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

Nature of Statutory Criteria/Case Summary: An enrollee has requested mastectomy revision procedures for treatment of the patients gender dysphoria. Based on the patients gender dysphoria and identification as a male, the aim is for a normal appearance of the breasts for a male. Fat grafting on the right inferior breast and nipple/breast revision on the left is consistent with this goal. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Based on the documentation provided for review, the patient has significant abnormality of the right inferior lateral breast and significantly asymmetric nipple areolar complexes. The patient previously had the appearance of female breasts and underwent bilateral mastectomies and free nipple grafting to achieve a male contour of the chest. His current appearance is considered abnormal. The patients abnormal structure of the body is based on his diagnosis of gender dysphoria, a disease or developmental abnormality. The proposed surgery is being performed to create a normal appearance to the extent possible, as the patient has a significantly abnormal appearing chest contour based on the right lateral inferior breast and asymmetric nipple areolar complexes. In addition, the requested fat grafting and resizing of the left nipple areolar complex would be expected to provide more than a minimal improvement in the appearance of the patient. However, the request for excision of axillary fullness has not been established as medically necessary or reconstructive in nature for treatment of the patients medical condition. Based on the documentation provided, the axillary fullness and bilateral dog ears are considered part of the normal male contour. Therefore, a portion of the requested surgeries are medically necessary and reconstructive in nature for treatment of the patients medical condition.Final Result: The reviewer determined that a portion of the requested surgeries are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturnedCredentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sovaldi and Ribasphere for 12 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer has 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. Per the guidelines, in treatment-naive genotype 2 patients, therapy is recommended with Sovaldi and Daklinza or Epclusa. This is based on the two studies for Sovaldi and Daklinza, and the ASTRAL-2 trial for Epclusa.  Sovaldi and ribavirin are no longer recommended. The guidelines cite data showing that delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, although hepatitis C treatment is needed, the request for Sovaldi and Ribasphere for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. 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 I am actively practicing 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 pulsed radiofrequency neurolysis for treatment of the enrollees right-sided sciatic nerve pain. Findings: Three physician reviewers found that the request for pulsed radiofrequency neurolysis is not likely to be beneficial for treatment of the patients medical condition. Niemisto and colleagues assessed the effectiveness of radiofrequency denervation for the treatment of musculoskeletal pain disorders. The authors concluded that high quality random controlled trials with larger patient samples are needed as the current evidence is inconclusive. In this case, the requested procedure is likely to have limited efficacy for this patient due to the multiple pain generators present. The localization of pain generation to the posterior rami innervating the facet joints is not likely to include the full range of pain generation in this patient. Therefore, the requested procedure 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 procedures 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. 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 Sovaldi for treatment of the enrollees chronic hepatitis C virus genotype 3a. 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. The recommendations apply regardless of fibrosis stage. The guidelines do not recommend Sovaldi with ribavirin any longer for genotype 3. This is based on the significantly higher effectiveness of two other regimens (Nelson, et al; Foster, et al). For these reasons, Sovaldi for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested for an oral device for treatment of the enrollees obstructive sleep apnea (OSA). Findings: The physician reviewer found that the American Academy of Dental Sleep Medicine (AADSM) currently recommends oral appliance for the treatment of mild to moderate obstructive sleep apnea in patients who cannot tolerate CPAP therapy. In addition, several U.S. Food and Drug Administration (FDA) approved oral appliances are available for treatment of obstructive sleep apnea syndrome. The use of oral appliances is well described for use in this clinical setting. Thus, the oral device provided is supported as medically necessary for treatment of this patients obstructive sleep apnea.Final Result: The reviewer determined that the device at issue was 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 oral and maxillofacial 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 digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings: Two physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as being extremely dense. While one could make the argument that her mammogram has not changed since the last study, 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, the digital breast tomosynthesis has been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two 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.
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 enrollee who presented for a breast screening mammogram.  Findings: Two physician reviewers found that the patient was evaluated with screening mammogram and digital breast tomosynthesis. The report noted stable findings with no evidence of malignancy. The Health Plan has denied reimbursement for digital breast tomosynthesis. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is evidence-based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to be more effective to this patient than had her examination been performed using two dimensional imaging alone.Final Result: Two 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi for treatment of the enrollees chronic hepatitis C virus genotype 3a.  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. The recommendations apply regardless of fibrosis stage. The guidelines do not recommend Sovaldi with ribavirin any longer for genotype 3. This is based on the significantly higher effectiveness of two other regimens (Nelson, et al; Foster, et al). For these reasons, Sovaldi for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.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 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 autonomic nervous system function testing for evaluation of the enrollees medical condition. Findings:  Two physician reviewers found that the current medical evidence supports a portion of the services at issue.  The records indicated a diagnosis of postural orthostatic tachycardia syndrome, and subsequent testing confirmed this.  Postural orthostatic tachycardia is generally clinically suspected, and testing may confirm this diagnosis.  The medical literature supports tilt table testing for confirmation of postural orthostatic tachycardia syndrome.  Thus, this portion of the testing was likely to have been more efficacious than other methods of evaluating this patient.  However, the remainder of the testing was not likely to add to the clinical diagnosis or change treatment. Final Result: The reviewers determined that a portion of the services 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 partially overturned. Credentials/Qualifications: All three physician reviewers are board certified in neurology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for the enrollees breast cancer screening.  Findings: Two physician reviewers found that the patient with bilateral screening mammogram with digital breast tomosynthesis was denied reimbursement for the digital breast tomosynthesis portion of the examination. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. According to Skaane and colleagues, 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. Ciatto and colleagues noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Therefore, the medical literature supports the use of digital breast tomosynthesis over standard mammogram due to improved cancer detection rate. In sum, digital breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.Final Result: Two 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 overturnedCredentials/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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genotype testing for genetic polymorphisms to determine drug metabolizer status for evaluation of the enrollees depression and possible bipolar disorder. Findings:  The 3 physician reviewers found that the Millennium Pharmacogenetic Testing (PGT) is a non-invasive genetic test utilizing either an oral swab or saliva specimen to identify how a patients genetic profile may impact his or her response to certain medications. Pharmacogenetic testing in psychiatry is a newly evolving field and is rapidly gaining wide acceptance but large randomized controlled trials are needed to further substantiate the utility of genetic testing in psychiatry. A review of the available literature regarding pharmacogenetic testing suggests that it has been studied that to the extent that genetic factors are associated with the efficacy, tolerability, and safety of different drugs, pharmacogenetic tests may be used to personalize medication treatments for an individual. However, there is a paucity of large randomized controlled trials that demonstrate the efficacy of pharmacogenetic testing in psychiatry. Based on the review of the submitted documentation, the genotype testing for genetic polymorphisms to determine drug metabolizer status performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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: Physician reviewer number one is board certified in 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.Physician reviewer number two is board certified in 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.Physician reviewer number three is board certified in 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 reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. 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.  In this patients case, her breasts were described as heterogeneously 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 performed was likely to have been superior over 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing facility admission including physical therapy and occupational therapy for treatment of the enrollee, who sustained a hip injury after falling. Findings:  The physician reviewer found that the skilled nursing facility level care was not medically necessary. The patient had a unilateral lower extremity impairment. She was weight bearing as tolerated and had a slightly limited prior level of function requiring a cane. The patient had purchased a walker.  The documentation did not indicate complex wound care needs. Her medical condition was stable and her pain was being managed with oral medications. She was able to ambulate greater than household distances and perform essential activities of daily living without hands-on assistance. The patient did not require physician oversight of her condition on an inpatient basis. The patients care needs could have been met at an alternative level of care such as home based or outpatient level of care. Therefore, based on the reasons stated above, the three additional days including physical therapy and occupational therapy at a skilled nursing facility were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 management 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.