided for review does not support the medical necessity of the requested procedure. Since the ablation of the patients bilateral GSV (great saphenous vein), her symptoms have resolved and there is no medical record documentation of any symptoms on the left side. Further, there is no documentation of the presence of an ulcer that is resistant to compression treatment or that the patient has been using medical grade compression stockings on a regular basis. For these reasons, the requested endovenous ablation of the left leg is not medically necessary for treatment of this patients varicose veins.  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 physician reviewer is board certified in surgery with sub-specialty certification in vascular 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for treatment of her medical condition. Findings: Three physician reviewers found that in this clinical setting, primary prevention guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  All told, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were 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 reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 laser hair removal for treatment of his medical condition.  Findings: The physician reviewer found that Pilonidal disease describes a spectrum of clinical presentations, ranging from asymptomatic hair-containing cysts and sinuses to large symptomatic abscesses of the sacrococcygeal region that have some tendency to recur.  Part of the pathophysiology of the disease is attributed to the hair follicles and hair in the region.  It been established to be safe and effective to treat the spectrum of pilonidal disease with laser hair removal to remove one of the causative factors.  It is accepted medical care to treat the excess and pathologic hair growth in the region with laser to decrease the recurrence of the pilonidal disease.  This is a chronic problem and while surgery is part of the treatment, removal of hair in the area is also part of the treatment.  In sum, the requested laser hair removal is medically indicated for the treatment of this patient.  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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Afirma gene expression classifier testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that while a fine needle aspiration (FNA) biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15 % of FNA biopsy results are considered to be indeterminate (Alexander et al). Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign (Miller et al).  A relatively new test, the Afirma Thyroid FNA Analysis, utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures (Duick et al). Therefore, the diagnostic test at issue was likely to be more beneficial for the evaluation of this patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:    An enrollee has requested a positron emission tomography (PET) scan for evaluation of her medical condition.  Findings:  Two physician reviewers found that peer-reviewed scientific literature does not support utilizing PET/CT as an appropriate first line in the evaluation of localized adenopathy. PET/CT is not part of the algorithm of diagnosis, until after a diagnosis is established by tissue sampling. While PET/CT is a very sensitive test, it lacks specificity, making it an unreliable test in the screening setting. A paper by Schoeder and Gonen discussed screening exams, and the limitations of using PET/CT as an evaluation tool of localized adenopathy or lymphoma. Until a biopsy is attempted, PET/CT as a first line diagnostic tool for this incidental finding is not likely to be more efficacious for evaluation of this patients medical condition than available standard therapy. Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  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 a continuous positive airway pressure (CPAP) machine for treatment of his medical condition.   Findings: The physician reviewer found that based on the available medical records, the requested CPAP device is medically necessary for this patient. The patient carries a diagnosis of known obstructive sleep apnea (OSA).  The current medical literature has demonstrated that patients can have OSA managed with the home use of auto-titrating CPAP if a fixed CPAP pressure has not been found to be optimal. The patient can be initiated on an auto-titrating CPAP in the home environment and pressure range changes can be performed at subsequent office visits if needed. In doing so the patient will derive the numerous benefits of having his OSA treated which will ultimately lead to a net improvement in health outcomes. Thus, the requested CPAP device is supported as medically necessary.  Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: The physician reviewer is board certified in neurology and 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested participation in a clinical trial for treatment of his medical condition.   Findings:  Two physician reviewers found that often there is no better therapy to offer a patient than enrollment onto a well-designed, scientifically valid, peer-reviewed clinical trial. According to the National Comprehensive Cancer Network (NCCN) guidelines the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Per NCCN guidelines, the first recommendation for patients over 60 years of age is a clinical trial. In sum, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested services are 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 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 varicose vein heat therapy for treatment of her medical condition.   Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services.  The medical records document a history of varicose veins.  The patients prior treatment has included leg elevation, nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve discomfort, and compression stockings.  The records demonstrate that the patient is symptomatic, and she reports leg pain.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested varicose vein heat therapy is medically indicated for the treatment of this patient.  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 vascular 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 breast tomosynthesis for evaluation of her medical condition.   Findings: Three physician reviewers found that tomosynthesis is a technique that was developed 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 the dense breast tissue. 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. Based on the clinical documentation submitted for review, breast tomosynthesis was 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Prometheus Anser ADA testing for evaluation of his medical condition.   Findings:  Two physician reviewers found that the current medical evidence does not support the services at issue in this patients case.  The use of Anser ADA has not been clinically proven to improve patient clinical outcomes. The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect.  Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. Clinical guidelines for management of inflammatory bowel disease do not recommend testing for anti-drug antibody during clinical management.  In sum, the superior effectiveness of Prometheus Anser ADA testing has not been demonstrated.   Final Result: Two reviewers determined that the services at issue were 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested reduction mammaplasty, panniculectomy, and abdominoplasty for treatment of her medical condition.  Findings:  The physician reviewer found that the request for reduction mammaplasty and panniculectomy are medically necessary for treatment of the patients medical condition. The patient presents with well-documented signs and symptoms of significant symptomatic macromastia and a symptomatic lower abdominal pannus that has failed reasonable conservative dermatologic management.  Her photographs, multiple examinations and recommendations from multiple physicians have supported her condition and she would likely have functional improvement from surgical intervention in the form of bilateral breast reduction and lower panniculectomy. Reduction mammaplasty is a well-known procedure that directly addresses functional deficits and is appropriate given the above factors.  In addition, the patient has symptomatic lower abdominal pannus that has failed reasonable non operative treatment. Her functional deficits would likely be significantly improved with lower panniculectomy. Thus, panniculectomy is medically necessary for treatment of the patients medical condition. However, the request for abdominoplasty has not been established as medically necessary for treatment of the patients medical condition. There is insufficient medical documentation that a functional deficit exists for the upper abdomen that would be corrected with an abdominoplasty. Thus an abdominoplasty, which treats the upper abdomen, is not medically indicated. The functional impairment of this patient is likely related to the lower abdomen and not the upper abdomen. According to the American Society of Plastic Surgeons a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. Abdominoplasty typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. Thus, the abdominoplasty is not medically necessary.  Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a blood pressure monitor for treatment of his medical condition. Findings:  The physician reviewer found that based on the records provided for review the patient presents with essential hypertension and no documented subjective symptoms or objective findings to support malignant hypertension or end organ damage as a result of hypertension. In this circumstance of essential hypertension without malignant features or evidence of end organ damage home blood pressure monitoring is not medically necessary. Regular blood pressure checks with the patients provider is medically reasonable and should be sufficient in the ongoing evaluation and management of the patients essential hypertension. All told, the requested blood pressure monitor is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast reduction surgery for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has significant back and neck pain related to her macromastia that is well-documented to be affecting her activities of daily living.  She has been treated with medical management, physical therapy and analgesic injections.  Her macromastia has been noted to affect her posture.  These interventions have not provided a resolution to her functional problem.  Her examination and photographs support that her macromastia is likely contributing significantly to her functional complaint of pain.  Breast reduction is a well-known procedure that directly addresses this functional deficit.  All told, the requested breast reduction surgery is medically indicated for the treatment of this patient. 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 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.