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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDX-melanoma test for evaluation of his malignant melanoma. Findings:  The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by the staging system as documented by Balch and colleagues. Mitotic index has also been thought to add a bit more to the prognostics. By these determinations, this patient has an excellent prognosis. DecisionDX is a study of 31 genes in the melanoma cells. It then classifies that melanoma as either high or low risk for recurrence. The National Comprehensive Cancer Network (NCCN) guidelines state there is interest in these newer genetic profiles. However, medical studies are not clear as to how DecisionDX data compares to the 10 year data of the Balch determinations and whether it is useful in clinical practice for patients with a good prognosis, as is true in this patients case. This patient will most likely not undergo sentinel node biopsy, in view of his excellent prognosis. While this test has some limited support for its use in identifying treatment options for those patients diagnosed with cutaneous melanoma, this assay has not been shown to be superior over other modes of therapy.  Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewers 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 computed tomography (CT) scan of the heart without dye with calcium test for evaluation of the enrollees chest pain, abnormal electrocardiogram, and mixed hyperlipidemia. Findings:  Two physician reviewer found that Use of the calcium score has been supported by the American College of Cardiology (ACC) as a class IIa or IIb category, which states that this testing may be beneficial in asymptomatic individuals with intermediate coronary risk. Other studies such as exercise testing or coronary angiography are recommended in symptomatic individuals. Since this individual was having chest pain and abnormal EKG with right bundle branch block pattern and past history of syncope, the contrast CT coronary angiogram was indicated, but calcium scoring is not recommended in symptomatic patients. Accordingly, the CT scan of the heart without dye (CPT code 75574) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy while the calcium test 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 a portion of 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 partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular medicine and are 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 capsule endoscopy for evaluation of the enrollees bladder problems and abdominal pain. Findings:  Two physician reviewers found that current American Society for Gastrointestinal Endoscopy guidelines for endoscopy in IBD recommend the use of capsule endoscopy in the diagnosis of Crohns disease. Data from retrospective and prospective studies have shown that capsule endoscopy is useful for the diagnosis of Crohns disease even if imaging tests such as small bowel follow through and ileoscopy are negative or unsuccessful. In these studies, capsule endoscopy has proven more sensitive in the detection of small bowel Crohns disease than the alternatives such as computed tomography scan, small bowel follow-through, and enteroclysis. Capsule endoscopy resulted in a change in management in a significant number of patients based on findings missed by other tests. A recent study reported that capsule endoscopy has sensitivity of 89.6 percent and specificity of 100 percent for Crohns disease. Regarding the need for upper endoscopy in patients with suspected Crohns disease, American Society for Gastrointestinal Endoscopy guidelines for endoscopy in inflammatory bowel disease recommend capsule endoscopy as the next step after colonoscopy, and only recommend upper endoscopy before capsule endoscopy in pediatric patients. Final Result: The reviewers determined that the services at issue were likely to have been 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 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Oncology Colorectal SCR (fecal DNA testing).  Findings:  The physician reviewer found that the evidence on impact or on healthcare outcomes of fecal DNA testing versus standard medical care is lacking, and the requested services are not standard of care at this time.  There is not a consensus in clinical guidelines and clinical literature to support that the requested services have a positive impact on health outcomes.  Although fecal DNA testing is able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop. The long-term health outcomes of foregoing regular polyp removal and instead performing fecal DNA testing has not been determined.  Additionally, health outcomes using the requested services have not been compared over the long-term with other screening methods for colon cancer.  Thus, the requested Oncology Colorectal SCR (fecal DNA testing) is not likely to be more efficacious than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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: all three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 prescription medication, Treximet. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. This patient has had migraine headaches for many years as confirmed by her medical record.  The medical literature and medical evidence regarding Treximet show that Treximet has different pharmacokinetics and tolerability profile when compared to the generic sumatriptan and naproxen alone. The literature also indicates that Treximet has fewer side effects and patients experience a greater probability of sustained freedom from pain. The patients description of her results from Treximet is in line with the data provided in the medical literature.  She has been using Treximet as her abortive therapy for treatment of her migraine headaches for years, and this has proven to be effective. The records also show that she has tried and failed other medications. All told, Treximet is medically necessary for the treatment of this patients medical 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 neurology 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 reimbursement for Prometheus Anser IFX diagnostic test for evaluation of his Crohns disease. Findings:  Two physician reviewers found that Prometheus Anser IFX testing was ordered to determine Remicade (infliximab) level and whether antibodies to infliximab were present. The use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear infliximab levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing. Researchers reported that future prospective controlled studies are needed, especially considering that anti-TNF levels are influenced by several variables that can fluctuate over time and among individuals. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the breast tomosynthesis for evaluation of her breast cancer examination. Findings:  Three physician reviewers found that there is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. According to the a study, 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. 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: 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: Reviewers 1, 2, and 3 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of her breast cancer examination. Findings:  Two physician reviewers found that There is a lack of peer-reviewed literature that supports the use of digital breast tomosynthesis compared to currently available techniques. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in the peer-reviewed literature as superior to currently available standard medical therapies. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2, and 3 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gastric sleeve surgery for treatment of her obesity.  Findings:  The physician reviewer found that review of the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested surgery. Although this patient does have documented obesity with a BMI of at least 35 and hypertension, she is not an appropriate candidate for bariatric surgery as there is no documentation that she has completed a thorough multidisciplinary evaluation that would include a dietary, psychological and surgical evaluation. Therefore, although this patient may be a potential candidate for treatment of obesity, she does not meet the criteria for bariatric surgery. Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: A female enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who presented for a breast examination.  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, there are multiple indications for tomosynthesis.  First, her breast tissue is extremely dense.  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.  Similarly, areas of asymmetry can often be resolved by tomosynthesis.  Lastly, patients who are BRCA1 positive are at a very high risk for developing breast cancer. She is currently undergoing a very intensive program of magnetic resonance imaging (MRI)/mammography/ultrasound as well as physical examinations. The American College of Radiology, in its Appropriateness Guidelines, indicates that mammography and MRI are complementary examinations and that one should not replace the other.  Further, they give tomosynthesis their highest appropriateness rating for patients who are BRCA positive.  One of the disadvantages of MRI is that magnetic resonance scanning can be exceedingly sensitive, but it is not as specific as tomosynthesis. Tomosynthesis offers one advantage of better delineating a focal abnormality. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis used was medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the service at issue was 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 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

An enrollee has requested reimbursement for bilateral digital breast tomosynthesis performed.  Findings:  The physician reviewer found that the impression was benign. The breast tissue was average in density. The medical literature supports the use of digital 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: 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 trastuzumab (Herceptin) (CPT code J9355) and chemotherapy administration (CPT code 96413). Findings:  The physician reviewer found that this patient has GEJ adenocarcinoma with regional metastases and progression on standard multi-agent chemotherapy. Her tumor was submitted for the Foundation One mutational analyses which revealed multiple mutations, most notably ERBB3 amplification (HER3), epidermal growth factor receptor (EGFR) amplification, among others. ERBB3 is a transmembrane protein with limited kinase activity on its own. ERBB3 requires heterodimerization with ERBB2 (HER2). Recently, it has become important to identify mutations that may be amenable to targeted therapy. A study of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. Given the extensive clinical experience in gastric cancer, Herceptin is an appropriate next line of therapy in this clinical setting. Given the findings on this patients Foundation One mutational analyses and the current medical literature, the requested trastuzumab (Herceptin) (CPT code J9355) and chemotherapy administration (CPT code 96413) is supported as medically necessary for treatment of this patients GEJ invasive adenocarcinoma. 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 medical oncology with sub-specialty certification in hematology 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 reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care. Findings:  The physician reviewer found that residential treatment center services from the date of service in question, forward were not and are not medically necessary for treatment of the patients behavioral health condition. Her weight was 136.4 pounds, BMI was 24.6, and 121% of IBW. Her vital signs were stable with only mild orthostatic change in pulse and no blood pressure change on standing. There is a lack of evidence showing that she would not respond to treatment in a less intensive setting. Her ADLs were intact and her alcohol use was of a binge nature and it was not documented for what time period she had been engaging in this behavior. Her eating disorder behavior was noted to involve restricting. There was no description as to whether she was over-exercising at the time or purging. All told, as of the date of service in question, she did not require 24-hour residential staff intervention to monitor eating disorder behavior, and could have returned to the less restrictive level of care. Thus, 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 physician reviewer is board certified in psychiatry with sub-specialty certification in addiction 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.