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 medical condition. Findings:  Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. In addition, there is support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, as this case. Therefore, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 an acrylic herbst oral appliance for treatment of his medical condition.  Findings:  The physician reviewer found that based upon the submitted documentation, the medical necessity of the acrylic herbst oral appliance has not been established. Per the submitted documentation, the patient was found to have a normal AHI score.  The patient also presented with an Epworth Sleepiness score which was also normal. Moreover, there is no documentation of daytime hypersomnia. The record does indicate there was a postural component and it was recommended that the patient should avoid supine sleep. The recommended treatment for those with significant postural obstructive sleep apnea (OSA) with an AHI of 15 or higher, is with a vest that has a ball in the back to preclude supine sleep. The patients medical records do not indicate he has clinically significant OSA. All told, the oral device at issue was not medically necessary for treatment of the patients medical condition.    Final Result: The reviewer determined that the device at issue was 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 pulmonary disease 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 bilateral endoscopic lumbar sympathectomy surgery for treatment of her medical condition.  Findings:  Three physician reviewers found that according to the documentation submitted for review the patient presents with disabling plantar hyperhidrosis. She has tried and failed multiple medications and treatments. Sympathectomy is a surgical procedure involving clipping of the sympathetic chain of nerves which has been shown to reduce sweating.  Typically involving the thoracic sympathetic chain, this treatment is used to reduce hyperhidrosis of the hands.  This patient had relief of her symptoms involving the hands following this procedure, but continues to have disabling symptoms on her feet.  Treatment of the lumbar sympathetic chain would be expected to address those symptoms. As there is a lack of available standard therapeutic options available for this patient, lumbar sympathectomy for lower extremity hyperhidrosis is clinically indicated. Therefore, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested services are 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 reviewers are board certified in dermatology 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 shoe inserts for treatment of her medical condition.  Findings:  The physician reviewer found that submitted documentation supports the medical necessity of the requested equipment.  The progress notes indicate that this patient has left foot pain.  Overpronation for this patient is causing left foot pain as well as peroneal brevis tendinitis.  Orthotics will stabilize the medial and lateral column of the foot allowing for pain-free ambulation.  Furthermore, the patient has a limb length discrepancy which may cause knee and hip pain.  Compensating for this with a 5 mm elevation to the left orthotic is likely to alleviate this patients pain.  In sum, the requested shoe inserts are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 podiatry 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). Given the support above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 Cytomel for treatment of his medical condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the medication at issue was not medically necessary for treatment of the patients medical condition. Most patients with hypothyroidism, a condition in which the thyroid produces insufficient amounts of thyroid hormone, will require lifelong thyroid hormone therapy (Gaitonde, et al). Upon reviewing this patients laboratory data, it appears that he is persistently biochemically thyrotoxic, likely over-replaced on thyroid hormone medication.  Further, the documentation submitted for review does not demonstrate intolerance to generic liothyronine or an adverse effect from it. Given the above, Cytomel has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the medication at issue was 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 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 breast tomosynthesis for evaluation of her breast cancer screening. Findings:  Two physician reviewers found that peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial than any available standard therapy. 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 continuous positive airway pressure (CPAP) device supplies for treatment of her medical condition. Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. The patient had a diagnostic polysomnography performed which provided a diagnosis of mild obstructive sleep apnea. The patients apnea-hypopnea index was in the normal range. Given the above, the services at issue were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 certification in pulmonary disease 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 Afirma gene expression classifier for evaluation of her medical condition.  Findings:  Three physician reviewers found that Afirma gene expression classifier testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient presented with an enlarging thyroid nodule. Cytopathology report noted Hurthle cell lesion, falling under the category of follicular lesion of undetermined significance (FLUS). The risk of malignancy is 5-15% in these lesions (Cibas, et al). According to recent guidelines by the American Thyroid Association For nodules with [atypia 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. In this case, molecular testing was consistent with a benign lesion, and a repeat biopsy or hemithyroidectomy was not necessary. Therefore, the requested services prevented the patient from an unnecessary procedure or surgery and their risks. 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 reviewers are board certified in internal medicine with sub-specialty certification in endocrinology and metabolism 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 a powered robotic lower body exoskeleton for treatment of his medical condition.   Findings:  Three physician reviewers found that the device in question is not an efficient or reliable means of mobility in comparison to standard mobility devices such as wheelchairs.  Recent evidence suggests that these type of exoskeletal ambulation devices have high feasibility challenges and have not met users high expectations of benefits.  There is no expected significant health benefit of walking using an externally powered exoskeleton to power the lower limbs.  Standard of care for this condition would be promoting physical activity using volitionally active musculature, including regular propulsion of a manual wheelchair, wheelchair sports and other adaptive sports/exercise activities.  Compared to these standard activities, the physical activity promoted by powered exoskeleton-aided ambulation is very modest.  There is no expected marginally significant health benefit of this requested device over standard care.  Additionally, the type of device in question puts users at risk of injury.  The benefits of the requested device with respect to health and mobility in the setting of this condition have not been established.  Therefore, the requested powered robotic lower body exoskeleton is not likely to be of greater benefit than other treatment options.  Final Result: Three reviewers determined that the requested device 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 reviewers are board certified in physical medicine and rehabilitation 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 hip surgery for treatment of her medical condition.   Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this patients case.  Magnetic resonance arthrogram documented a labral tear and intraoperative findings confirm this tear.  The preoperative anatomical studies also document acetabular osteophytes around the rim of the acetabulum.  Hip reconstructive orthopedic surgery is a method of delaying or significantly altering what would otherwise be an ongoing progressive degenerative change. By delaying treatment, the only other alternative for surgical treatment is total hip arthroplasty.  In sum, the services at issue were likely to have been of greater benefit than other treatment options.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested nuchal translucency screening for evaluation of her medical condition.  All pregnant patients should be offered some form of aneuploidy screening.  For patients at increased risk for fetal aneuploidy due to advanced maternal age or family history, invasive testing with chorionic villus sampling or amniocentesis or noninvasive prenatal testing (NIPT) for cell-free fetal DNA may be appropriate.  For patients without these risk factors, such as this patient, options for screening include combined first trimester screening with maternal serum PAPP-A and HCG and sonographic measurement of the fetal nuchal translucency or second trimester multiple marker screening, or a combination of the two.  Combined first trimester screening has the advantage of providing results earlier in pregnancy allowing more time to make decisions regarding pregnancy options.  All told, the requested nuchal translucency screening to detect fetal abnormalities in the first trimester is medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested general anesthesia for a dental procedure in an outpatient surgery center for treatment of the enrollees dental condition. Findings: The physician reviewer found that the patient meets medical necessity criteria for general anesthesia in an operating room setting for his dental procedure. General anesthesia is often employed to facilitate extensive dental treatment particularly in younger pediatric patients, such as this patient, who do not have the psychological or emotional maturity required to cooperate in an office setting. The combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for pediatric patients. Because dental restoration under general anesthesia does not require cooperation from the child it is a very efficient treatment modality. It can usually be completed in one procedure. In this case, the patient has met the criteria as outlined in the medical record: use of in office conscious sedation was not feasible based on the medical needs of the patient. For these reasons, administration of general anesthesia in an outpatient surgery center setting is medically necessary and appropriate in this case.  Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients dental condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician reviewer is board certified in anesthesiology 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 breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that current medical evidence supports the services at issue in this patients case.  Breast tomosynthesis often allows radiologists to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers especially in patients with heterogeneously or extremely dense tissue.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done with the two-dimensional technique alone. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the enrollees medical condition than any available standard therapy.  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.