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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer. Two physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited. All told, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested sling procedure surgery for treatment of her urinary stress incontinence.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested surgery. There is lack of documentation submitted for review supporting a diagnosis of stress urinary incontinence. The urodynamic study did not reveal detrusor overactivity or leak with stress/urgency. The study suggests a high post void residual along with no detrusor function. This could be suggestive of overflow urinary incontinence with urinary retention and placement of a sling will increase outflow resistance leading to urinary obstruction. Moreover, the European Association of Urology (EAU) guidelines on urinary incontinence state, In clinical practice, it is a convention that non-surgical therapies are tried first because they usually carry the least risk of harm. They are often used in combination which makes it difficult to determine which components are effective. Per EAU guidelines conservative therapies include simple clinical intervention, behavior and physical therapies, lifestyle intervention and pharmacologic management. In this case, other than Vesicare which was noted to be helpful, there is lack of evidence showing the patient has tried and failed conservative therapy such as physical therapy. Based on the clinical documentation submitted, the sling procedure surgery is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested dutasteride (Avodart) for treatment of his skin condition. The physician reviewer found that androgenetic alopecia (AGA) develops with a distinctive patterned hair line recession. Research on patients with androgen insensitivity syndromes, or 5 alpha-reductase deficiency, suggest that AGA is induced via activation of androgen receptors in hair follicles by dihydrotestosterone (DHT). The primary precursor of DHT in men is testosterone. The density of androgen receptors in hair follicles varies with location. Drug therapies specifically approved for treating AGA are limited to minoxidil and finasteride. Avodart is approximately three times more potent than finasteride. Clinical trials for AGA have demonstrated a dose-dependent increase in hair growth with Avodart. The available medical records indicate that this patient has AGA with the hair loss improved on Avodart. He also had folliculitis treated with a topical corticosteroid and has been treated with anti-fungal therapy for possible tinea capitis. Since the efficacy of Avodart for the treatment of AGA is superior to finasteride, and Avodart has been already successfully used by this patient, the requested Avodart is supported as medically necessary. Final Result: The reviewer determined that the medication dosage 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 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 has requested IgG food sensitivity testing (CPT code 86001) for treatment of her allergies and fatigue. Three physician reviewers found that in this case, the patient underwent IgG food testing for possible food allergy and allergic rhinitis. The medical records submitted for review do not demonstrate a diagnosis consistent with a food allergy. The current National Institutes of Health National Institute of Allergy and Infectious Disease expert panel states that IgG food testing is not validated. Moreover, the Joint Task Force on Practice Parameters for the Allergy and Immunology also state that IgG food testing is not validated. As such, the IgG food testing is not the standard of care and was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final 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: One reviewer is board certified in allergy and immunology and is actively practicing. Two 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 a 12-week course of Sovaldi for treatment of his hepatitis C.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The requested treatment regimen is standard of care for the treatment of patients with hepatitis C, genotype 2 infection.  All told, the requested 12-week course of Sovaldi is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, because of the myriad benefits associated with successful HCV treatment, patients should be treated with antiviral therapy with the goal of achieving a sustained virologic response (SVR), preferably early in the course of their chronic HCV infection before the development of severe liver disease and other complications. Recent reports suggest that initiating therapy in patients with lower stage fibrosis may extend the benefits of SVR. In a long-term follow-up study, 820 patients with Metavir stage F0 or F1 fibrosis confirmed by biopsy were followed for up to 20 years. The 15-year survival rate was statistically significantly better for those who experienced an SVR than for those whose treatment had failed or for those who remained untreated. Therefore, based on the documentation submitted for review and national guidelines Harvoni for eight weeks is medically for treatment of the patients medical condition. Final Result: Two reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Zoster vaccine for treatment of his medical condition.  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for the Zoster vaccine has not been established. There is a lack of support in the medical literature for the services at issue in this clinical setting. In this case, the patient has a diagnosis of perioral dermatitis/acne rosacea. There is no known connection between this type of cutaneous problem and Herpes zoster infection. Therefore, the shingles vaccination is not indicated for this patient. All told, the Zoster vaccine was not medically necessary for treatment of the patients medical condition. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 for treatment of her chronic hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, 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 is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Given this support, the requested 12 week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.   Final Result: Three reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested proton beam therapy for treatment of his prostate cancer.  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested services. Proton beam therapy for treatment of prostate cancer is not routinely offered to patients. Other treatment approaches such as intensity modulated radiation therapy (IMRT) are highly effective and well tolerated. Whether proton therapy affords a benefit over other standard approaches such as IMRT for the treatment of prostate cancer remains an area of investigation. To date, there is a lack of compelling data to suggest that proton therapy is superior to or more beneficial than IMRT. There is also the possibility that proton therapy is disadvantageous. The study by Sheets and colleagues concluded that proton therapy has resulted in a greater risk of gastrointestinal toxicity versus IMRT. For the reasons provided above, the requested services are not medically necessary for treatment of the 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 radiation oncology 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 radiofrequency neurolysis for treatment of her medical condition. Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  The majority of peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected.  In this patients case, there is a lack of documentation of a quantified result of the positive diagnostic medial branch block for the requested treatment levels. Additionally, the medical records noted degenerative scoliosis with L2-3, L3-4 degenerative disc disease and lateral listhesis.  However, there were no pathological findings noted for the sacroiliac joint.  There is a lack of support for the requested services in this clinical setting.  All told, the requested radiofrequency neurolysis is not likely to be of greater benefit than other treatment options.  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 anesthesiology with sub-specialty certification in pain medicine 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 procedure code 64999 (unlisted nervous system procedure) and 64640 (neurolysis of peripheral nerve or branch) for treatment of his lumbar radiculopathy and sacroiliac joint arthritis. 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. According to the documentation submitted for review, the physical examination does not show objective signs of sacroiliac pain including pain with facet loading or a positive Patricks test. In addition, there is a lack of documentation showing that the patient has failed conservative therapy, such as physical therapy. Based on the reasons provided above, the services at issue were not likely to be more beneficial 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 anesthesiology with sub-specialty certification in pain medicine 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 Otezla for treatment of her plaque psoriasis.  The physician reviewer found that traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of certain cancers. In addition, patients treated with anti-TNF drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. Otezla provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Its effects on cyclic adenosine monophosphate regulated intracellular signaling, gene expression, and subsequent protein levels allow apremilast to modulate the immune responses that cause the inflammation associated with psoriasis. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings:  Three physician reviewers found that the joint guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommend treatment for all patients with chronic HCV infection, except those with short life expectancies owing to comorbid conditions. AASLD/IDSA guidelines further indicate that treatment delays may decrease the benefit of sustained virologic response (SVR). In a report of long-term follow-up in France, 820 patients with biopsy-confirmed stage F0 or F1 were followed for up to 20 years. The authors noted 15% rapid progression of fibrosis, and in those patients treated successfully long-term survival was better. Specifically, at 15 years, survival was 92% for those with an SVR versus 82% for treatment failures and 87% for those not treated (AASLD/IDSA). Therefore, the request for Sovaldi for 12 weeks is medically necessary for treatment of the patients HCV genotype 2.   Final Result:  Three reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.