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

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee risk for breast cancer and has been diagnosed with extremely dense breast tissue.  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.  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 was likely to have been more efficacious than other methods of evaluating this patient.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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary. An enrollee has requested digital breast tomosynthesis for the enrollees breast cancer screening. Findings: Three physician reviewers found that the patient was asymptomatic with respect to her breasts.  The patient has a family history of breast cancer with mother who was diagnosed at age 47 and a paternal aunt at age 78. The patient underwent a routine screening mammogram consisting of a three dimensional tomosynthesis study with synthetically reconstructed two dimensional views. The current images were compared to a prior mammogram, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breasts were described as being dense. The Health Plan has denied reimbursement for digital breast tomosynthesis.  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 (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 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 was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections.Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use of Synvisc injections for the treatment of pain in patients with osteoarthritis of the knee. However, there are no current medical studies that support the use of these injections in the treatment of symptomatic medial plica. Literature generally supports surgical excision for recalcitrant cases of symptomatic plica that has undergone irrevocable morphological changes. This patient presents with chronic bilateral knee pain that significantly limits his physical activities. Clinical examination findings documented bilateral knee medial plica that was thickened and painful to palpation. He has reported benefit with prior Synvisc One injections. He has failed physical therapy, medications, and corticosteroid injections. However, there is no imaging or radiographic evidence of osteoarthritis or articular cartilage pathology in the submitted medical records to support the medical necessity of Synvisc injections. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for blood testing (lipoprotein) for evaluation of the enrollees hyperthyroidism. Findings:  Three physician reviewers found that based on the documentation provided for review, the patient underwent advanced lipoprotein testing including lipid sub-fractionation. Current guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. In addition, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Therefore, the blood testing (lipoprotein) was not likely to be more beneficial for evaluation of the patients medical condition than available standard therapy. Final Result: The reviewers determined that the testing 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: All three physician reviewers are board 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed for the enrollees breast cancer screening. Findings:  Three physician reviewers found that the patient was asymptomatic with respect to her breasts.  She underwent a routine screening mammogram consisting of two dimensional images.  On that mammogram, there was a questionable abnormality observed on only the cranio-caudal view, and further imaging was recommended.  She returned for spot compression and magnification views.  In addition, a breast tomosynthesis as well as a targeted sonogram were performed. The images were compared to prior mammograms and the more recent mammogram.  No significant abnormalities were seen. There were no masses, areas of architectural distortion, or abnormal calcifications.  The prior abnormality was felt to represent summation artifact. During their studies, the breasts were described as being heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis portion of the examination performed. 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 (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 patient, breast tomosynthesis was utilized as a problem solving tool.  Once a questionable abnormality was noted, further imaging was appropriately performed. Breast tomosynthesis was warranted on both that basis to evaluate the suspected abnormality as well as to evaluate the dense nature of her 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. For these reasons, the digital breast tomosynthesis performed was superior to the available standard modality available for evaluation of 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for acute inpatient psychiatric hospitalization services provided for treatment of the enrollees major depressive disorder with suicidal ideation. Findings:  The physician reviewer found that although presenting to nursing with shoestrings around his neck, the patient was not truly suicidal as per his admission to his provider. He endorsed the fact that the act was attention seeking in nature and without intent. He denied homicidal ideation. Although he showed inappropriate sexual acting out behavior, this type of behavior does not warrant inpatient level of care. He was not psychotic or manic and he was medically stable. He had improved and no new problems had arisen. He tolerated his medications and was compliant with treatment. He had stabilized and no longer required 24-hour supervision at the inpatient level of care. He could have been treated in an ambulatory setting with psychotherapy and medication management in an intensive outpatient program (IOP). Thus, the acute inpatient psychiatric hospitalization services provided were not medically necessary for treatment of this 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues 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, the 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 diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. 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 that was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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.Credentials/Qualifications: All three physician reviewers are 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 implantation of hormone pellets for treatment of the enrollees menopausal symptoms. Findings:  Three physician reviewers found that there are many U.S. Food and Drug Administration (FDA) approved treatments available for menopausal symptoms and for atrophic vaginitis.  Atrophic vaginitis can cause painful intercourse, which can impact libido, and there are several FDA-approved treatments, both topical and oral, for this condition.  In addition, decreased libido is multifactorial, and there is no evidence in the record of any evaluation or attempts at therapy other than hormone pellet implants.  If the goal is treatment with estrogen and testosterone, there is an available oral FDA-approved estrogen/testosterone combination that can be prescribed (Covaryx).  Udoff noted the use of testosterone is limited by the lack of approved and commercially available products for women. In addition, the doses of testosterone used and the mean serum concentrations of total testosterone achieved in women are supraphysiologic, resulting in important side effects such as acne and hirsutism. The long-term consequences of these relatively high serum testosterone concentrations are unknown.  In this case, the patient received a very high dose of testosterone, 200 mg, which is likely to cause supraphysiologic levels and potential side effects.  In sum, implantation of hormone pellets was not likely to have been of greater benefit than other treatment alternatives.   Final Result: Three reviewers determined that the services at issue were 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 obstetrics and gynecology 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 digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings: Three physician reviewers found that despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional (2D) imaging alone. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had the exam been done with 2D imaging alone. Accordingly, 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 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 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 Sovaldi and Daklinza for treatment of the enrollees chronic hepatitis C virus genotype 3.  Findings: The physician reviewer found that according to 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 regardless of fibrosis stage should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Although, a possible enlarged lymph node was seen on ultrasound, there is no established medical condition in this case that limits life expectancy to less than one year. This patient should be considered treatment-naive because although she took a partial course of interferon, she did not fail a course of peg-interferon and ribavirin due to nonresponse or relapse. Per the guidelines, in treatment-naive genotype 3 patients, Sovaldi and Daklinza for 12 weeks is the recommended regimen. This is based on the ALLY-3 trial showing a 97% cure rate in this population (Nelson, et al). Further, delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested Sovaldi with Daklinza for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Epclusa 400 mg  100 mg for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, treatment-naive genotype 3 patients should be treated with Sovaldi and Daklinza for 12 weeks, or Epclusa for 12 weeks. This is based on the ALLY-3 trial for Sovaldi and Daklinza, and the ASTRAL-3 trial for Epclusa (Nelson, et al; Foster, et al). There is no controlled direct comparison trial showing that Epclusa is more effective than Sovaldi with Daklinza. In addition, non-cirrhotic treatment-naive genotype 3 patients had a 97% cure rate with Sovaldi and Daklinza in the ALLY-3 trial, similar to the 98% cure rate with Epclusa in ASTRAL-3.  There is a lack of medical records showing a contraindication to treatment with Sovaldi and Daklinza. Although hepatitis C treatment is needed, Epclusa has not been established as medically necessary 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.