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

Standard Review :The parent of a transgender male enrollee has requested authorization and coverage for a consultation with a plastic surgeon regarding bilateral mastectomy for male chest reconstruction. The Health Plan has denied this request indicating that the requested service is not medically necessary for evaluation of the enrollees gender dysphoria. 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. Nature of Statutory Criteria/Case Summary: Based on the documentation provided, the patient presents with gender dysphoria and is in the process of transitioning from female to male.  Based on the patients gender dysphoria and identification as a male, a normal appearing male chest is the goal. A resolution from the American Psychiatric Association (APA) presented its report in June 2012. This resolution concluded that the medical research demonstrated the effectiveness and necessity of mental health care, hormone therapy and sexual reassignment surgery for individuals diagnosed with gender dysphoria or gender identity disorder.  The surgical concept of treating breasts in individuals undergoing female to male reassignment surgery is well established and documented within the community of plastic surgeons.  Each patient must be reviewed on a case-by-case basis to determine the medical appropriateness of the treatment. In this patients case, he is an adolescent and is only seeking a surgical consultation at this point in time. A plastic surgeon is qualified to provide an evaluation and determination as to the ultimate suitability for the surgical transition. Thus, it is medically reasonable and appropriate to proceed with a surgical consultation at this time. As such, the requested consultation with a plastic surgeon regarding bilateral mastectomy for male chest reconstruction is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service is medically necessary for the evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the nonsteroidal anti-inflammatory drug medication Flector 1.3% patch for treatment of the enrollees hip pain. Findings:  The physician reviewer found that the medical literature supports the use of the Flector patch for short-term use in the management of acute pain. The true safety profile of topical NSAIDs can only be determined after many years of use in a large patient population. Therefore, long-term, head-to-head trials comparing the efficacy and safety of topical versus oral NSAIDs may be necessary. Future research should also include patients with [osteoarthritis] OA involving multiple joints and comorbid conditions to confirm the safety of topical NSAIDs in patients who may have the highest risk for developing tolerability issues. In this case, the patient has a history of hip pain, osteoarthritis of the left hip and left knee pain. The patient has been treated with the Flector patch with reported relief. Although there is medical literature supporting the Flector patch for short-term use, there is a lack of support for long-term use. Accordingly, the request for NSAID Flector (diclofenac) 1.3% patch has not been established as 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 reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the IgG test for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that use of food-specific IgG level does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods. The standard evaluation of food allergy consists of blood IgE level for foods and skin testing. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. For the reasons provided, the IgG test has not been established as likely to be more beneficial for evaluation of the patients medical condition. Final Result: All three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in allergy and immunology and 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 Executive Function education therapy by an education therapist for treatment of the enrollees autism spectrum disorder.Findings:  Two physician reviewers found that the submitted documentation and relevant literature fails to support the requested therapy in this clinical setting. At this time, executive function training requires further evaluation through well-planned clinical trials to assess its efficacy and long-term outcome. There is currently a lack of definitive evidence in the form of multiple reproducible randomized clinical trials that demonstrates the long-term utility of this therapy in adults with autism spectrum disorders. In addition, the use of Executive Function education therapy has not been definitively proven to be useful in short-term studies of children with autism spectrum disorders. Final Result: Two reviewers determined that the requested therapy 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 neurology 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 reimbursement for the breast tomosynthesis screening mammogram for the evaluation of the enrollees risk of breast cancer. Findings:  Two physician reviewers found that in the presence of breast implants it is important to obtain implant displacement views, which was done in this case. In addition, the patient has breasts that have been described as heterogeneously dense. It is specifically patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Two reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the sacroiliac joint fusion for treatment of the enrollees sacroiliitis. Findings:  Two physician reviewers found that the SI joint fusion was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In the medical literature, one study showed that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. The International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive SI joint fusion provide specific indications for surgery. The criteria includes: significant SI joint pain or significant limitations in activities of daily living because of SI joint pain; SI joint pain confirmed by at least three positive SI joint provocative tests; confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period; failure to respond to at least six months of non-surgical treatment including medications, rest, physical therapy, and SI joint steroid injection or rhizotomy; and, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been clearly considered, investigated and ruled-out. In this case, the patient presented with chronic and function-limiting left hip and buttock pain radiating into the left lower extremity that progressively worsened over a one year period. Her pain was described as constant, severe and debilitating. Clinical exam findings documented five positive SI joint provocative signs. Imaging demonstrated SI joint spondylosis. A positive SI joint diagnostic injection was documented with 100% pain relief in the immediate post injection period. Detailed evidence of at least six months of conservative therapy was documented. Alternative diagnoses of L4-5 disc pathology were investigated, considered and ruled out at the primary source of pain and disability. Final Result: Two reviewers determined that the procedure at issue was 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Harvoni 90-400 mg tablet for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for eight weeks. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks, as in this case. 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine  and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5 mg twice per day for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that peer reviewed guidelines do not support the use of Xeljanz in rheumatoid arthritis without demonstration of failure from treatment with methotrexate and at least two anti-tumor necrosis factor agent (TNF) inhibitor biologic agents. In this patients case, there is no documentation of failure of two anti-TNF biologic agents. The Health Plans requirement that the patient try at least two anti-tumor necrosis factor agent (TNF) inhibitor biologic agents prior to treatment with Xeljanz is medically appropriate. 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 rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis screening mammogram 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. 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 reimbursement for digital breast tomosynthesis examinations for evaluation of the enrollees history of breast cancer. Findings:  Two 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. With regard to this patient, the tomosynthesis images of the 5/4/16 were available for review at the time of the diagnostic study of 5/10/16 and likely added nothing of value to the magnification views obtained on that date. Thus, the addition of tomosynthesis as part of the right diagnostic mammogram of 5/10/16 likely added nothing of value. Final Result: Two reviewers determined that a portion of the diagnostic procedures 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 partially 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 reimbursement for digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. 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. This particular patient was noted to have breasts that are described as being heterogeneously dense. While one could make the argument that the patients mammogram has not changed since the last study, it is specifically the patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing for evaluation of the enrollees rectal cancer. Findings:  The physician reviewer found that the pathology report submitted for review showed an adenocarcinoma, however the report did not determine the depth of invasion. The tumor did appear within an adenomatous polyp suggesting that it likely did not penetrate the rectal wall. The specimen was submitted for mutational analysis through Foundation One. Typically, Foundation One testing is reserved for cases that have exhausted standard therapeutic options. There is a lack of documentation demonstrating that standard options are have been exhausted or were contraindicated for this patient. Adjuvant chemotherapy has significantly changed outcome for patients with all stages of disease. Modern regimens such as FOLFOX have even impacted the survival of stage IV patients compared to treatment with 5-FU/leucovorin. The standard of care chemotherapy regimen may include modification of the FOLFOX regimen, but targeted therapy that is genetically directed is premature at this clinical juncture. Accordingly, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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.