Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld 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 breast tomosynthesis was not likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is a lack of peer-reviewed literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques. Although digital breast tomosynthesis is a promising tool in breast imaging, further evidence is needed to establish its place in breast cancer diagnosis and screening. As such, breast tomosynthesis was not likely to be more beneficial for evaluation of this patient than standard modalities. Final Result: Two reviewers determined that the diagnostic 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 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 a gene test for evaluation of his thyroid nodule.   Findings:  Three physician reviewers found that the testing at issue was likely to be more effective for this patient than other available treatment options. Typically, fine-needle aspiration (FNA) biopsy of a suspicious thyroid nodule is an accurate means of assessing whether the nodule is benign or malignant, with approximately 15% of FNA biopsy results considered to be indeterminate. Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma gene test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Therefore, the testing at issue was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.   Final Result: Three reviewers determined that the testing at issue was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Two reviewers are board certified in endocrinology and metabolism and are actively practicing. One reviewer is board certified in medical oncology and metabolism and is 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 Botox injections for treatment of her migraine headaches.  Findings:  Two physician reviewers found that based on the documentation provided for review, Botox injections are supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of migraine headaches that are defined as chronic, meaning greater than 15 days per month. The available medical records provided for review support the patient had migraine headaches on a near daily basis prior to initiation of Botox and following Botox administration, the patient experienced a significant decrease with reported objective increase in functionality.  As such, Botox is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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 reviewers are board certified in neurology 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 Anser IFX measurement of serum infliximab and antibodies to infliximab (ATI) for treatment of his medical condition. Findings:  Two physician reviewers found that the testing at issue was likely to be more effective for this patient than other available options. The loss of response to infliximab can be due to sub-therapeutic infliximab levels or the presence of antibodies to infliximab. While more research is needed to fully explore this area, the available data suggest that measuring drug and/or antibody levels could help clinicians to optimize anti-TNF therapy by adjusting drug doses or switching to alternative therapies in patients who are unlikely to respond to continued treatment with a particular agent. The concept of dose adjustment based on drug levels has several potential benefits, one of which is that providers could not only increase drug doses in patients with sub-therapeutic drug levels but could also reduce drug doses in patients with super-therapeutic levels, thereby making the treatment safe for the patients. Therefore, measuring both IFX and ATI concentrations may help guide patient management, optimize care, and prevent complications and reduce long-term morbidity and mortality from complications. In this patients case, Prometheus Anser IFX testing 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 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 gastroenterology 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 the intermittent limb compression device not otherwise specified (cooling or combined heating/cooling unit) CPT code E0676 for treatment of her status post hip and knee surgeries. Two physician reviewers found that the device at issue provides intermittent sequential compression therapy intended as deep vein thrombosis (DVT) prophylaxis, intermittent dynamic compression therapy intended to reduce swelling, and controlled cold therapy intended to reduce both pain and swelling. In this case, there are no identified risk factors for DVT. If DVT prophylaxis was determined to be necessary, there is no contraindication to use of an oral or injected agent for DVT prophylaxis such as warfarin, fondaparinux or rivaroxaban. In this clinical setting, the intermittent limb compression device was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result:  Two reviewers determined that the device at issue was 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 physical medicine and rehabilitation 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 rhinoplasty and lip filler injections for treatment of her gender dysphoria. The physician reviewer found that per the World Professional Association for Transgender Health (WPATH) Standards of Care regarding the medical necessity of sexual reassignment surgery (SRS) including facial feminization surgery, `Professionals who provide services to patients with gender conditions understand the necessity of SRS, and concur that it is reconstructive, and as such should be reimbursed, as would any other medically necessary treatment.` In this patients case, multiple practitioner notes clearly document the patients diagnosis of gender dysphoria. The Health Plan has approved frontal bone contouring with hairline lowering and laryngochondroplasty, thus establishing that a component of this patients gender dysphoria is related to the masculine appearance of her face. All told, the requested rhinoplasty is medically necessary to treat the patients gender dysphoria. This procedure is also considered reconstructive in nature in that the patients nose contributes to the masculine appearance of her face and therefore in the context of her being a transgender woman, the nose has developed abnormally for a genetically born female. Further, the proposed rhinoplasty should improve the patients appearance to a softer, more feminine appearance and is likely to result in more than a minimal improvement in her appearance. With regard to the requested lip filler injections, lip augmentation is not considered to be a standard treatment for gender dysphoria. Thin lips, or lips that would benefit from a more full appearance, can occur in any female and are not considered a marker for a masculine appearance. As such, the proposed lip filler injections are not medically necessary or considered reconstructive in this case. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition and is reconstructive in nature. Specifically, the requested rhinoplasty is medically necessary and reconstructive in nature. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a gene test for evaluation of her medical condition.  Findings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  A relatively new test, the Afirma Thyroid FNA Analysis, utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  Therefore, gene testing was likely to have been superior over other methods of evaluating this patient.  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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The American College of Radiology (ACR) statement of breast tomosynthesis states that tomosynthesis should no longer be considered investigational as it is a valuable tool in breast imaging. While there is a lack of long term studies proving an increased survival rate when tomosynthesis is used as part of a screening mammogram the addition of the technique has been embraced by providers due to an associated decrease in callbacks and an increase in detection of small cancers due to the tomographic quality of the technique which permits providers to separate dense glandular tissue from underlying architectural distortion.  Such distortion is often an indication of invasive ductal cancer.  The technique has proven to be especially valuable in patients with dense or heterogeneously dense breast tissue. Thus, the addition of tomosynthesis was likely more beneficial to this patient than two-dimensional digital mammography alone.   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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her 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 should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  All told, Harvoni for 12 weeks 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 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 the wearable cardioverter defibrillator (LifeVest) for treatment of his medical condition.  Findings:  The physician reviewer found that based on the records provided for review, the patient has a newly recognized tachycardia mediated cardiomyopathy. In this circumstance there is potential for recovery of left ventricular function over time with cardioversions and medical therapy. There was no clinical indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of more than 90 days where continued left ventricular dysfunction ejection fraction of less than or equal to 35% is documented to persist in spite of appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. Medical studies assessing efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction of less than or equal to 35% before ventricular function has had a chance to recover have not demonstrated improved outcome. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. At this time prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed due to infection or required explantation. Therefore the medical necessity for the wearable cardioverter defibrillator has not yet been demonstrated by existing scientific literature at this time in this clinical setting. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine and 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 Harvoni for 12 weeks for treatment of his hepatitis C virus (HCV). Findings:  The physician reviewer found that as per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic active hepatitis C are eligible for treatment and should be treated regardless of fibrosis score. In this case, Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C genotype 1. In addition, Treatment with a once-daily, single-tablet regimen of ledipasvir and sofosbuvir resulted in high rates of sustained virologic response among patients with HCV genotype 1 infection who had not had a sustained virologic response to prior interferon-based treatment. As such, the medical necessity for Harvoni for 12 weeks has been established in this clinical setting. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an overnight hospital stay and hospital care for treatment of his medical condition. Findings:  The physician reviewer found that the overnight hospital stay was not medically necessary in this clinical setting. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. Outpatient observation admission is appropriate when the physician is unsure about the patients need for inpatient admission and requires time for short-term treatment, assessment, and reassessment in order to make that decision or the physician anticipates that the patients condition can be evaluated/treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this case, the patient had symptoms of palpitations, at the time of admission his symptoms had improved and he was in stable condition. In this case the patient was admitted in stable condition and could have been treated at an observational level of care. As such, the hospital care received was medically necessary; however, the overnight hospital stay was not medically necessary. 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 partially overturned.  Credentials/Qualifications: The reviewer is board certified in internal 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.