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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a four week extension of Harvoni 90/400 mg (from 12 to 16 weeks). 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), treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. This recommendation is 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. The AASLD/IDSA guidelines do not recommend extending therapy on the basis of detectable viral load at any point. The guidelines state that the significance of a positive hepatitis C viral load result at week 4 that remains positive, but lower, at week 6 or week 8 is unknown. No recommendation to stop therapy or extend therapy can be provided at this time. In cases in which the recommended duration of Harvoni therapy fails as defined by detectable viral load 12 weeks after completion of treatment due to relapse or nonresponse, the guidelines provide specific recommendations to assess for resistance and choose alternative therapies. However, the guidelines do not recommend extension of therapy in this clinical setting.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oral medication Korlym 300 mg daily. Findings:  The physician reviewer found that the patient has a history of metastatic breast cancer that is estrogen receptor (ER) and progesterone receptor (PR) positive. She was diagnosed with right breast cancer in 2004 and advanced bilateral disease in 2007. Imaging performed in July 2016 shows oligometastatic disease to the bone. The patient has received multiple adjuvant chemotherapies in the past with severe neuropathy and profound fatigue. She also has semi-paralysis of her lower extremities. She is felt to be a poor candidate for further chemotherapy and her provider recommends treatment with Korlym. The patient has requested authorization and coverage for oral medication Korlym 300 mg daily. The Health Plan has denied this request as investigational. Korlym is not U.S. Food and Drug Administration (FDA) approved for the treatment of breast cancer and is not supported by major drug compendia for off-label use. It is also not mentioned in the National Comprehensive Cancer Network (NCCN) guidelines. There is a lack of phase 2 or 3 trials using Korlym for the treatment of metastatic ER and PR positive breast cancer. A phase 1 trial showed efficacy in combination with chemotherapy in patients with triple negative breast cancer, but not ER/PR positive, and now a phase 2 trial is being conducted. Given the lack of support per national guidelines, Korlym is 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 requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and is 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 reimbursement for the general anesthesia provided for treatment of the enrollees gross tooth decay. Findings: The physician reviewer has found that the patient was found to have painful infected teeth that were in need of removal. The patients provider determined that the patient needed intravenous anesthesia in order to accomplish the procedure. Performance of the procedure under anesthesia can result in improved safety for the patient as there is evidence that a more relaxed patient may have a blunted autonomic response to stress and anxiety. Given the patients clinical findings this procedure would likely have been extremely difficult with local anesthesia. Thus, the general anesthesia provided was medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the service at issue was 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 oral and maxillofacial 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the evaluation of the enrollee, who was asymptomatic with respect to her breastsFindings:  Three physician reviewers found that the patient was asymptomatic with respect to her breasts.  On 8/2/16, she underwent a routine screening mammogram consisting of a three dimensional tomosynthesis study with synthetically reconstructed two dimensional views.   The current images were compared to prior mammograms dated and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breast parenchyma was described as being dense. The Health Plan has denied reimbursement for digital breast tomosynthesis performed on 8/2/16. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. .Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography 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 particular patient, she has breasts that have been described as being dense. While one could make the argument that her mammogram has not changed since the last study, 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: All three reviewers determined that  the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement and prospective authorization and coverage for Euflexxa injections provided. Findings:  The physician reviewer found that evidence based peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Hyaluronic acid has been found to be better than injected placebo or injected corticosteroids. In addition, the American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network meta-analysis. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. In this case, the patient has been diagnosed with osteoarthritis of both knees. She had been treated with corticosteroid injection, extensive physical therapy, medications, and activity modification without sustained relief. She has undergone prior series of viscosupplementation with reported significant sustained relief of her chronic osteoarthritis pain. Therefore, the Euflexxa injections provided and requested were and are medically necessary for treatment of the enrollees condition. Final Result: The reviewer determined that the services at issue were and are 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 orthopedic 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for bilateral digital breast tomosynthesis performed.  Findings:  The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography 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 particular patient, she has breasts that have been described as being dense. While one could make the argument that her mammogram has not changed since the last study, 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. In sum, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the 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: Upheld Decision of Health Plan

An enrollee has requested reimbursement for ambulatory event monitor (loop recorder). Findings:  The physician reviewer found that in this patients case, there was no documentation that the patient would not be able to manage these devices or that these external devices have been tried and failed.  Guidelines endorsed by national organizations also consider these external monitoring devices appropriate for the initial evaluation of recurrent dysrhythmias.  Although implantable loop recorder monitoring may be a more sensitive method of detecting recurrent dysrhythmias compared to wearable devices it is not clear that the incremental identification of a low burden of atrial dysrhythmias would change treatment in this patient, who is already anticoagulated and on appropriate medical therapy.  Therefore, the ambulatory event monitor (loop recorder), either patient activated or auto-activated was not medically necessary for evaluation of this patient. Final Result: The reviewer determined that  the services at issue were not medically necessary for evaluation 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 cardiovascular 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

An enrollee has requested authorization and coverage for rib plating surgery (internal fixation of rib fractures) and one day hospital stay.  Findings:  The physician reviewer found that the current medical evidence supports the requested services in this patients case.  The patient had severe trauma resulting in rib fractures.  The original operation involved resecting a portion of several ribs to allow the ribs to fit better together.  This helped for several years.  However, the patient subsequently developed increased instability of the chest wall with increased popping of the overlapping ribs associated with pain.  X-rays confirmed the presence of nonunion of the ribs.  Stabilization of the ribs using a plating system can be expected to benefit this patient and likely is the only surgical treatment that could have such an expected benefit.  Thus, rib plating surgery (internal fixation of rib fractures) and one day hospital stay are likely to be more effective than other methods of treating this patient.  Final Result: The 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: The physician reviewers are board certified in orthopedic surgery, thoracic and cardiac surgery and surgery, respectively, 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

An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that at issue is whether digital breast tomosynthesis is superior to two dimensional digital mammography in the detection of breast cancer in a routine screening population. The digital breast tomosynthesis performed was likely to be more beneficial for this patient than other available standard modalities. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional digital breast tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. All told, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening. Final Result: The reviewers determined that the the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the physician reviewer numbers 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 authorization and coverage for transcranial magnetic stimulation for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that Transcranial magnetic stimulation is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder.  Transcranial magnetic stimulation tends to be very well-tolerated, with fewer barriers and side effects than electroconvulsive therapy.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  Although transcranial magnetic stimulation has not been adequately studied for treatment of substance use disorders and obsessive compulsive disorder, the patients affective illness is not disputed and there is no contraindication for transcranial magnetic stimulation because of said diagnoses, which happen to be questionable in this case.  The patient has remained symptomatic despite several antidepressant medication trials, complex pharmacotherapy, and multiple non-pharmacologic interventions. Transcranial magnetic stimulation is a medically appropriate treatment which is reasonably expected to improve the patients condition and prevent a more serious episode of illness.  Therefore, transcranial magnetic stimulation is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are 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 psychiatry 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

An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that the current images were compared to prior mammograms and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Benign calcifications were seen.  Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography 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. 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. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the 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 authorization and coverage for Lyrica 50 mg capsules for treatment of the enrollee who has a history of myofascial muscle pain, fibromyalgia, and lumbago. Findings:  The physician reviewer found that The medical literature supports the requested medication in this clinical setting. Specifically, the patients WPI score was noted to be greater than 10 without Lyrica. The American College of Rheumatology recommends a symptom severity score of at least a 5. This patients symptom severity score was a 6. Moreover, the provider noted failure with gabapentin, amitriptyline, and nortriptyline for eight months. Additionally, the medical literature supports Lyrica as a treatment option for fibromyalgia and is approved for such an indication. All told, Lyrica 50 mg capsules are  medically necessary for 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  The physician reviewers found this technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the 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:  Physician reviewers number one, two, and three are board certified in diagnostic radiology 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.