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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for unilateral breast tomosynthesis for evaluation of the enrollee, who had an abnormality on a prior mammogram. 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.  Considering the dense nature of her breasts, the initial tomosynthesis was warranted.  However, there is a lack of support for the repeat tomosynthesis after only a two-week interval.  The sonogram was critical in excluding a significant lesion.  Thus, unilateral breast tomosynthesis was not likely to be of greater benefit than other methods of evaluating this patient. Final Result: Two of three reviewers determined that the service at issue was 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:  Physician reviewer number one, two, and three 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing for evaluation of the enrollees thyroid nodule. Findings:  The physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  The Afirma Gene Expression Classifier test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration 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.  In sum, Afirma Gene Expression Classifier testing was likely to have been of greater benefit than other methods of evaluating this patient. 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.
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 agb 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 heterogeneously dense.  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, digital breast tomosynthesis was likely to have been superior over other methods of 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 three 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wireless capsule endoscopy for evaluation of the enrollees follicular non-Hodgkins lymphoma of the intestine. Findings:  The physician reviewer found that according to the American Society for Gastrointestinal Endoscopy (ASGE), evaluation of small intestinal tumors is a valid indication for wireless capsule endoscopy. Wireless capsule endoscopy is capable of discovering small bowel tumors not visualized with endoscopy and traditional radiologic imaging. Wireless capsule endoscopy is a useful diagnostic tool for defining the extent of bowel involvement in patients with gastrointestinal lymphoma. Patients with primary intestinal follicular lymphoma should undergo endoscopic examinations, including wireless capsule endoscopy, to evaluate the entire gastrointestinal tract prior to consideration for potential treatment. For these reasons, wireless capsule endoscopy is supported as medically necessary for the evaluation of this patients intestinal follicular lymphoma. Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Life Vest wearable cardioverter defibrillator (WCD) for treatment of the enrollees ST elevation myocardial infarction (STEMI) involving left anterior descending (LAD) coronary artery, atrial flutter, and acute respiratory failure. Findings:  Two physician reviewers found that based on the records provided, the patient presented with severe left ventricular dysfunction soon after coronary stenting for acute myocardial infarction. Cardiac arrest in the immediate acute infarction period generally does not increase risk of subsequent cardiac arrest. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there was no indication for immediate placement of a defibrillator such as recurrent sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest in the post infarction period. Placement of a prophylactic defibrillator is not recommended until a period of time, approximately 90 days has elapsed, when continued left ventricular dysfunction demonstrated by an ejection fraction of 35% or less, is documented to persist despite of appropriate treatment. A prophylactic defibrillator before this time has not been demonstrated to improve outcome. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. All told, the Life Vest WCD at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the device at issue was 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 internal medicine with sub-specialty certification in cardiovascular disease 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 reimbursement for PCA3/KLK3 antigen test for evaluation of the enrollee, who has a history of elevated prostate specific antigen (PSA).  Findings:  The physician reviewers found the clinical utility of this test is uncertain, as there is a lack of evidence that the use of PCA3 antigen test can be used to change management in ways that improves outcomes. PCA3 is a gene that has been found to be highly overexpressed in prostate cancer. It is one of the most prostate cancer-specific genes identified, with over-expression in about 95% of cancers tested. The PCA3 urine assay uses transcription-mediated amplification to quantify PCA3 in prostate cells found in urine samples. The main target population of this non-invasive test is men with concerns about prostate cancer (raised/rising PSA, abnormal exam) after a prior negative prostate biopsy. However, these studies are preliminary and lack standardization in their reports on clinical performance and interpretation of PCA3 results. Based on the available evidence, the overall certainty of clinical validity to predict the diagnosis of prostate cancer using PCA3 is deemed low. Therefore, the PCA3/KLK3 antigen test was not likely to have been more efficacious than other standard modalities in evaluating this patient. Final Result: All 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: Physician reviewers number one, two, and three are board certified in urology 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy for the enrollees breast cancer. Findings:  The physician reviewer found that there is a lack of medical literature supporting treatment with proton beam radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques for breast cancer. Standard treatment with photon radiation is associated with a very low risk of toxicity. There is also a lack of data submitted that suggests that treatment with proton techniques will be able to significantly improve sparing of the skin, heart, and/or lungs compared to standard breast radiation with photon techniques. In addition, the National Comprehensive Cancer Network (NCCN) group guidelines do not support the use of proton beam radiation therapy in this clinical setting. Based on these reasons, proton beam radiation therapy was 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 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 reviewers number one, two, and three are board certified in radiation oncology and actively practicing. The reviewer 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 reimbursement for peripheral bone density testing for evaluation of the enrollee, who has a family history of osteoporosis. Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The U.S. Preventive Services Task Force recommends testing of all women age 65 and older and younger women whose fracture risk is equal to or greater than that of a 65-year-old woman who has no additional risk factors.  In this case, the patient is premenopausal. Unless she had a secondary condition to suspect osteoporosis, such as glucocorticoid therapy, rheumatoid arthritis, or primary hyperparathyroidism, there is no indication for a baseline bone density test.  Thus, peripheral bone density testing performed was not likely to have been superior over other methods of evaluating this patient. Final Result: The 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 physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 and coverage for human chorionic gonadotrophin (hCG) for treatment of the enrollees hypogonadotropic hypogonadism. Findings:  Two physician reviewers found that although this patients records support a diagnosis of partial empty sella syndrome and secondary hypogonadism, there is a lack of evidence of polycythemia as noted by the provider, which would be a contraindication for testosterone therapy. Further, the records provided for review do not include sufficient documentation that the patient has experienced side effects with testosterone therapy. Thus, although hCG treatment has a role for patients who desire fertility, the requested hCG therapy is not supported for use as a routine treatment for patients with secondary hypogonadism. Given the availability of standard options including dermal patches, the requested hCG is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested medication 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 internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism 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 computed tomography (CT) scan of the chest for treatment of the enrollee, who has a history of a cough.  Findings: The physician reviewer found that the the submitted documentation fails to demonstrate the medical necessity of the requested services.  Lung nodules are one of the few entities where there is general agreement concerning guidelines for further evaluation.  The Fleischner Society is an international, multidisciplinary medical society for thoracic radiology, dedicated to the diagnosis and treatment of diseases of the chest.  This organization has published widely accepted guidelines for the evaluation of incidentally detected lung nodules.  For patients with solid nodules less than or equal to 4 mm in size, these guidelines recommended no follow-up for low-risk patients. For high-risk patients in this clinical setting, the guidelines recommended follow-up at 12 months and if no change, no further imaging is needed.  Based on the records, this patient does not meet criteria for a repeat CT scan.  CT scanning involves the risk of unnecessary radiation exposure.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested CT scan of the chest is not medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are 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 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 Myrbetriq for treatment of the enrollees overactive bladder. Findings: The physician reviewer found that the records indicate that this patient has a diagnosis of overactive bladder. Anticholinergic medications are first-line therapy for management of this medical condition. Myrbetriq is a beta 3 agonist which relaxes the bladder by a mechanism which is different than anticholinergic medication. The patient has tried and responded to Myrbetriq. In phase III clinical trials, Myrbetriq at daily doses of 25, 50, and 100 mg demonstrated significant efficacy in treating symptoms of overactive bladder. Results have been maintained for up to one year in some studies. However, the current medical literature has not demonstrated better efficacy of Myrbetriq over anticholinergic therapy for treatment of overactive bladder in head to head trials. Hence, treatment with Myrbetriq is not 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 urology 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: The parent of an enrollee has requested continued residential mental health and substance use for treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  She did not evidence suicidal or homicidal ideations, she had no evidence of psychosis, and she did not require medical intervention for her substance abuse diagnoses.  None of the medication changes that occurred required around-the-clock medical supervision.  The patient continues to have anxiety, although this does not appear to be severe enough to result in impairment in different settings, nor severe enough that it could not have been treated at a less restrictive level of care, such as outpatient care.  All told, continued residential mental health and substance use treatment was not and is not medically indicated for the treatment of this patient. Final Result: The reviewer 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 reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings: Three physician reviewers found that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population. 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. For the reasons provided, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three 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.