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

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for L4-5 artificial disc replacement. Findings:  The physician reviewer found that there is sufficient support for the requested services in this patients case.  The U.S. Food and Drug Administration (FDA) approval for the ProDisc-L total disc replacement states that this device is indicated for spinal arthroplasty in patients who are skeletally mature, have degenerative disc disease at one level in the lumbar spine from L3 to S1, have no more than grade 1 spondylolisthesis at the involved level, and have had no pain relief after at least six months of non-surgical treatment. FDA exclusions include bony lumbar spinal stenosis and isolated radicular compression syndromes, especially due to disc herniation.  A study found that patients with degenerative disc disease undergoing either total disc replacement or circumferential arthrodesis maintained significant improvement during the five-year follow-up.  The total disc replacement group had significantly better improvement on some scales.  This patient has had persistent and worsening low back pain that has failed to respond to at least six months of comprehensive conservative treatment.  Functional difficulty is documented in activities of daily living and work ability.  There is imaging and discogram confirmation of single level degenerative disc disease at L4-5, with grade 1 or less spondylolisthesis at the involved level, and no evidence of spinal stenosis or nerve root compression due to disc herniation.  The patient meets the generally accepted standards of medical practice for lumbar artificial disc replacement. Therefore, the requested L4-5 artificial disc replacement is medically indicated for the treatment of this patient.Final Result: The reviewers 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: Physician reviewer number one is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Supartz injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the medical evidence supports the requested services in this clinical setting.  Evidence based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections.  In this case, the patient has been diagnosed with osteoarthritis of both knees.  Ongoing self-care measures have included medications, activity modification, and stationary bike.  He has undergone prior series of viscosupplementation approximately every six months in 2015 and 2016, with reported symptomatic relief of his chronic osteoarthritis pain.  He does not want to proceed with knee replacements at this time.  There is sufficient support for the requested services in this clinical setting.  Therefore, Supartz injections are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for estriol micronized powder 100% and prospective authorization and coverage for continued refills for treatment of the enrollee, who is status post total hysterectomy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue. This patient has requested reimbursement and prospective authorization and coverage for a compounded hormone face cream with estriol.  It appears she is also taking estrogen and progesterone in some other form, as well as testosterone.  She says she believes the compounded hormone is safer for her, and that she does not want to take animal-based hormones.  The medical evidence does not support the medication at issue in this clinical setting.  There is a lack of evidence that compounded bioidentical hormones are safer or more efficacious than standard U.S. Food and Drug Administration (FDA) approved and tested options.  Due to issues related to compounding, dosing is frequently inconsistent.  This may actually increase the risk of such treatments.  All told, estriol micronized powder 100% and continued refills was not and is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the medication at issue was not and 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomaticFindings:  Two physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa (sofosbuvir-velpatasvir tablets 400-100 mg) for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  This applies regardless of fibrosis stage.  The guidelines support treatment in patients with cryoglobulinemia, stating that adverse extrahepatic effects such as renal impairment and vasculitis can result from cryoglobulinemia.  Per the guidelines, Epclusa is recommended as first-line for treatment-naive genotype 2 patients. Delay in treatment may result in decreased survival.  For these reasons, Epclusa (sofosbuvir-velpatasvir tablets 400-100 mg) is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturnedCredentials/Qualifications: Physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Subsys for treatment of the enrollees pain. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. Subsys is U.S. Food and Drug Administration (FDA) approved for the treatment of breakthrough cancer pain. It is not approved to treat migraine headaches or transformed headaches.  There is no documentation to suggest that she has metastatic disease that is causing her headaches.  The fact that she has a remote history of breast cancer does not change the indication for this medication.  The current medical evidence does not support the requested medication in this clinical setting.  All told, Subsys is not medically indicated for the treatment of 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed 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 performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ 20 mg for treatment of the enrollees short stature. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  This patients pre-treatment height was more than two standard deviations delayed, and his bone age was delayed for chronological age.  According to the Pediatric Endocrinology Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; growth velocity less than the 25th percentile for bone age; bone age more than two standard deviations below the mean for age; low serum insulin-like growth factor 1 (IGF-1) and/or insulin-like growth factor-binding protein 3 (IGFBP-3); and/or other clinical features suggestive of growth hormone deficiency.  This patient does meet some of the above criteria, and his growth has accelerated while on growth hormone therapy.  Continuation of therapy is medically necessary for this patient.  All told, Nutropin AQ 20 mg is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 the digital breast tomosynthesis enrollee has requested reimbursement for the digital breast tomosynthesis. Findings:  Three physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical. 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 performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic vertical sleeve gastrectomy for treatment of the enrollee, who has a history of morbid obesity. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity for the services at issue in this clinical setting. This patient documents a BMI of 40.5 kg/m2 and she has completed a multidisciplinary evaluation, which did not reveal any obvious dietary, behavioral or medical barriers to surgery. She has failed dietary efforts including supervised weight loss. Per the submitted documentation, this patient meets standard nationally accepted criteria for bariatric surgery as established by the National Institutes of Health guidelines as well as the American Society for Metabolic and Bariatric Surgery. Therefore, the requested laparoscopic vertical sleeve gastrectomy is medical necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 reimbursement for breast cancer index test performed on 4/19/16.Findings:  Two physician reviewers found that hormone receptor positive breast cancer responds to adjuvant anti-estrogen therapies such as aromatase inhibitors and tamoxifen. These drugs are usually administered for five years after mastectomy. However, patients are at risk for recurrence of about 2% per year, nearly 15 years after diagnosis and initial surgical resection. Thus, a biomarker may help providers identify those patients who are at higher risk and making them candidates for extended anti-estrogen therapy. Along these lines, BCI is a gene expression test that generates a risk for five year recurrence. The test was studied retrospectively on paraffin embedded material from patients on the TransATAC study. In this well controlled clinical study, the breast cancer index was a good prognostic marker of breast cancer recurrence and performed better than other gene expression tests.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and hematology 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 panel of gene tests for evaluation of the enrollees breast cancer. Findings: Two physician reviewers found that per the National Comprehensive Cancer Network (NCCN) guidelines high risk assessment, BRCA testing is indicated for patients with a personal history breast cancer at age 45 or younger, a personal history at age 50 or younger with a first degree relative with breast cancer, a personal history at age 60 or younger and triple negative breast cancer, or two first degree relatives with breast cancer. The U.S. Preventive Services Task Force (USPTF) recommends genetic counseling for patients with a history breast cancer. However, after genetic counseling this patient would not meet criteria for BRCA testing. Further, the testing is indicated for patients with sarcoma or who have Chompart criteria with breast cancer at or before age 46. Moreover, all other genetic mutations are not endorsed by NCCN guidelines. For these reasons, the panel of gene tests performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: The physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 authorization and coverage for Zepatier 50/100 mg oral tablets for 12 weeks. Findings:  The physician reviewer found that according to the most recent 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 limited life expectancy due to non-liver-related conditions. This recommendation applies regardless of fibrosis score. The guidelines recommend that treatment-naive genotype 1b patients should be treated with Zepatier for 12 weeks, regardless of NS5A resistance testing results. These guideline recommendations are based on high-quality clinical trial data. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.