Persius/hicric huggingface dataset:
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 evaluation of the enrollee, who was asymptomatic.  Findings: Two physician reviewers found that the Health Plan has denied the request for reimbursement for the digital breast tomosynthesis.  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. Thus, the medical literature supports the use of digital breast tomosynthesis over conventional 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 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 enrollees risk for breast cancer.  Findings: Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was 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 enrollees risk for breast cancer.  Findings: Two physician reviewers found that 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, by separating the various layers of breast tissue, one can better detect abnormalities. This 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. Thus, in this clinical setting, the use of the digital breast tomosynthesis is 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 is 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested transcranial magnetic stimulation (TMS) treatment for treatment of the enrollees major depressive disorder.  Findings: The physician reviewer found that, as noted in the medical literature, TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. The procedure has been approved by the U.S. Food and Drug Administration (FDA) for this indication. TMS tends to be well tolerated with fewer barriers and side effects than electroconvulsive therapy. TMS can help avoid the possible need for treatment in a more restrictive setting to address suboptimal treatment of clinical depression. Further, the American Psychiatric Association (APA) endorses TMS for patients in the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. The primary study that secured FDA clearance was conducted on a patient population ranging from 18 to 70 years of age. In this particular case, the patients affective illness was not disputed. Considering the medical records, endorsement from the APA and the peer-reviewed literature base, TMS represented a safe, appropriate treatment consistent with good medical practice that was reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the TMS treatment was medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene tests (MyRisk panel) for evaluation of the enrollees risk for cancer. Findings: Two physician reviewers found that this patient has no personal history of cancer, and with no family history suggestive of hereditary cancer syndrome is not eligible for panel gene testing. In keeping with National Comprehensive Cancer Network (NCCN) guidelines, patients with suggestive personal or family history of a single cancer syndrome should only be tested for the syndrome in question. Panel or multi-gene testing is not appropriate in similar patients. There is a lack of prospective randomized controlled studies showing improved outcomes correlating the results obtained from similar tests with improved overall survival, progression free survival, or quality of life. Further, these tests have yet to be correlated with improved health outcomes. Thus, the gene tests (MyRisk panel) rendered is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the testing at issue is 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 medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested laser hair removal for treatment of the enrollees gender dysphoria. Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. Facial hair in a female would be considered abnormal and is referred to as hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in a female in areas that are normally found in males. The abnormal hair is congenital, in that the hair growth is determined by the genetic and hormonal make-up of this patient. The requested facial hair removal can provide substantial improvement in the appearance of terminal hair and create as normal an appearance as possible. It would be abnormal for a female to have terminal hair on the face. A female would be expected to have terminal hair in the scalp, axilla and on the arms and legs. In order to correct the patients abnormal appearance or give the patient a normal appearance to the extent possible, facial laser hair removal is necessary. These treatments will create a more feminine facial appearance. Moreover, the requested services are indicated to improve the patients emotional function. Therefore, the requested facial laser hair removal is medically necessary. For the reasons stated above, the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition.Final Result:The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:The reviewer is board certified in dermatology 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 quantitative sensory testing for evaluation the enrollees neuropathic symptoms. Findings: Two physician reviewers found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Quantitative sensory testing is able to capture and quantify stimulus-evoked negative and positive sensory phenomena, and as such should become standard if not a critical tool in neuropathic pain research and practice. Although quantitative sensory testing is not indicated for every patient, it can be useful for patients with evidence suggestive of a peripheral neuropathy without a definitive etiology. The testing at issue was able to further classify this patients neuropathy in preparation for appropriate therapeutic intervention. Given the clinical documentation submitted for review, quantitative sensory testing was reasonable and within standard clinical practices. Accordingly, the quantitative sensory testing has been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of three reviewers determined that the testing 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 neurology and are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has Doppler guided transanal hemorrhoidal dearterialization surgery for treatment of the enrollees third degree hemorrhoids. Findings: Two physician reviewers found that Transanal hemorrhoidal dearterialization (THD) is a technique used by colorectal surgeons as one of the treatment options for hemorrhoids. The 2010 American Society of Colon and Rectal Surgeons practice parameters for the management of hemorrhoids describes Doppler guided hemorrhoidectomy as a potential treatment for hemorrhoids and states that larger studies including variations on the Doppler technique and comparisons with other methods with longer follow-up intervals are required before definitive recommendations on this method. However, it should be noted that these practice parameters were published and multiple studies in support of THD have been published since that time. For example, a recent systematic review and meta-analysis was published regarding the clinical outcomes and effectiveness of surgical treatments for hemorrhoids. The authors concluded that THD was associated with less postoperative bleeding and therefore less emergency reoperations as well as decreased postoperative complications, shorter operative time, and decreased pain than standard interventions. All told, the THD procedure was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the procedure at issue was 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 physician reviewers are board certified in surgery with sub-specialty certification in colon and rectal 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 reimbursement for the insertion of intrastromal cornea implants and riboflavin application with ultraviolet and riboflavin application with ultraviolet for treatment of the enrollees keratoconus without scarring of the right eye. Findings:  Three physician reviewers found that the use of Intacs and collagen cross-linking have become the standard of care in the treatment of keratoconus. Keratoconus is caused by an abnormally distensible corneal collagen matrix, which allows the cornea to become warped and distorted. Since the cornea is the primary refracting surface of the eye, this deformation causes a profound visual handicap. Collagen cross-linking helps to strengthen the collagen matrix of the corneal stroma and reduce the tendency to continue its progressive distortion. In this case, the use of Intacs and collagen cross-linking was clinically indicated to treat the patients progressive condition. Accordingly, the insertion of intrastromal cornea implants and riboflavin application with ultraviolet (UVA) performed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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 physician reviewers are board certified in ophthalmology 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency room services provided on 3/14/16. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services provided on 3/14/16 were necessary for treatment of an emergency medical condition. According to the documentation submitted for review, the patient is a 52-year-old man who presented with left-sided chest pain. Although his pain had commenced several days prior, it had worsened on the day of presentation. The pain he described was not dull or exertional, as with typical angina, but was associated with sweating. The patient reports that his father died of coronary artery disease at the age of 61, but the patients family history is not noted in the chart. Further, although the patient had no history of hypertension, his blood pressure on arrival was 162/104. The patients EKG showed a non-specific inter-ventricular conduction delay. No ST segment elevations were present, but non-ST segment elevation myocardial infarctions (non-STEMI) may present with non-specific finding on EKG and due to this concern cardiac enzymes were ordered. In addition, the treating provider felt it necessary to order cardiac biomarkers to rule out a cardiac event, and was not content ruling out an acute coronary syndrome based on the patients symptoms and EKG alone. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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 reimbursement for genotype testing.Findings:  Three physician reviewers found that genetic testing was requested with the rationale being that the patient failed multiple neuropsychiatric medications, and has demonstrated sensitivity to others.  However, the medications tried and failed, and those she was sensitive to were not listed.  Genetic testing results would show if a patient is a normal responder of certain classes of medications, may be more or less likely to respond to certain medications, is at low risk of certain adverse events, at higher risk of others, or may have decreased activity of a certain enzyme activity.  Studies have shown that clinically useful predictors in genetic testing are scarce for antidepressant therapy, with results being inconsistent and only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability in the treatment of depression.  The current evidence does not support the use of genotyping when choosing an antidepressant, and even less is understood about its use in the treatment of anxiety disorders.  Genetic testing lacks evidence-based research to show its effective use in guiding the clinician towards choosing a medication regimen.  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 physician reviewers are board certified in psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgery using microdissection and image guidance using neuronavigation to remove all of the remaining chordoma cancer in the pharyngeal prevertebral region near the C2 vertebrae, or surgery to remove all of the remaining chordoma cancer in the pharyngeal prevertebral region near the C2 vertebrae.  Findings: The physician reviewer found that the Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees cervical chordoma.  The current medical evidence supports the requested services in this clinical setting.  There are several well-known characteristics of chordomas.  First, and foremost, complete surgical resection is the only way to cure this disease.  This should be done by a surgeon well versed in chordoma surgery. This surgery should be performed with intraoperative navigation by highly trained neurological surgeons and/or spine surgeons.  The requested services are standard of care in this patients case. In sum, the requested surgery using microdissection and image guidance using neuronavigation to remove all of the remaining chordoma cancer in the pharyngeal prevertebral region near the C2 vertebrae is 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 neurological 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.