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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Vascepa for treatment of her hypertension, hyperlipidemia and hypertriglyceridemia. Findings:  The physician reviewer found that per the submitted records, this patient is at risk for coronary heart disease. The patients laboratory report includes very high triglycerides, and increased liver enzyme tests while on low intensity statin medication.  In this circumstance where a patient presents with very high triglycerides, in spite of maximum tolerated statin medication, additional treatment to reduce triglyceride levels is clinically reasonable and appropriate. Standard accepted practice in the medical community supports treatment options of medications which are directed at reducing triglycerides. These medications include fibrates, nicotinic acid, and fish oil. However, both fibrates and nicotinic acid are contraindicated with preexisting liver enzyme elevation in this patient. Likewise, higher dose statin medications are relatively contraindicated for the same reason. Therefore, the preferred medication for treatment of this patient's medical condition is a fish oil preparation, such as Vascepa with close monitoring of liver function enzyme levels. In sum, the requested medication is medically necessary for 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 reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 transcatheter embolization of pelvic veins for treatment of the enrollees medical condition.  Findings: Two physician reviewers found that chronic pelvic pain is a very complex problem and is poorly understood.  It is typically very difficult to treat as the disease process is multifactorial without one specific etiology, and clinically can present in different ways and can change over time.  A specific diagnosis is not found in the majority of cases. Some common diagnoses include endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis.  In this patients case, the clinical presentation is strongly suggestive of pelvis congestion.  Other pelvic pathology has been ruled out. The medical evidence supports the requested services in this clinical setting.  She has failed medical management and comparisons of the surgical management options specific to her medical situation indicate she would be a better candidate for occlusion therapy.  In sum, the requested transcatheter embolization of pelvic veins is likely to be more effective than other treatment options.Final Result: Two reviewers determined that the requested services are 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 obstetrics and gynecology and are actively practicing. The reviewers are 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 Sovaldi and Daklinza for treatment of the enrollees 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. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based partially on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al). In addition, delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications 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 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 gastroenterology consultation and endoscopy for treatment of the enrollees medical condition. Findings: The physician reviewer found that this patient has symptoms consistent with gastroesophageal reflux disease and dyspepsia, but also potentially consistent with esophagitis, gastritis, or ulcer of the esophagus, stomach, or small bowel. Persistent pain or dyspepsia is an indication for gastroenterology consultation. The American College of Physicians guidelines recommend endoscopy for investigation of symptoms when those symptoms are refractory to proton pump inhibitor for four to eight weeks without response.  American Society for Gastrointestinal Endoscopy guidelines for diagnosis of dyspepsia state that endoscopy is an appropriate initial test for dyspepsia.  In this case, there is sufficient support for the requested services for this patient.  All told, the requested gastroenterology consultation and endoscopy 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 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 Armour Thyroid medication for treatment of the enrollees thyroid cancer status post thyroidectomy.  Findings: The physician reviewer found that the patient has a history of hypothyroidism. The patient was managed with levothyroxine (T4) and Cytomel (T3) in the past, but reports sub-optimal efficacy on these medications. In the medical literature, levothyroxine has remained the standard of care for treatment of patients with hypothyroidism (Jonklaas, et al). In spite of this, some patients prefer to take desiccated thyroid preparations, such as Armour Thyroid. However, while desiccated thyroid does contain both T4 and T3, the balance of T4 and T3 can lead to non-physiologic levels of thyroid hormones. Further, the amounts of T4 and T3 can vary in each batch of desiccated thyroid, thereby making it more difficult to maintain steady blood levels of the hormones. Given these findings, the requested Armour Thyroid medication is not medically necessary for treatment of this patients hypothyroidism.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 endocrinology, diabetes and metabolism 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 genetic test for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that the patient is diagnosed with invasive ductal carcinoma of the breast.  The records also indicate that the patient has a family history of cancer in her mother, maternal grandmother and a maternal aunt. On her paternal side, her grandfather had gastric cancer and her grandmother had colon cancer. The patient consulted with a genetic counselor who requested genetic testing of the patient. The Health Plan denied genetic test as investigational for evaluation of this patient. The National Comprehensive Cancer Network and the U.S. Preventative Task recommend testing of women for BRCA mutations in certain clinical settings. In this case, BRCA testing was appropriate and of clinical benefit to the patient. This patient is under the age of 50 and diagnosed with breast cancer. The patient also has two relatives with breast cancer. Under the recommended guidelines, the genetic test for the BRCA mutations was appropriate. However, genetic test (CPT code 81479) includes panels of other gene mutations. Although many of the other genetic mutations are of real interest and are being studied, for the most part, these tests have not been found to be significant. Such broad testing is not included in the guidelines by the major organizations. American Society of Clinical Oncology recommends the use of genetic tests that are of clinical utility. The records indicate that the Health Plan had approved BRCA testing for this patient. Therefore, in light of current medical literature and guidelines, the genetic test with CPT code 81749 was not likely to be more beneficial for evaluation of this patient than any available standard testing of this patients medical condition.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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. 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 in 2014 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 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested dual energy x-ray absorptiometry (DEXA) (peripheral bone mineral density measurement) and parathyroid planar imaging single photon emission computed tomography/computed tomography (SPECT/CT) scan for evaluation of the enrollees markedly elevated serum calcium and elevated parathyroid hormone. Findings: Two reviewers found that the parathyroid glands are small endocrine glands in the neck that produce parathyroid hormone in order to regulate blood calcium levels. Hyperparathyroidism results in excess production of parathyroid hormone, which may lead to numerous complications including weakness and fatigue, bone pain, muscle soreness, decreased appetite, nausea, kidney stones and osteoporosis. SPECT/CT fusion is a recent imaging technique that provides three dimensional functional imaging with advanced contrast resolution to greatly improve preoperative localization of parathyroid tumors (Kraeber-Bodere, et al). Because of the improved surgical outcomes following preoperative localization with SPECT/CT imaging, this study was likely to provide helpful data in this patients treatment. Similarly, the DEXA scan was an important part of this patients pre-operative work-up to determine whether the patient was already osteoporotic. Consistent with these findings, the DEXA (peripheral bone mineral density measurement) and parathyroid planar imaging SPECT/CT scan were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  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 endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned 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 current medical evidence supports the services at issue in this patients case.  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, increase in detection of small cancers and improvement in diagnostic accuracy compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done using two-dimensional imaging alone. 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 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 bilateral breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This new method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in diagnostic accuracy and detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  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: 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: Experimental/Investigational
Decision: Overturned 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 current medical evidence supports the services 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, increase in detection of small cancers and increase in overall diagnostic accuracy compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. 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 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 breast tomosynthesis for evaluation of her medical condition. Findings:  Three 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. In this particular patient, there was a new or changing development since prior studies. Tomosynthesis is of value in better distinguishing a mass in terms of its contours and margins than available alternative techniques. While tomosynthesis is generally not able to establish whether a mass is cystic or solid, a sonogram is generally performed as well to make that determination. Thus, in this clinical setting, the use of the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Three 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.  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 digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three 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.