Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi in combination with Daklinza for treatment of his hepatitis C virus.   Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks or Sovaldi, peg-interferon and ribavirin for 12 weeks. This is based on the ALLY-3 study for Sovaldi and Daklinza and the BOSON trial for Sovaldi, peg-interferon with ribavirin (Nelson, et al; Foster, et al). AASLD/IDSA was cognizant of the known side effects of these medications when creating these guidelines, and recommend monitoring patients for side effects during therapy with adjustments if needed. In this case, the patient does not have any of the medical contraindications to peg-interferon as defined in the AASLD/IDSA guidelines, or to ribavirin as defined in the U.S. Food and Drug Administration-approved prescribing information for ribavirin. For these reasons, the requested treatment with Sovaldi and Daklinza is not indicated for this patient. 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 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 a genetic test for peripheral neuropathies for evaluation of his medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this patients case.  The patient has had a chronic polyneuropathy that in the past reportedly responded to intravenous immune globulin, thus was presumed to be immune-mediated. Genetic neuropathy such as Charcot-Marie-Tooth disease is not likely to respond to intravenous immune globulin.  Guidelines for evaluation of symmetric polyneuropathy suggest that patients without a known cause should undergo a complete blood count, comprehensive metabolic panel, Vitamin B12, thyroid testing, serum protein electrophoresis with immunofixation, fasting glucose measurement, and glucose tolerance test.  There is no evidence in this case that other relevant metabolic, infectious, autoimmune, and toxic etiologies have been excluded.  Genetic testing is established as useful for diagnosis and classification of hereditary neuropathies.  However, it is not likely to lead to treatment options.  In sum, genetic testing for peripheral neuropathies was not likely to have been more efficacious than other modalities.  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 neurology 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 the Decision DX Melanoma Assay test for evaluation of his medical condition.  Findings:  Three physician reviewers found the Decision DX Melanoma assay was developed to help predict the risk of future metastatic spread of melanoma.  The assay tested gene expression in ocular melanoma, not cutaneous melanoma, and is not considered to be standard of care for the treatment of cutaneous melanoma.  The National Comprehensive Cancer Network guidelines indicate that genetic testing to predict metastatic risk, such as the Decision DX Melanoma Assay, should not be used outside of clinical trials.  Thus, Decision DX Melanoma Assay testing 15 was not likely to have been more effective than other methods of evaluating this patient.  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 dermatology 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 genetic testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that guidelines for the evaluation and management of dyslipidemia and cardiac risk do not recommend routine screening with specialized testing included the genetic tests in dispute (Greenland, et al; Stone, et al). Treatment change based on the results of these specialized tests has not been shown to improve cardiac outcomes incremental to that achievable using standard clinical risk profiles combined with basic lipid analysis. In sum, the testing at issue 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 testing 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:  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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Anser IFX testing for evaluation of his Crohns disease.  Findings:  Three physician reviewers found that it has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Generally, diminished or suboptimal response to infliximab or adalimumab can be managed in several ways such as shortening the interval between doses, increasing the dose, switching to a different anti-tumor necrosis factor (TNF) agent or switching to a non-anti-TNF agent based on clinical observation in lieu of Anser testing. All told, the testing at issue 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 testing 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:  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested physical therapy for treatment of the enrollees progressive joint stiffening and contractures secondary to Niemann-Pick disease. Findings:  The physician reviewer found that in this clinical setting, the requested services of physical therapy are not medically necessary for treatment of this patients medical condition. The submitted medical records fail to show the need for physical therapy performed by a skilled physical therapist versus continued exercise by a non-skilled health care worker or lay person.   Niemann-Pick disease type B is a condition that affects many body systems and has a wide range of symptoms that vary in severity. While the patient is noted to have joint stiffness due to his disease process, the most recent physical examination provided for review does not show that the patient has any functional deficits that would require physical therapy treatment at this time. The need for physical therapy treatment for this patient is not supported. Given the above, the requested services are not medically necessary.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation 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: Upheld 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 the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  This patients screening examination noted an area of suspicion in the one breast.  Coned compression spot films and ultrasound of the area in question were appropriate.  However, the addition of breast tomosynthesis to evaluate an area of concern already to be evaluated by compression spot films and ultrasound was likely of no added benefit to the patient since the area of concern had already been identified.  In sum, breast tomosynthesis was not likely to have been more efficacious than other methods of evaluating this patient.  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 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 the septorhinoplasty procedure for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested service.  The proposed procedure involves a rhinoplasty with major septal repair.  Correction of a dorsal hump and bulbous tip would be more in line with cosmetic procedures and does not appear to be the result of the previous procedure.  Additionally, the requested services are not reconstructive in nature.  Per the medical records, there is some loss of support of the nose that could be considered an abnormal occurrence as a result of the previous medically necessary procedure.  However, there is not sufficient documentation that the dorsal hump and bulbous tip is significantly abnormal.  There is no evidence that the proposed procedure would improve function.  Based on the submitted documentation, there is insufficient justification that the rhinoplasty part would correct a significantly abnormal appearance.  All told, the requested services are not reconstructive in nature and are not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested services are not reconstructive in nature 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested shoe inserts for treatment of her severe osteoarthritis and plantar fasciitis in both feet. Findings: The physician reviewer found that after review of the submitted clinical documentation, the requested orthotics are medically necessary to treat this patient's plantar fasciitis and midtarsal joint osteoarthritis. It is established in the progress notes that this patient is experiencing painful plantar fasciitis. Per the submitted documentation, custom functional orthotics have been used for many years to inhibit over pronation of both the subtalar joint and midtarsal joint, in treatment of plantar fasciitis and midtarsal joint osteoarthritis. These devices biomechanically support the foot and offload the painful area. Orthotic devices are considered standard of care for the treatment of plantar fasciitis and midtarsal joint osteoarthritis. For these reasons, the requested shoe inserts are medically necessary for treatment of the patients severe osteoarthritis and plantar fasciitis in both feet.  Final Result: The reviewer determined that the requested equipment 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 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 bilateral sacroiliac (SI) joint fusion surgery for treatment of her medical condition. Findings:  Three physician reviewers found that bilateral sacroiliac joint fusion surgery is not likely to be more beneficial for treatment of her medical condition than any available standard therapy. In this case, the patient has not had a complete SI exam. Local SI tenderness is not diagnostic of SI joint disease, nor is a single finding as a positive thrust test confirmatory of SI joint disease. There is a lack of confirmatory evidence that she has SI joint pain or that the SI joint is her pain generator. Moreover, there is a lack of large, prospective, randomized, scientific, studies that have shown the long term safety and effectiveness of SI fusion for chronic degenerative disease of the SI joint. Thus, the proposed surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three 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: All three physician 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 a mastectomy of the right breast for treatment of her medical condition. Findings: The physician reviewer found that unilateral mastectomy, considered to be prophylactic, may be appropriate in a patient in whom therapeutic mastectomy has previously been performed or is being contemplated for breast cancer.  Such women are at higher than normal risk for developing contralateral breast cancer.  However, when considering contralateral prophylactic mastectomy in a patient with cancer, it is important to recognize that many women overestimate their risk of developing a second cancer.  A detailed discussion of a patients risk of a contralateral breast cancer, the lack of impact of prophylactic mastectomy on mortality from the index cancer, and the significant benefit of endocrine therapy in reducing the risk of contralateral cancer should be included in the discussion of prophylactic mastectomy in this circumstance. This patient is not a candidate for endocrine therapy due to her estrogen receptor/progesterone receptor negative breast cancer. Mastectomy of the contralateral breast may be considered for risk reduction in patients at high risk for a contralateral breast cancer.  Additionally, mastectomy of the contralateral breast may be considered for patients in whom subsequent surveillance of the contralateral breast would be difficult.  This includes patients with clinically and mammographically dense breast tissue or diffuses indeterminate microcalcifications in the contralateral breast.  The requested services are medically appropriate in this patient with breast cancer and a mammogram interpreted as having heterogeneously dense to dense breast tissue with a nodular appearance.  Therefore, the requested mastectomy of the right breast is medically necessary 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 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 three-dimensional 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. 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.  Therefore, three-dimensional 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: Three physician 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 a VistaSeq Hereditary Cancer Panel for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the requested services in this clinical setting.  This patient had had two cancers at a young age and has family members with several types of cancers, making her at significant risk of a hereditary cancer.  Testing would affect how she is screened and treated for risk of additional cancers and also if her family members need to be tested to decrease their risk. Given her ethnicity and variety of cancers, panel testing is recommended over standard testing with only BRCA1 and BRCA2.  In sum, the requested VistaSeq Hereditary Cancer Panel is likely to be more effective than other methods of evaluating this patient. Final Result: Two reviewers determined that the requested services are 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 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.