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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis.Findings:  Two physician reviewers found that a study evaluated the impact of adding tomosynthesis to full field digital mammography (FFDM) in the detection and diagnosis of breast lesions. The study demonstrated that screening sensitivity of FFDM was increased from 60% to 94%, and specificity increased from 20.7% to 74% when tomosynthesis was applied. Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings by proving either a definite benign or malignant diagnosis. Tomosynthesis allowed unnecessary biopsy to be avoided in 37.3% of patients. In addition, the patients right breast is heterogeneously dense. Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are is 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400 mg  100 mg for eight weeks. Findings:  The physician reviewer found that According to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Epclusa for 12 weeks, 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 based on a high cure rate. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 physician reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Two physician reviewers found that the medical literature supports the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural disorder, resulting in a decrease in callbacks and increase in detection of small cancers and increase in overall diagnostic accuracy compared to two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done with two-dimensional imaging alone.  In sum, digital breast tomosynthesis performed was likely to have been more efficacious 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: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollees risk for breast cancer. Findings:  2/3 of the 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. This patient demonstrates the optimal use for tomosynthesis. An initial diagnostic mammogram did not clearly delineate the patients abnormality after she presented with a palpable mass. The initial mammogram demonstrated heterogeneously dense breast tissue, which could obscure a tumor. She then had additional images which demonstrated better the area of distortion. Additionally, the ultrasound was performed to better distinguish the solid nature of the lesion. She then underwent an ultrasonically guided biopsy. It is specifically this type of patient with dense breasts and a palpable mass that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the 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 reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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 that was performed for evaluation of the enrollee, who presented for a breast screening mammogram. Findings:  2/3 of the physician reviewers found that the patient is a female who presented for a bilateral screening mammogram with breast tomosynthesis. There was no mammographic evidence of malignancy. The breast tissue was average in density. There were no suspicious abnormality reported. The impression was negative. The Health Plan has denied the request for reimbursement for digital breast tomosynthesis performed. Per the Health Plan, the service at issue was investigational for the evaluation of this patient.There is clinical support for the service at issue. According to 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. Colleagues noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed was likely to have been more effective than other methods of evaluating this patient. Final Result: 2/3 of 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: Physician reviewer number one is board certified in radiology 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.Physician reviewer number two is board certified in radiology 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.Physician reviewer number three is board certified in radiology 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

An female enrollee has requested reimbursement for the coronary computed tomography (CT) angiogram. Findings:  The physician reviewer found that there are no documented symptoms of chest discomfort. A stress echocardiogram on 5/2/12 reported no provocable ischemia. An echocardiogram reported normal left ventricular function. A coronary computed tomography (CT) angiogram revealed a moderate 50-70% stenosis of the left anterior descending coronary artery. The patient has requested reimbursement for the coronary CT angiogram. In this circumstance of an asymptomatic patient guidelines for the assessment and management of coronary risk that are endorsed by several national organizations do not recommend coronary CT angiography. Moreover, if an assessment of coronary anatomy were to be indicated, then conventional coronary angiography is preferred due to improved accuracy and the ability to intervene with coronary revascularization during the same procedure if clinically indicated. All told, the coronary CT angiogram was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the diagnostic procedure 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: the physician reviewers are certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for modafinil (Provigil) for treatment of the enrollees narcolepsy. Findings:  Two physician reviewers found that this patient does not have a diagnosis of narcolepsy that is supported by the provided records. Her symptoms are suggestive of this condition, however, references to her previous sleep study document that it did not show the hallmarks of the condition. Although the HLA-DQB1 0602 allele is more common in patients with narcolepsy, approximately 25% of the population are positive for this allele, and the test result is irrelevant in the setting of a non-suggestive sleep study. 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: Two physician reviewers are board certified in sleep medicine and neurology and are actively practicing. One physician reviewer is board certified in internal medicine, pulmonary medicine and critical care medicine 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacral nerve stimulation for treatment of the enrollees anal pain and sphincterotomy. Findings:  Two physician reviewers found that within the field of colorectal surgery, the primary indication for sacral nerve stimulation is fecal incontinence. There is a lack of significant data supporting the use of sacral nerve stimulation for levator syndrome, anal pain or chronic pelvic pain. A systematic review on nerve stimulation for chronic pelvic pain and bladder pain syndrome concluded that there were no reported data for sacral nerve stimulation. Additionally, there is a paucity of literature reporting variable success of posterior tibial nerve stimulation in improving pain, urinary symptoms and quality of life for both chronic pelvic pain and bladder pain syndrome. Finally, a small study of 60 consecutive male patients with chronic pelvic pain demonstrated that transcutaneous electrical nerve stimulation (TENS) may be an effective and safe treatment for chronic pelvic pain and that larger randomized placebo controlled trials are warranted. Given these data, the requested sacral nerve stimulation is not likely to be more beneficial for treatment of the patients anal pain than any available standard therapy. Final Result: The reviewers determined that the requested service 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: Two reviewers are board certified in surgery with sub-specialty certification in colorectal surgery and are actively practicing. One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine 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 authorization and coverage for bunion surgery for treatment of the enrollees bunion. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Hallux valgus is a biomechanical malformation of a foot, causing strain and most often pain to the first metatarsophalangeal joint.  This patient complains of painful first metatarsophalangeal joint unresponsive to conservative care including steroid injections to the metatarsophalangeal joint.  She also relates a history of trauma which may exacerbate a bunion deformity.  In this clinical setting, a bunionectomy for hallux valgus is standard of care and may be beneficial in alleviating the first metatarsophalangeal joint pain for the patient.  All told, the requested bunionectomy is medically necessary 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 physician 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for colchicine 0.6 mg oral capsule, one capsule twice daily for treatment of the enrollees familial Mediterranean fever. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The drug colchicine is U.S. Food and Drug Administration (FDA) approved for the use in treatment of gouty flares and familial Mediterranean fever.  For the treatment of a gouty flare, a medication from the nonsteroidal anti-inflammatory drug (NSAID) class is considered first-line treatment.  If a patient cannot tolerate treatment with an NSAID or has a contraindication to use of these medications, then colchicine is recommended.  Familial Mediterranean fever is a hereditary auto-inflammatory disorder characterized by recurrent bouts of fever and serosal inflammation.  Colchicine is recommended to prevent acute attacks and minimize subclinical inflammation in between attacks, and to prevent the development and progression of amyloidosis for patients with familial Mediterranean fever.  In this case, the documentation submitted by the provider does not support a diagnosis of gout or familial Mediterranean fever.  Given the lack of medical records documenting that the patient has familial Mediterranean fever, the medical necessity for the continued use of colchicine is not established.  Thus, colchicine 0.6 mg oral capsule, one capsule twice daily is not medically indicated for the treatment of this patient. 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 physician reviewer is board certified in internal 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 authorization and coverage for Harvoni for eight 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), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. 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. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis. Findings:  Three physician reviewers 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 (CT) 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 patients case, her breasts were described as extremely dense.  In addition, there was clinical evidence of breast lumps.  Breast tomosynthesis has been shown to be valuable in this clinical setting.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor, and more confidently excluding malignancy.  When there are questionably palpable breast masses, it is imperative to exclude a focal etiology.  Final Result: 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.