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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a referral to a neurologist for evaluation of his medical condition.   Findings:  The physician reviewer found that the requested referral to a neurologist is medically necessary for treatment of the patients medical condition. This patient presents with numbness and tingling. His treating cardiologist recommended a neurology consultation, indicating a low likelihood that the patients symptoms are vascular. In sum, an evaluation by a neurologist is medically necessary given the patients symptoms that are suggestive of neuropathy. Final Result: The reviewer determined that the requested referral is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in neurology 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 a continued stay at a skilled nursing facility for physical therapy for treatment of her medical condition.  Findings: The physician reviewer found that tibial plateau fractures are complicated injuries, each requiring an individualized initial approach whether surgical or nonsurgical (Yoon, et al). These fractures can result in significant functional impairments. The patient was still early in her rehabilitation course following a significant injury resulting in functional deficits. The patient was still making steady progress. Thus, continued stay at a skilled nursing facility for physical therapy was initially medically necessary. However, subsequently the patient was at the level of independent to supervision/set up for her self-care and household level mobility. As such, further care could have been provided in a less intensive setting. Continued inpatient care while awaiting delivery of durable medical equipment would constitute custodial level care; as such, continued stay at a skilled nursing facility for physical therapy was not medically necessary.  Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Specifically, the patients continued stay at a skilled nursing facility for physical therapy was initially medically necessary.  Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a computed tomography (CT) angiogram for evaluation of his medical condition.  Findings: Two physician reviewers found that if coronary ischemia is suspected then some form of stress testing is considered standard of care and most appropriate accepted practice in the medical community (Hendel et al). Coronary CT angiography defines coronary anatomy only, and does not assess the functional significance of any potential stenosis identified. Moreover, Miller and colleagues found that coronary CT angiography is less accurate compared to conventional angiography and may miss small branch vessel stenosis that could be identified on stress testing which may be responsible for the patient's symptoms. Finally, if an assessment of coronary anatomy is thought to be warranted, then conventional coronary angiography is preferred not only because of its improved accuracy but also because of the ability to intervene with coronary revascularization during the same procedure. For these reasons, the diagnostic procedure at issue was not likely to be more beneficial for the evaluation of this patients medical condition than any available standard modality.  Final Result: Two reviewers determined that the procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested gene testing for evaluation of his medical condition. Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  While PCA3 testing may eventually have a role in reducing unnecessary biopsies, there are insufficient data on clinical outcomes to currently support routine use.  There is a lack of clear evidence that PCA3 is better than standard PSA testing with biopsies when indicated and some data that PCA3 may miss certain types of higher risk prostate cancer for which younger patients may be at risk.  In sum, gene testing was not likely to have been superior over other methods of evaluating this patient. Final Result: Two reviewers determined that the services at issue were 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Praluent injections every two weeks for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has hyperlipidemia, although the documentation does not support known coronary disease or familial heterozygous or homozygous hyperlipidemia.  Familial hypercholesterolemia usually manifests by a combination of physical exam findings low-density lipoprotein (LDL) cholesterol levels that are at minimum above 180 mg/dl.  This is not documented in the medical records provided.  Praluent is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  The medical records do not support the patient meets any of those criteria.  PCSK9 inhibitors have not been studied in other patient populations such as this patient.  Current guidelines which are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  Finally, there are other statin medications which have lower side effect profiles and have not been documented to be tried or not tolerated in this patient.  All told, the requested Praluent injections every two weeks 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:    An enrollee has requested Synvisc One injections in both knees for treatment of her bilateral knee pain.  Findings:  The physician reviewer found that evidence-based medical peer-reviewed literature supports the use of repeat series of viscosupplementation (hyaluronan) injections for the treatment of pain in patients with osteoarthritis of the knee. This has been found to be safe and effective and allows for delay of total knee replacement. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of hyaluronan were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis who failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has been diagnosed with bilateral knee osteoarthritis, worse on the right. She has undergone two prior viscosupplementation injections with long-term pain reduction documented and ability to avoid surgery. She has failed to respond to other conservative treatment. Therefore, the requested Synvisc One injections for both knees would be considered medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested therapy 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 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 a Praluent pen for treatment of his hyperlipidemia.  Findings:  The physician reviewer found that current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors (Praluent) in this primary prevention setting. PCSK9 inhibitors have not been studied in other patient populations such as this patient. There are other non-statin medications to treat hyperlipidemia such as Zetia (ezetimibe) that have lower side effect profiles. The submitted records do not show that these other non-statin medications have been tried or failed in this patient. Also, based on the record provided, the patient has no documentation of cardiovascular disease and no documentation of confirmed homozygous familial hypercholesterolemia or heterozygous familial hypercholesterolemia. Familial hypercholesterolemia usually manifests by a combination of physical exam findings (arcus cornealis below the age of 45, tendon xanthomata) and LDL-c levels that are at minimum above 180mg/dl (and usually significantly higher).  Praluent is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol; the documentation provided does not confirm that the patient meets any of those criteria. For these reasons, the requested medication is not medically necessary for treatment of the patients medical condition. 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 physician 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 requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this 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 reviewers are board certified in diagnostic radiology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C. Findings:  The physician reviewer found that according to the most recent 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. Per the guidelines, treatment-naive genotype 1 patients should be treated with Viekira Pak, or with Harvoni.  Both medications are U.S. Food and Drug Administration (FDA) approved for patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  There are no head-to-head direct comparison trials showing that Harvoni is superior to Viekira Pak.  In this patients case, no contraindication to Viekira Pak/ribavirin is provided.  For this reason, although hepatitis C treatment is needed in this case, Harvoni is not supported over Viekira Pak.  For these reasons, the requested treatment with Harvoni 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 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: 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 breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography (FFDM, 2D) alone. Recall rates are reduced by 15-17%: 3D allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries). Studies have also shown that there has been an increase in cancer detection by 33-53%: cancer detection increased from 6 cancers/1000 women screened with 2D to 8 cancers/1000 women screened with 3D. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening.  Final Result: Three 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 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 an Afirma gene test for evaluation of her medical condition. Two physician reviewers found that thyroid nodules are commonly managed by diagnostic fine needle aspiration to evaluate the cytopathology. In this case the finding by this standard technique was atypia of undetermined significance (Baloch, et al). This diagnostic category creates a dilemma with regards to recommended surgery. In this case, the patient was facing total thyroidectomy if malignancy was present, but only subtotal thyroidectomy if the lesion turned out to be benign. Hence, the sample was submitted for gene expression analysis. The Afirma gene test has demonstrated a very high negative predictive value for malignancy (Alexander, et al; Chudova, et al). The overall conclusions of the last two cited studies are that unnecessary thyroid surgeries may actually be prevented by implementation of the gene expression test. The studies are well conducted and the utility of the Afirma gene test has been demonstrated in the medical literature. As such, the he Afirma Gene Expression Classifier test was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.   Final Result: Two 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested BRCA testing for evaluation of her medical condition. Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  This patient has a strong family history of breast cancer.  Per the current medical evidence, testing should be considered in appropriate high-risk individuals where it will impact the medical management of the tested individual and/or their at-risk family members.  In this patients case, a positive or negative test would alter how this patient is managed.  All told, BRCA testing was likely to have been superior over other modalities for evaluating this patient. 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 internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast reduction surgery for treatment of his Klinefelters syndrome.  Findings: The physician reviewer found that this patient presents with significant bilateral gynecomastia in the setting of a low testosterone state, consistent with Klinefelters syndrome. The examination documentation is consistent with severe abnormal male breast enlargement and more consistent with female anatomy. Thus, the requested surgery is to correct a congenital breast deformity known as severe gynecomastia. The procedure is expected to significantly improve the patients appearance and would make a more than minimal improvement. Consistent with this finding, the requested bilateral breast reduction surgery is reconstructive in nature and medically necessary.  Final Result: The reviewer determined that the requested surgery is reconstructive in nature and medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Qualifications/Credentials: The physician 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.