Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the UroLift procedure for treatment of enrollee's benign prostatic hyperplasia (BPH).  Findings:  Three physician reviewers found that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The study by Sonksen and colleagues compared prostatic urethral lift to transurethral resection of the prostate (TURP) in regard to lower urinary tract symptoms improvement, recovery, worsening of erectile and ejaculatory function, and continence. The study concluded that participants who underwent prostatic urethral lift responded significantly better than those who underwent transurethral resection of the prostate as therapy for benign prostatic hyperplasia with regard to important aspects of quality of life. Moreover, the UroLift procedure is a well-established treatment for patients with benign prostatic hyperplasia. The UroLift procedure is a superior alternative to TURP as it can be performed as an outpatient with minimal bleeding and no need for a post-operative catheter with little risk of long-term incontinence.Final Result: All three reviewers determined that the requested procedure is 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 physicians are board certified in urology and are actively practicing. The reviewer are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen crosslinking procedures for treatment of the enrollees keratoconus. Findings:  Two physician reviewers found that corneal collagen crosslinking has been approved by the U.S. Food and Drug Administration for corneal ectasia and post-refractive ectasia. The primary purpose of crosslinking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus and post-refractive ectasia. Prior to this treatment, patients with keratoconus who failed medical treatment (glasses and contact lenses) and whose disease continued to progress would proceed with surgical management with corneal transplantation. Multiple studies have been published which demonstrate that patients who underwent corneal crosslinking showed an improvement in keratometry values, uncorrected visual acuity and best corrected visual acuity. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in ophthalmology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) for evaluation of the enrollees knee pain. Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI. According to the documentation submitted for review, the physical examination does not indicate evidence of meniscal or ligament derangement. In addition, the medical records fail to document left knee pain refractory to six weeks of conservative treatment such as nonsteroidal anti-inflammatory drugs (NSAIDS), ice or physical therapy. In the absence of failed conservative treatment, the requested MRI is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 Harvoni for 12 weeks treatment of the enrollees hepatitis C infection.Findings: The physician reviewer found that according to the 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication regimen is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of the patients hepatitis C infection. 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 authorization and coverage for Praluent Pen every two weeks for treatment of her mixed hyperlipidemia, atherosclerotic disease, and family history of coronary artery disease.Findings: The physician reviewer found that the provider documented that the patient in this case has been treated with atorvastatin, rosuvastatin, simvastatin, simvastatin in combination with Zetia, and fluvastatin, all of which were either not tolerated due to myalgias, myositis, or liver function test abnormalities. In addition the patient has a documented history of carotid atherosclerosis and a family history of coronary artery disease. The patient is in need of lipid lowering therapy. Thus, the requested Praluent Pen 75 mg every two weeks (two pens every 28 days) is medically necessary given the need to lower the patients total cholesterol and LDL. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing performed for evaluation of the enrollees hepatitis B. Findings: Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. The patient needed the test called the FibroTest, which is an accurate noninvasive panel of blood tests that include alanine aminotransferase, alpha-2-macroglobulin, apolipoprotein A1, total bilirubin, gamma glutamyl transferase, and haptoglobin. Based on the values of these six tests, one can accurately estimate the degree of liver inflammation and fibrosis in a patient with hepatitis B or C. This test was not performed to assess cardiac risk but was performed in order to guide the course of treatment for this patients hepatitis B infection. The provider was deciding whether treatment was indicated. Of these six tests, apolipoprotein A1 testing is an advanced lipoprotein test. However, it is a key part of the panel and needs to be done in conjunction with the five other tests. For these reasons, the advanced lipoprotein testing performed was likely to have been more beneficial than the other standard methods for the evaluation of this patient.  Final Result: The 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 gastroenterology 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 rhinoplasty for treatment of the enrollees nasal injury.Findings: The physician reviewer found that based on the patients complaints and review of the photographs, rhinoplasty consisting of external nasal bony work is supported as medically necessary for treatment of this patients nasal fracture and reconstructive in nature. The patient presents with an abnormal condition as the result of nasal trauma. The patient has nasal deformity and nasal airway obstruction as a direct result of the previous nasal fracture. As noted by the American Society of Plastic Surgeons (ASPS), reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. From the ASPS, nasal surgery is considered reconstructive surgery and medically necessary to improve nasal respiratory function, treat anatomic abnormalities caused by birth defects or disease and revise structural deformities resulting from trauma. The patient had significant nasal trauma producing a predictable pattern of deformity and impairment. This is supported by post-injury examination detail and analysis of the photographs. Rhinoplasty would be consistent with standard of care in the setting of residual nasal deformity and nasal airway obstruction as a result of nasal fracture. The patient has an abnormal condition as the result of trauma. Corrective measures should be considered reconstructive and medically necessary. Moreover, based on the photographs, more than a minimal improvement would be expected. All told, the requested rhinoplasty is supported as medically necessary for treatment of this patients nasal fracture and reconstructive in nature. Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Decision DX Melanoma Gene Assay testing performed for evaluation of her melanoma.  Findings:  Three physician reviewers found that the medical evidence does not support the services at issue in this patients case. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials according to published data available. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. In sum, Decision DX Melanoma Gene Assay testing performed was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are 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 reimbursement for the hysterectomy performed for treatment of the enrollee's menopausal bleeding, uterine fibroids, and bladder adhesions.Findings:  The physician reviewer found that postmenopausal bleeding is defined as any bleeding from the genital tract of a woman which occurs after a period of amenorrhea lasting six months or longer. Approximately 10% of patients with postmenopausal bleeding are diagnosed with endometrial cancer or hyperplasia. In addition, postmenopausal bleeding incurs a vastly increased risk for developing endometrial cancer. Therefore, postmenopausal bleeding requires assessment by ultrasound or endometrial biopsy with further evaluation indicated if the endometrial thickness on transvaginal ultrasonography is greater than 4 mm. In a patient with recurrent postmenopausal bleeding and an endometrial thickness greater than 4 mm, the diagnostic work-up includes tissue sampling. If tissue sampling cannot be obtained due to a stenotic cervical os, a hysterectomy was an appropriate procedure since the presence of complex hyperplasia or endometrial cancer cannot be excluded. Given these reasons, the hysterectomy performed was medically necessary for treatment of this patients recurrent postmenopausal bleeding. Final Result: The reviewer determined that the service at issue was 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) with sedation for evaluation of the enrollees cervical spine lesion. Findings:  The physician reviewer found that the documentation submitted for review supports a medical indication for MRI with sedation. The American College of Radiology (ACR) Appropriateness Criteria has devised multiple variants under the category of myelopathy.  The variant most closely matching this patient is described as sudden onset or slowly progressive. Under this variant, MRI is considered the most appropriate imaging study. Moreover, the request for MRI with sedation is clinically indicated. In general, MRI can be performed on non-sedated patients, however there are occasional patients who need sedation. Most of these patients can be managed with sedatives such as limited doses of Valium, but there are also some patients who require more substantial sedation. In this case, given the patients constellation of progressive symptoms and providers recommendation for MRI with sedation, the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure 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 diagnostic radiology 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 authorization and coverage for a single photon emission computed tomography (SPECT) scan for evaluation of his Parkinsons disease. Findings:  Three physician reviewers found that it has been well established in the current peer-reviewed medical literature that functional imaging in Parkinson disease is much more beneficial than static imaging. In SPECT imaging, there is a measurement of dopamine terminal function sensitivity detection in both symptomatic and patients at risk for Parkinsons disease and associated dementia versus Alzheimers dementia. Such differentiation is important in the treatment planning of the two diseases. Static imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) does not incorporate the physiology of such diseases. The use of SPECT allows the evaluation of the physiology of the substantia nigra for striatal dopamine deficiency, the hallmarks of Parkinsons disease and to exclude other causes of tremors including dystonic tremors and those associated with exogenous agents such as dopamine receptor blocking drugs. Functional imaging can detect the presence of dopaminergic dysfunction, cortical hypometabolism and amyloid pathology in dementia thus aiding in their classification which in turns helps planning for treatment. This information is not available in static imaging such as MRI. For these reasons, the requested SPECT scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: All three reviewers determined that the requested service is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The 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 authorization and coverage for Arthroflex for treatment of the enrollees left Achilles tendinosis. Findings: The physician reviewer found that there are limited studies available addressing clinical outcomes of arthroflex in tendon augmentation or in any other application. Barber and colleagues reported that their study suggested that GraftJacket augmented Achilles tendon repair could withstand a more aggressive rehabilitation program, potentially decreasing ankle stiffness and allowing earlier return to full activities. However, this study is of limited benefit given the small number of Achilles tendons evaluated. All told, the requested Arthroflex is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The three physician reviewers determined that the requested service is 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 physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the hormone implants for treatment of his hypogonadism.  Findings: The physician reviewer found that the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The standard practice in the medical community is for evaluation to assess for low testosterone levels prior to the initiation of testosterone replacement therapy. The documentation submitted for review does not document the patients testosterone levels. In addition, there is no report of an evaluation regarding the patients low testosterone level. The records do not document if the patient has primary or secondary hypogonadism. All told, the hormone implants received were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three physician reviewers determined that the service 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 physician reviewers are board certified in urology 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.