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 the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Two physician reviewers found that despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 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: Three reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an male enrollee has requested authorization and coverage for Harvoni for 12 weeks. Findings:  The physician reviewer found that the guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for occipital nerve stimulation for treatment of the enrollees occipital neuralgia. Findings:  The physician reviewers found that the use of ONS is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. While the effectiveness of ONS compared to sham control has been shown in multiple randomized controlled trials, the average effect size is modest and may be exaggerated by bias as achieving effective blinding remains a methodological challenge. Further measures to reduce the risk of adverse events and revision surgery are needed. Based on the lack of adequate support in the peer-reviewed literature, the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested service is 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 reviewers number one, two, and three are board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who presented for a breast screening examination. Findings:  Two physician reviewers found that the patient presented for a screening mammogram with digital breast tomosynthesis. The impression was negative, BIRADS 1. The breast tissue was described as average. The patient requested reimbursement for the tomosynthesis portion of the examination. The Health Plan has denied the request for reimbursement for bilateral breast tomosynthesis.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is medical support for the service at issue in this clinical setting. According to one study, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Another study noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the medical literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, bilateral breast tomosynthesis performed was likely to have been more effective than other methods of evaluating this patient. Final Result: 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: All three 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: The parent of a female enrollee has requested reimbursement for neuropsychological testing provided for evaluation of the enrollee, who has a history of academic struggles and underperformance. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The description of her behavior noted during the testing sessions meets most of the diagnostic criteria for the diagnosis of attention deficit/hyperactivity disorder.  Therefore, simple observation of this patient by the parents and teachers as reported on an accepted attention deficit/hyperactivity disorder rating scale would have provided the same information as the hours of testing that were performed.  If there were any doubt, the patient could have been administered the Test of Variables of Attention (TOVA) test only.  TOVA is a good test of the patients ability to focus and sustain attention.  The patients performance on this test was highly supportive of the attention deficit/hyperactivity disorder diagnosis.  Thus, there is a lack of support for the services at issue in this clinical setting.  All told, neuropsychological testing provided was not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that services at issue were not medically necessary for evaluation 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for immediate surgery to remove a left ovarian cyst. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested procedure in this clinical setting. This patient describes pain over the last year, and a cyst that has decreased in size. These symptoms are more consistent with a functional ovarian cyst, which arises from the normal functioning of ovaries, as opposed to a pathologic cyst, such as a chocolate cyst. Pathologic cysts are often related to endometriosis and do not get smaller. The patient's provider noted an interval decrease in the size of the lesion. In a review on adnexal/ovarian masses,  A study noted A cyst may also become hemorrhagic without rupture. Immediate surgical intervention is required only if there is concern that brisk bleeding from the cyst may cause anemia or hemodynamic instability. Other patients may be managed with pain management and follow-up for resolution of the pain and the mass.  If this patients pain is related to a hemorrhagic cyst, it should resolve with conservative management.  There can be many other causes of abdominal and pelvic pain, most of which do not require surgical intervention. The provided documentation do not indicate that conservative management have been assessed for treatment of this patient. The medical studies show that hemorrhagic cysts are common and transient and often resolves over time. Moreover, this patient had prior surgeries with unsatisfactory results. As such, it would not be clinically prudent to proceed with surgery when there are no clear indications to do so.  There is no clinical indication for surgery at this time.  Therefore, immediate surgery to remove a left ovarian cyst is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested procedure 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left knee platelet rich plasma procedure for treatment of the enrollees left knee pain. Findings:  Three physician reviewers found that the current medical evidence fails to demonstrate the superior efficacy of the services at issue in this clinical setting. Middleton and colleagues concluded that despite its pervasive use, the efficacy of platelet rich plasma therapy in the healing of soft tissue injuries and varying mechanisms of action have yet to be established.  Researchers concluded that overall, there is currently insufficient evidence to support the use of platelet rich therapies for treating musculoskeletal soft tissue injuries. Other researchers documented two studies as to the use of platelet rich plasma for meniscal applications with potential for meniscus healing, but this field is largely unexplored. There is a lack of long term, high volume studies that establish the superior efficacy of platelet rich plasma injection over standard treatment options. Final Result: The reviewers determined that the requested services are 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: The reviewers are board certified in orthopedic surgery and is 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 Repatha SureClick 140 mg/mL for treatment of the enrollees hyperlipidemia.Findings:  The physician reviewer found that the records document hyperlipidemia.  However, the medical record documentation does not support known coronary disease or findings of homozygous familial hyperlipidemia.  This diagnosis requires not only elevated low-density lipoprotein levels which significantly exceed 180 mg/dL, but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a strong family history of coronary disease (younger than 50 years in second-degree relative or aged younger than 55-60 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria.  Repatha is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein cholesterol.  The medical record documentation does not support that this patient meets either of those criteria.  PCSK9 inhibitors have not been studied in other patient populations such as 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on the dated of dispute was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: 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 reviewers 1, 2, & 3 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization for radiofrequency neurolysis of the occipital nerve for treatment of the enrollees occipital neuralgia. Findings:  All three physician reviewers found that the patient has a history of occipital neuralgia, cochlear implant, spondylosis, degenerative disc disease, lumbar radiculopathy and post-laminectomy syndrome. The patient presented with chronic severe head, face and ear pain with ongoing low back pain. The patient has tried treatment with medication, massage, epidural injections and stem cell injections at L5 and S1 and stromal vascular fraction (SVF). The provider recommends radiofrequency lesioning of the occipital nerve. The patient has requested authorization and coverage for radiofrequency neurolysis of the occipital nerve.  One study reported that occipital nerve radiofrequency has not demonstrated long-term benefit for treatment of neuralgia. In addition, another study reported that occipital nerve radiofrequency is not supported as there is a lack of demonstrated long-term benefit from the therapy. Moreover, there is insufficient published peer-reviewed controlled studies regarding radiofrequency of the occipital nerve to support the treatment. In this case, the documentation submitted for review do not support the requested procedure. The records do not show a contraindication to current conservative care to support radiofrequency of the occipital nerve.  Final Result: All three reviewers determined that the requested service is 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: All three physician reviewers are board certified in neurology with sub-specialty certification in pain medicine 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 authorization and coverage for Norco and appetite suppressants for treatment of the enrollees chronic low back pain and obesity. Findings:  The physician reviewer found that the medical records show the patient has chronic nonmalignant low back pain. In terms of weight loss, there is no evidence that the patient has failed a weight loss program including a low calorie diet and increased physical activity. A trial of pool therapy with a self-directed aquatic program would be a potentially ideal treatment for both his low back pain and as a mean of weight loss. In addition, non-opioid alternative therapies for pain treatment should be tried before resorting to chronic opioid therapy including pharmacologic therapy with non-opioid pain medications such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) as well as physical activity including graded exercise matched to the condition being treated. There are complementary treatments such as acupuncture, massage, and yoga that can also be considered for this patients medical conditions. 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 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: 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:  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 (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were extremely dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, digital breast tomosynthesis was likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: All three reviewers determined that the  service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers number one, two and there 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.