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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for evaluation of her type A aortic dissection.  Findings:  Three physician reviewers found that genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient sustained an aortic dissection at a young age. The medical literature shows that mutations in genes causing aortopathy are found in a minority of patients who do not meet clinical criteria for Marfan syndrome. When mutations are identified in specific genes known to be associated with dissection and rupture at much smaller aortic sizes than typically associated with Marfan syndrome (MYLK, ACTA2, TGFBR1, TGFBR2), this justifies early pre-emptive surgical intervention to prevent dissection. Therefore, genetic testing results could impact medical management of this patient with resulting improvement in health outcome.  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:   One reviewer is board certified in cardiovascular disease and is actively practicing.  Two reviewers are board certified in clinical genetics and clinical biochemical genetics 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 doxycycline hydrate (Oracea) for treatment of her acne.   The physician reviewer found that acne vulgaris is the most common dermatological disorder in adolescence and young adults. In the adult female, acne is a chronic condition with a substantial negative psychological, social and emotional impact. The morphological characteristics of adult female acne are often distinct from adolescent acne. Adult acne is mainly mild-to-moderate in severity and may be refractory to treatment. Doxycycline has been approved by the U.S. Food and Drug Administration (FDA) as adjunctive therapy in severe acne. In adult female acne, the creation of papules, pustules and nodules is mediated through immune mechanisms. Recent observations help understand in greater detail the role that inflammation plays in this disease, and the mechanisms by which doxycycline exerts its effect by modulating inflammatory processes. Berman and Zell concluded that subantimicrobial dose doxycycline is effective in the treatment of acne vulgaris. Oracea is a low dose doxycycline capsule with anti-inflammatory activity in both rosacea and acne vulgaris. As this patient has already failed all other systemic and topical therapies, the requested Oracea is medically necessary for treatment of this patients medical condition. 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 dermatology 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 Levitra for treatment of his testicular hypofunction and erectile dysfunction. The physician reviewer found that currently, there is a lack of evidence in the medical literature that combination therapy with Levitra and daily Cialis is effective for erectile dysfunction. Oelke and colleagues concluded that although monotherapy with tadalafil (Cialis) or tamsulosin resulted in significant similar improvements versus placebo, only Cialis improved erectile dysfunction. All told, the requested Levitra is not supported as medically necessary for treatment of this 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 urology 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 three level disc replacement (insertion of more than one (three) artificial intervertebral discs) for treatment of his medical condition.  Three physician reviewers found that in this patients case, the services at issue were not likely to have been superior over other treatment options.  Hacker and colleagues noted that despite their similarities, cervical arthroplasty and fusion were not equivalent procedures in regard to very late complications.  The authors noted that delayed device related complications may occur with cervical arthroplasties, and these complications commenced beyond the time frame for complications associated with traditional cervical spine procedures.  Although the records noted the patient continued to have complaints of upper extremity pain and subjective complaints of radicular symptoms as well as decreased muscle strength, the clinical information submitted did not provide documentation of hyperreflexia or pathologic reflex deficits.  The sensory examination was noted to be intact as well.  Per the medical literature, further studies are needed to determine the long-term efficacy of the services at issue.  All told, the superior efficacy of the three level disc replacement has not been established. Final Result: Three 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 orthopedic surgery 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 an implanted hypoglossal nerve stimulator for treatment of his obstructive sleep apnea (OSA).  Two physician reviewers found that review of the current medical literature indicates that hypoglossal nerve stimulation for treatment of OSA shows positive and beneficial outcomes with minimal adverse effect. For patients who fail CPAP trials, either no treatment or more invasive surgical treatments have been standard therapy. Some data suggests that hypoglossal nerve stimulation can result in improved health outcomes in well selected patients. However, further outcomes data, especially regarding long-term effects, is recommended before hypoglossal nerve stimulation is demonstrated to be as good as or better than standard available therapies in this circumstance. Thus, the requested implanted hypoglossal nerve stimulator is 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 requested services are 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 otolaryngology 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 Synthroid for treatment of her Hashimotos thyroiditis. The physician reviewer found that the American Thyroid Association (ATA) guidelines state that changes between levothyroxine products could potentially result in variations in the administered dose and should generally be avoided for that reason. The ATA also noted that it is recommended that once the therapeutic target is reached, the patient should remain on the same dose and preparation of medication to the extent possible. Carswell and colleagues reported that studies suggest that different levothyroxine preparations are not bioequivalent in congenital hypothyroidism. In this case, the patients clinical history includes treatment with generic levothyroxine in the past with poor results. The patient was then changed to Synthroid brand and has done well for many years. A switch back to a preparation to which the patient responded poorly is not consistent with proper medical practice. Thus, the patient should continue with Synthroid brand as she has been treated with this preparation successfully. Consistent with these findings, Synthroid was and is medically necessary for treatment of this patients Hashimotos thyroiditis. Final Result: The reviewer determined that the medication at issue was and 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 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 nerve testing (autonomic testing) for evaluation of her orthostatic dizziness, fibromyalgia, Ehlers-Danlos syndrome (EDS) and fatigue.  Two physician reviewers fund that this patient presents with a complex medical history with symptoms suggestive of Postural Orthostatic Tachycardia Syndrome (POTS). Autonomic testing is a widely used group of tests typically performed in specialized autonomic laboratories. This testing is useful in a variety of clinical situations, and has been utilized in patients with fibromyalgia and symptoms of lightheadedness and dizziness to tease out autonomic neuropathy from POTS, cardiac problems, and other conditions that can be difficult to diagnose. In this case, the utilization of autonomic testing was likely to be more beneficial than standard testing. 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 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 fecal DNA testing for evaluation of her risk for colorectal cancer.  Findings:  Three physician reviewers found that Cologuard is U.S. Food and Drug Administration (FDA) approved for screening for colon cancer. Cologuard has been demonstrated to be 92% sensitive for the detection of colon cancer, and is able to detect most adenomas with high-grade dysplasia. The use of the test is recommended by the American Cancer Society (ACS) for colon cancer screening. Based on the clinical literature and current guidelines, in this patient with a history of adverse issues during prior colonoscopy, the fecal DNA testing was likely to have been more beneficial for evaluation of her medical condition than any available standard therapy. 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One reviewer is board certified in pediatrics with sub-specialty certification in genetics and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 a panel of genetic hereditary cancer tests (MyRisk `Colaris` testing) for evaluation of her further risk of cancer.  Findings:  Two physician reviewers found that this patient has both breast and endometrial cancer and a strong family history of breast cancer. She has tested negative for BRCA and pathology shows a low likelihood of Lynch syndrome. Panel testing is supported by the National Comprehensive Cancer Network (NCCN) guidelines for patients such as in this case. There is also a role for multi-gene testing in individuals who have tested negative (indeterminate) for a single syndrome, but whose personal or family history remains strongly suggestive of an inherited susceptibility. All told, this patient is likely to benefit from the panel of genetic hereditary cancer tests with MyRisk. For the reasons provided, the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Two reviewers determined that the requested testing 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: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  Two reviewers are board certified 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 requested hair removal via electrolysis in preparation for vaginoplasty for treatment of her gender dysphoria.  Findings:  The physician reviewer found that the arguments for electrolysis hair removal in anticipation of vaginoplasty are strong, in that hair removal cannot be easily accomplished after the surgery and there are risks of infection associated with persistent hair growth in the area following surgery. However, in this case the patient has not yet met criteria for approval of the gender reassignment surgery. Although the hair removal procedure is considered to be part of the gender reassignment surgery and should ultimately be authorized if and when the surgery is to be performed, the request to undergo electrolysis at this time is premature as the patient has not yet met criteria for gender reassignment surgery. Further, it is possible that the amount of electrolysis needed for adequate hair removal may decrease in the coming months as the hormone replacement therapy takes effect. Therefore, the request for electrolysis is not medically necessary at this time.  Final Result: The reviewer determined that the requested service 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 dermatology 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 requested AmniSure laboratory testing for evaluation of her premature labor.  Findings:  Three physician reviewers found that the AmniSure testing performed was not likely to be more effective for this patient than any available standard therapies.  According to the clinical records submitted for review, there is no documentation of a speculum exam and evaluation of vaginal secretions by pH or microscopic examination. There was also no mention of dilation, effacement, presentation, position or vaginal secretions. For the reasons provided, AmniSure testing was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapyFinal Result: 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: Two reviewers are board certified in obstetrics and gynecology and are actively practicing. One reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal fetal medicine 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested right breast implant removal for treatment of her ruptured left breast silicone implant.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested surgery. Based on the documentation submitted for review, there is insufficient evidence of a functional deficit related to the right breast implant and thus its removal is not considered medically necessary. There is no evidence that the original implants were placed for reconstructive reasons. There is no evidence of rupture or capsular contracture. In addition, the medical documentation notes a plan for replacement of the left breast implant, which would not tend to create severe volume asymmetry. As noted in the medical literature, complications that arise from this surgery are well documented to include implant rupture and capsular contracture. According to the medical literature, It has become increasingly apparent in recent years that breast implant recipients experience a significant incidence of complications and a relatively high rate of reoperation.  In large-scale follow-up studies conducted by manufacturers, it was reported that by the end of 5 years, women undergoing augmentation with saline-filled implants had a 10 percent rate of significant (Baker grade 3 or 4) contracture. The study reported that capsular contracture is the most common and severe complication associated with silicone breast implants. In this case, there is no evidence that there is rupture of the right breast implant or painful capsular contracture.  With regard to whether the proposed procedure meets reconstructive surgery criteria, the patient presents with no complications related to the right breast implant. There is no evidence of a functional deficit related to the right breast implant. In addition, the requested procedure is not being performed to create a normal appearance as the authorized left breast implant replacement would not create an abnormal appearance. In addition, the requested surgery does not offer more than a minimal improvement in the patients appearance as there is no evidence that the authorized left breast implant replacement would create a significant abnormal appearance. Therefore, the requested surgery does not meet the reconstructive surgery criteria. Final Result: The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic and reconstructive 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and ribavirin for 12 weeks for treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that as recommended by the joint guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Per the AASLD/IDSA guidelines, daily sofosbuvir (Sovaldi) and weight-based ribavirin for 12 weeks is recommended for treatment-naive patients with hepatitis C genotype 2. As such, the requested treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C genotype 2.  Final Result: All three reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. One reviewer is board certified in gastroenterology 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.