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 Afirma Gene Expression Classifier for the evaluation of her medical condition.  Findings:  Three physician reviewers found that the medical evidence supports the services at issue in this patients case.  The genetic testing was a major determining factor in delineating the further course of action to see if a possible surgical procedure was warranted.  There is sufficient literature indicating that this test can be performed to avoid needless surgeries.  Thus, Afirma Gene Expression Classifier was likely to have been superior over other methods of evaluating this patient. 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 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 uroplasty (percutaneous tibial nerve stimulation) for the treatment of her medical condition.  Findings:  Two physician reviewers found that there is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of percutaneous tibial nerve stimulation in patients with urinary urgency and frequency.  However, most trials have a small number of patients with short term follow-up.  The current guidelines recommended behavioral therapies as a first-line of therapy for patients with overactive bladder. Behavioral therapies may be combined with pharmacologic management. Clinicians should offer oral antimuscarinics or oral 3-adrenoceptor agonists as a second-line therapy.  Percutaneous tibial nerve stimulation is recommended as a third-line therapy.  In this patients case, there are alternative treatments such as Botox injections and sacral neuromodulation.  Per the medical evidence, Botox injection is a standard third-line therapy and graded better.  All told, the services at issue were not likely to have been superior over other treatment options. Final Result: Two 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:   All three reviewers are board certified in urology 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 Cxbladder urine testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that  Cxbladder urine testing was not likely to be more effective for this patient than other available options. Cxbladder may eventually have a role in defining clinical outcome in known bladder cancer, however at this time there is a lack of evidence in the peer-reviewed literature supporting its use. Moreover, there is a lack of support for the use of Cxbladder in the clinical setting of known BPH, negative urinalysis, and negative risk factors for bladder cancer. All told, the Cxbladder performed 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 urology 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 Regranex topical gel for treatment of his medical condition.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient presents with ulceration to the plantar aspect of the right second metatarsal head. Regranex gel is indicated for the treatment of diabetic ulcerations. The highlights of prescribing information states that the efficacy of Regranex has not been established for pressure ulcerations, which this patient has. As Regranex does not have a documented indication for the treatment of pressure ulcerations, the medication has not been established as medically necessary for this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested joint manipulation under anesthesia during surgery to remove a plate and screws from the arm for treatment of her medical condition. Findings:  Two physician reviewers found that peer reviewed literature supports the use of manipulation under anesthesia (MUA) for conservative treatment of isolated dislocation of the pisiform bone, scapholunate dislocation, and adhesive capsulitis of the wrist in small case studies. However, there is a lack of long-term peer-reviewed outcome studies to support the use of MUA in the wrist, beyond closed reduction of acute displaced fractures. There is a lack of current evidence based medical peer-reviewed support for the use of MUA in the wrist to improve range of motion status post hardware removal. The use of this procedure for improving range of motion of a joint is generally supported for the shoulder following failure of conservative treatment where range of motion remains significantly limited. In this case, the patient reported limited wrist range of motion, especially pronation and supination. Moreover, there is a lack of compelling rationale presented to support MUA in the absence of a conservative treatment trial. Therefore, the joint manipulation under anesthesia during hardware removal surgery was not likely to be more beneficial for the treatment of the patients medical condition than any available standard treatment. Final Result: Two 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:  All three reviewers are board certified in orthopedic surgery 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 surgery for treatment of his medical condition.   Findings:  The physician reviewer found that the evidenced-based medical literature supports the recommended surgical treatment plan. In the setting of necrotic tissue with possible residual osteomyelitis, adequate debridement of the surgical area prior to attempted revision fusion is crucial, as any retained necrotic tissue could result in recurrence.  The re-implantation of hardware in this patients case would not be supported, as it tends to become secondarily infected. The use of a circular fixation device would be supported to maintain hindfoot alignment following bone grafting. Therefore, the requested surgery is medically necessary for the treatment of this patients medical condition.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in orthopedic 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a laparoscopic hysterectomy and bilateral salpingo-oophorectomy for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted records support the requested services in this patients case.  This patient has had chronic pelvic pain, with endometriosis confirmed surgically.  This has been unsuccessfully treated with hormone therapy, which she is now unable to be used due to side-effects.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested laparoscopic hysterectomy and bilateral salpingo-oophorectomy are 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 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: 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 there is sufficient support for the services at issue in this clinical setting.  The advantage of breast tomosynthesis relates to the ability to separate dense glandular elements from architectural distortion which in turn may indicate malignancy.  In this particular case where architectural distortion would have been inevitable due to lumpectomy and radiation therapy, this technique would have been of great advantage to the radiologist.  Hence, the addition of breast tomosynthesis was likely to be more beneficial to this patient than had the examination been done only with the two-dimensional technique. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested modafinil for treatment of her medical condition.  Findings:  The physician reviewer found that modafinil is medically necessary for treatment of the patients medical condition. Modafinil is widely used in the treatment of MS related fatigue as well as excessive daytime somnolence. In this case, the patient has taken modafinil with reported benefit. She indicates that when she takes a lower dose or misses medication, she becomes much less functional. Although the medical literature on the use of modafinil in MS is mixed, there are many case series that strongly suggest a significant benefit in some patients. Rammohan and colleagues assessed the efficacy and safety of modafinil for the treatment of fatigue in MS. The authors concluded that modafinil improves fatigue and is well tolerated. All told, modafinil is medically necessary for the treatment of this patients MS related fatigue.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested spinal epidural injections for treatment of her medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  This patient has signs and symptoms of sciatica.  Epidurals may be appropriate for radiculopathy or sciatica when tumor or non-spine pain origin has been ruled out, and the patient has failed two weeks or more of conservative measures.  In this patients case, there is no tumor or space occupying lesion.  The patient is unable to tolerate physical therapy.  Per the medical records, she continues to experience symptoms.  There is sufficient support for the requested services in this clinical setting.  All told, the requested spinal epidural injections are 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Otezla for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Recently released guidelines for the treatment of psoriatic arthritis note that conventional synthetic disease modifying antirheumatic drugs are recommended as initial therapy after failure of nonsteroidal anti-inflammatory drugs.  Then, if necessary, biological disease-modifying antirheumatic drugs or a targeted synthetic disease-modifying antirheumatic drug may be appropriate.  In this case, the patient has a medical history which is not currently contraindicated for the treatment with anti-tumor necrosis factor agents or other biological agents.  As such, the request for Otezla is not medically necessary. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: 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 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.  As noted by a researcher, breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  In this patients case there was an indication for further evaluation.  One could have obtained further compression views to separate overlapping structures, but the breast tomosynthesis technique is a more optimal means to better evaluate a suspicious lesion.  Thus, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.   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: 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 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.  Researchers noted that breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  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.  Thus, breast tomosynthesis was likely to have been more efficacious than other methods of evaluating this patient.   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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency neurolysis for treatment of her medical condition. Findings:  Two physician reviewers found that radiofrequency neurolysis was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain, due to facet pathology as long as the patients are appropriately selected. In reviewing the medical records, there is documentation of failed conservative therapy as well as previous positive response to lumbar facet radiofrequency which provided significant reduction in pain over a good number of months. Therefore, the services at issue were likely to be more beneficial for treatment 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 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 anesthesiology 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: 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 available standard modalities. There is peer-reviewed literature that supports the use of three-dimensional (3D) breast tomosynthesis in addition to mammography alone. Tomosynthesis has been associated with a decrease in callbacks and increase in detection of small cancers, since underlying dense tissue may be separated from mass/architectural distortion with the technique and was thus more likely to have been beneficial to this patient than had the mammogram been done with two-dimensional (2D) imaging only.  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.