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 current medical evidence supports the services at issue in this patients case.  Breast tomosynthesis offers advantages to radiologists reading mammograms, especially in women with heterogeneously and extremely dense tissue.  This new technique often allows the reader to separate dense glandular elements from underlying architectural distortion/mass, resulting in a decrease in biopsies, increase in detection of small cancers and decrease in callbacks.  For these reasons, the addition of breast tomosynthesis to the usual two-dimensional mammographic imaging protocol was likely of greater benefit to the patient than had she had the examination with two-dimensional imaging 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 physician 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested computed tomography (CT) scans of the head and spine on an emergent or urgent basis.  Findings: The physician reviewer found that in this case, the patient was transported to the emergency department after a significant motor vehicle accident. An ambulance transported the patient to the emergency department for evaluation. In this clinical setting, the CT scans of the head and spine provided were indicated given the potentially serious internal conditions which may not be evident on the initial history and physical exam, including internal bleeding, subluxation and fracture of vertebra, cerebral contusion, and intracranial bleeding. Therefore, the patients symptoms were of sufficient severity that a prudent layperson would reasonably believe a delay in seeking medical attention would place his health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of any bodily organ or part. Thus, the CT scans of the head and spine did meet prudent layperson criteria for emergency care.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency services. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in emergency 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 Afirma gene expression classifier and BRAF testing for evaluation of her medical condition.  Findings: Three physician reviewers found that while fine needle aspiration (FNA) biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only method to establish whether the nodule was thyroid cancer was via surgical excision (Miller, et al). The Afirma Thyroid FNA analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries (Duick, et al). Thus, the Afirma gene expression classifier and BRAF testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: All 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 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 rituximab for treatment of her medical condition.  Findings:  Two physician reviewers found that the medical records indicate a condition of primary progressive MS for which the current peer-reviewed literature does not support rituximab as a proven therapy. Studies have not demonstrated significant improvement with this therapy for primary progressive MS. He and colleagues noted there is insufficient evidence to support the use of rituximab as a disease-modifying therapy for MS because only one randomized controlled trial is available for review. Hawker and colleagues findings did not reach significance. All told, there is a lack of scientific data demonstrating that the requested rituximab 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 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 reviewers are board certified in internal medicine and neurology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that 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 (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. In this clinical setting, the use of 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 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.that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested tumescent lymph-sparing liposuction, three to four surgeries with preoperative conservative therapy of manual lymphatic drainage (MLD) (Vodder technique) prior to the proposed surgery date,and postoperatively, postoperative garments and general intravenous infusion stem cell therapy, manual lymph drainage therapy by a Vodder trained MLD therapist, and aquatic therapy for treatment of her medical condition. Findings: The physician reviewer found that this patient presents with lipedema and Dercums disease that has failed conventional therapy. The patient previously had significant improvement with surgical intervention. As no other therapy can reasonably treat this condition, this procedure is medically necessary for this patient. Although there are no double-blind, placebo controlled studies, there is enough relevant literature that supports lipedema liposuction as a surgical correction/improvement in functional deficits related to lipedema. Therefore, lymph-sparing liposuction, three to four surgeries with preoperative conservative therapy of MLD (Vodder technique) prior to the proposed surgery date, and postoperatively, postoperative garments, manual lymph drainage therapy by a Vodder trained MLD therapist, and aquatic therapy is medically necessary in this clinical setting. However, there is insufficient evidence to support the request for general intravenous infusion stem cell therapy is medically necessary for this patient.  Final Result: The reviewer determined that a portion of the requested services are 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Suboxone for treatment of his behavioral health conditions.   Findings:  The physician reviewer found that as an opioid agonist, buprenorphine can cause euphoria, respiratory depression and other opioid effects.  Thus, an opioid antagonist, naloxone, is added to buprenorphine, creating Suboxone, which minimizes misuse and diversion.  This addition also introduces the possibility of inducing withdrawal if Suboxone is administered in the absence of an opioid-free state. Long-term Suboxone maintenance therapy represents a proven, evidence-based intervention for opioid use disorder. Although the literature supporting the use of Suboxone for the treatment of heroin addiction is less robust, there is adequate evidence to warrant its use in this setting. Given the patients history, treatment with Suboxone is medically reasonable and appropriate at this time. As such, the requested Suboxone treatment is medically necessary for the treatment of this patients condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested skilled nursing facility (SNF) services for treatment of his medical condition. Findings:  The physician reviewer found that upon review, the submitted medical records do not establish the medical necessity of skilled nursing facility (SNF) services at issue.  There was no documentation of significant changes in the patients condition, medication or treatment plan. The submitted documentation did not indicate that the patient required the skills of a professional nurse on a daily basis in an SNF setting.  The record reflects that the patient care needs were chronic and custodial.  Skilled therapy was also not required to establish a maintenance program or prevent deterioration in active daily living.  All told, this patient did not require the skilled services of a SNF level of care.  Therefore, the services at issue were 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 internal medicine with sub-specialty certification in geriatric 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a labiaplasty for treatment of her medical condition.  Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. Rouzier and colleagues reviewed the records of 163 patients and found that the motives for requesting surgery were aesthetic concerns in 87% of the cases, discomfort in clothing in 64%, discomfort with exercise in 26%, and entry dyspareunia in 43%. In this case, the patient has a functional impairment. She complains of dyspareunia, pain with activity and pain with wearing clothes. The physical examination documents the abnormality. The patient has functional concerns, and cosmetic concerns do not appear present for this patient. Based on the medical documentation submitted for review labiaplasty is medically necessary for treatment of the patients medical condition. 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 plastic 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 for breast tomosynthesis for breast cancer screening.  Findings: Two reviewers found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons,  breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.  Final Result: Two 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees 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. The advantage of tomosynthesis relates to the advantage afforded the radiologist to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. For this reason, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the exam been done with two-dimensional technique 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 physician 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 Repatha for treatment of his medical condition.  The physician reviewer found that the patients medical records do not document absolute contraindication to the currently prescribed lipid medications, or absolute intolerance to the currently prescribed lipid medications, and given that the patient has experienced effective lipid lowering to a goal on current medications, a PCSK9 inhibitor such as Repatha is not medically necessary at this time. Medical studies support the use of PCSK9 inhibitors for patients who are unable to take statin medications and/or need additional reduction in LDL cholesterol; the patients records do not document either in this case. For these reasons, the requested medication is not medically necessary for treatment of the patients coronary disease. 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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his medical condition.  Findings:  Three physician reviewers found that IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Three-dimensional conformal radiotherapy (3DCRT) for the treatment of mesothelioma is an inefficient process. The matching of the electron beams and photon blocks can be inaccurate, thus coverage of the treatment volume is compromised. However, IMRT is optimal in providing adequate coverage of a curved treatment volume. These factors have led to 3DCRT for mesothelioma being largely being abandoned by the radiation oncology medical community. The use of IMRT allows the treating clinician more control over where the radiation falls over within the target volume compared to 3DCRT (Patel, et al). Buduhan and colleagues evaluated a retrospective cohort of 46 patients with mesothelioma over a 10-year period that were treated with neoadjuvant chemotherapy followed by extrapleural pneumonectomy. Twenty-four of these patients then received 3DCRT, and 14 received IMRT. Local recurrence rates with 3DCRT was 41.7%, and only 14.3% IMRT. In addition, Krayenbuehl and colleagues retrospectively analyzed 39 patient treated with neoadjuvant chemotherapy followed by extrapleural pneumonectomy. Local recurrence rates were significantly improved from 72.7% to 27.3% in the 14 patients that received IMRT versus the 25 that received 3DCRT. Given the inability of 3DCRT to provide adequate dose coverage of a curved treatment volume, IMRT is a superior treatment in this clinical setting.   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 radiation oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her 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 non-liver-related conditions. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 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.