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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90/400 mg treatment of the enrollees hepatitis C virus. 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 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. For these reasons, the requested treatment with Harvoni 90/400 mg for 12 weeks is supported as medically necessary for the treatment of this 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay for evaluation of the enrollees prostate cancer. Findings:  The physician reviewers found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features such as the grade of tumor and prostate-specific antigen level.  This helps guide the most appropriate therapy for patients taking into account their age and comorbidities.  Many patients will not require therapy and may be followed closely instead.  Oncotype DX is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS).  The testing performed was indicated in this clinical setting.  The medical evidence supports the Oncotype DX test to better stratify such patients with localized disease.  In sum, Oncotype DX Prostate Cancer Assay testing was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Two of 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: 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings: Three physician reviewers found that 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 due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging especially in patients with dense tissue such as in this case. Thus, the addition of tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Accordingly, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 the Afirma gene test.  Findings:  Three physician reviewers found that in this case, the cytopathology was consistent with AUS, and the specimen was sent for genetic testing, which was consistent with a benign finding. The Bethesda System recommends a second fine needle aspiration (FNA) when the cytopathology is consistent with AUS (Cibas, et al). The American Thyroid Association guidelines state that for nodules with [atypia of unknown significance/follicular lesion of undetermined significance] (AUS/FLUS) cytology after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making.  The median risk of malignancy on AUS lesions is 15%. According to the Bethesda system and the American Thyroid Association guidelines a second biopsy is recommended. However, molecular testing may be used as an alternative. If the genetic test is suspicious the risk of malignancy increases to 40%. However, the risk of malignancy decreases to less than 6% with benign findings by genetic testing. Thus, the testing at issue is beneficial for the medical decision making. Proceeding directly to the genetic testing prevented a second biopsy procedure. The benign finding would allow the patient and provider to make an informed decision on whether to continue surveillance or proceed to surgery. In this clinical setting proceeding with genetic testing was the best management option for this patient and was appropriate with current standard of care. Final Result: Three 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 physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 Botox injections for treatment of the enrollees neck pain and migraine headaches.  Findings: Three physician reviewers found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The documentation submitted for review does not describe the quality of the headaches, duration, or frequency. There is also no mention of previously tried preventive therapy. This patient is reported to have migraine headaches; however there is inadequate information in the records to support a diagnosis of migraine or of chronic migraine. There is no report of number of headaches reduced per month, or change in severity or use of acute medication. The treatment paradigm seems to be aimed to treat neck pain. There is a lack of peer-reviewed literature supporting the treatment of neck pain with Botox injections. Accordingly, the Botox injections were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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 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 digital breast tomosynthesis.Findings:  Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this case, the patient has breasts that have been described as extremely dense. It is specifically those 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested gastric emptying study, a computed tomography (CT) angiography and a fecal microbiota transplant for treatment of the enrollee, who has a history of abdominal pain.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  This patient has symptoms consistent with gastroparesis, but also consistent with other diseases.  Camilleri and colleagues noted since accelerated gastric emptying and functional dyspepsia can also present with symptoms similar to gastroparesis, documentation of delayed gastric emptying is necessary before selecting therapy with prokinetics agents.  The importance of accurate diagnosis is underscored by the fact that other diseases such as chronic gallbladder disease can overlap gastroparesis and dyspepsia symptoms, resulting in unnecessary surgery.  Another potential cause for the patients symptoms, including abdominal pain after eating, is mesenteric ischemia, which presents a diagnostic challenge due to nonspecific symptoms such as abdominal pain and bloating; laboratory tests are neither sensitive nor specific.  Based on the provided information, a gastric emptying study and CT angiography are medically indicated in this case.  However, fecal microbiota transplant is not currently indicated for the patient, as there is a lack of evidence that he has Clostridium difficile infection.  For these reasons, the requested gastric emptying study and CT angiography are medically necessary in this case, but fecal microbiota transplant is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services is 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 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 of Epclusa and ribavirin 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 nonliver-related conditions. Per the guidelines, patients with cirrhosis are high priority for treatment and re-treatment. Based on clinical studies, patients with hepatocellular carcinoma, who have failed NS5A-based treatment, as in this patients case, the recommended treatment is with Epclusa and ribavirin for 24 weeks. This applies regardless of the results of any resistance testing. For these reasons, the request for Epclusa and ribavirin (?) for 24 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication regimen 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 monthly intravenous immunoglobulin (IVIG) for treatment of the enrollees common variable immunodeficiency (CVID).  Findings: The physician reviewer found that as noted in the medical literature, IVIG infusion does possess risk, but this is reduced in patients receiving chronic infusions of replacement doses. Stiehm described that systemic adverse reactions can be immediate (60% of reactions) occurring within six hours of an infusion, delayed (40% of reactions) occurring six hours one week after an infusion, and late (less than 1% of reactions), occurring weeks and months after an infusion. Immediate systemic reactions such as head and body aches, chills and fever are usually mild and readily treatable. Immediate anaphylactic and anaphylactic reactions are uncommon. The most common delayed systemic reaction is persistent headache. Brennan and colleagues reported that no severe reactions occurred and the reaction rate was low at 0.8%. This patient presents with presumed CVID and possible connective tissue disorder but has normal labs. The patient has been receiving replacement immunoglobulin therapy for 26 years. Per the patient, she can only receive this infusion over two days and in a hospital setting due to previous anaphylaxis. However, the medical records provided for review fail to document any adverse reactions to prior infusions. In addition, since she has been receiving therapy for many years, her overall risk with recurrent infusions is low. As such, the request for monthly IVIG treatments to be provided in a hospital based center is not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested services are 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 certifications in allergy and immunology and 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested calcitonin, salmon, synthetic 200/spray/pump (Miacalcin) medication for treatment of the enrollees severe hypercalcemia. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the medication at issue. Calcitonin has limited efficacy for hypercalcemia. Treatment with calcitonin results in tachyphylaxis. Thus, the long-term impact is limited beyond the first 48 hours. Calcitonin may be utilized with hydration of bisphosphonates for a few days. Therefore, in this clinical setting, other treatments options for the patients hypercalcemia should be considered. All told, calcitonin, salmon, synthetic 200/spray/pump (Miacalcin) medication obtained was not and is not medically necessary for treatment of the patients hypercalcemia.Final Result: The reviewer determined that the medication at issue was not and 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 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 proton beam radiation therapy for treatment of the enrollees recurrent invasive ductal carcinoma in situ (DCIS).  Findings: Two reviewers found that A proton is the charged nucleus of a hydrogen atom. Charged particles can be used to deliver therapeutic radiation. Standard radiation is delivered with a linear accelerator (LINAC), which delivers photon therapy, while protons and other charged particles are generated from a cyclotron. The difference between proton and photon irradiation is that the protons stop abruptly in the tissue so there is less exit dose through normal tissue. Clinically meaningful reductions in the heart volume receiving high doses can warrant consideration of proton therapy. Despite the uncertainty of any benefit of proton therapy for use in the general population, there is some understanding about acceptable heart exposure relative to risk of cardiac toxicity. Based on my review of the intensity modulated radiation therapy (IMRT) plan, the requested proton beam radiation can result in a clinically meaningful benefit to this patient with respect to cardiac sparing. The IMRT plan resulted in a higher mean heart dose in the setting of prior radiation such that it is plausible that proton therapy could benefit this patient. While routine use of proton therapy is not an accepted standard of care, proton therapy can be used for select patients with unique anatomic considerations or prior radiation. Accordingly, proton beam radiation therapy is 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 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 radiation oncology 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 reimbursement for anesthesia/monitored anesthesia care for a colonoscopy performed for treatment of the enrollee, who underwent a colonoscopy. Findings:  The physician reviewer found that per the medical evidence, during endoscopic procedures such as colonoscopy, monitored anesthesia care is warranted in prolonged or painful procedures such as polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care is more likely necessary in patients with failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature.  According to current guidelines, during colonoscopy, consciousness during the procedure is acceptable and is the goal during most procedures. For these reasons, the provided records do not support the medical necessity of monitored anesthesia care performed. 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 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.