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

Nature of Statutory Criteria/Case Summary: An enrollee has requested stereotactic body radiation therapy (SBRT) for treatment of the enrollees pancreatic cancer.  Findings: Two reviewers found that the patient with a recent diagnosis of unresectable pancreatic cancer who presented to the emergency room with symptoms of abdominal pain, jaundice and dark urine. A computed tomography (CT) showing a pancreatic head mass abutting the superior mesenteric vein (SMV), narrowing the proximal portal vein, and abutting the celiac artery. Esophagogastroduodenoscopy/endoscopic ultrasound (EGD/EUS) and endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a pancreatic neck mass involving the portal vein confluence and celiac artery. The MRI also showed regional lymphadenopathy including a celiac node. Repeat EGD/EUS on eventually demonstrated adenocarcinoma on pathology. The patient has been referred to radiation oncology for stereotactic body radiation therapy (SBRT) for persistent disease. The Health Plan denied the requested services as investigational for treatment of this patient. Upon review of available data, SBRT is likely to be more beneficial in the treatment of locally advanced (unresectable) pancreatic cancer as compared to standard therapy consisting of conventionally fractionated radiotherapy. The 2016 American Society of Clinical Oncology (ASCO) Clinical Practice Guideline guidelines support the use of SBRT for the treatment of locally advanced pancreatic cancer with the quality of data supporting its use being assessed as intermediate. There are also other potential benefits of local control with regards to quality of life in preventing abdominal pain and bowel obstruction. Overall, there is a significant benefit in local control with SBRT with a small increase in toxicity. All told, the requested stereotactic body radiation therapy (SBRT) are likely to be more efficacious than current available methods in the treatment of this patient.Final Result: Two reviewers determined that the requested services are 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 radiation oncology 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 shoe inserts for treatment of the enrollees ankle and foot pain.  Findings: The physician reviewer found that the Health Plan has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollees ankle and foot pain.  The submitted documentation supports the medical necessity of the equipment at issue in this clinical setting.  It is well-documented in the progress notes that this patient has foot and ankle pain.  The records document an inability to ambulate comfortably, with foot and ankle pain affecting the patients activities of daily living. She underwent intensive physical therapy, without resolution of pain.  Orthotics are standard of care in the treatment of both mechanical overpronation at subtalar joint, as well as treatment of plantar fasciitis.  All told, the shoe inserts were medically indicated for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested intravenous lidocaine infusion for treatment of the enrollees new daily persistent headache.  Findings: Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  Intravenous lidocaine has been studied for the treatment of intractable headache in small pilot studies.  However, there is a lack of double-blinded, randomized, placebo-controlled prospective studies demonstrating efficacy.  Based on the lack of prospective randomized studies, the requested intravenous lidocaine infusion is not likely to be of greater benefit than other treatment alternatives.Final Result: Two reviewers determined that the requested services are 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 neurology 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 butalbital for treatment of the enrollee, who has a history of chronic migraines.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Based on the current use of butalbital, the diagnosis of medication overuse headache can be established.  Her current use of butalbital is not consistent with its intended use of only as needed.  Chronic daily use of butalbital is a common cause of chronic daily headache. The current medical evidence supports withdrawal from this medication and consideration of other preventative medications.  In sum, butalbital 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for breast cancer screening of the enrollee, who was asymptomatic.  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 breast tissue was described as heterogeneously 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.  Thus, digital breast tomosynthesis was likely to have been more effective than other modalities for evaluating this patient.Final Result: Three reviewers determined that the service at issue is 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 proton beam radiation therapy for treatment of the enrollees paranasal sinus cancer.  Findings: Two physician reviewers found that the use of proton therapy is an accepted radiation technology that has proven efficacy and tolerability.  Certain conditions, such as base of skull chordomas and chondrosarcomas, and pediatric central nervous system malignancies, are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. There is abundant data on proton therapy for sinonasal cancers as well, and proton therapy is an accepted treatment modality.  In general, proton therapy is more effective in sparing the normal tissues in and around the base of skull.  When these critical structures are in the target volume, proton therapy is often the only manner in which to safely treat the target.  In this patients case, there is documentation that intensity modulated radiation therapy would have resulted in an unacceptable plan given the location of disease.  There is sufficient support for the services at issue in this clinical setting.  All told, proton beam radiation therapy was likely to have been superior over other treatment options.Final Result: Two reviewers determined that the services at issue were 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 physician reviewers are board certified in radiation oncology 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: Three 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 is 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 is 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested LINX reflux management system for treatment of the enrollees gastroesophageal reflux disease (GERD) and esophagitis.  Findings: Two physician reviewers found that in the peer-reviewed medical literature, Lipham and colleagues noted that the LINX Reflux Management System provided long-term clinical benefits. The authors concluded that patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. The LINX device received U.S. Food and Drug Administration (FDA) premarketing approval for four years, the approved indication was for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. Two post-approval studies are designed to evaluate the long-term effectiveness of the device and incidence of adverse events. Lipham and colleagues also noted that appropriate patient selection is crucial before anti-reflux procedures. In prelude to surgical intervention for GERD, it is critical to document the presence of abnormal distal esophageal acid exposure, especially when anti-reflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture.This patients records document that she has undergone much of this pre-operative assessment. The patient has GERD based on pH recording off-acid blocker drugs. However, the same study with resumption of proton pump inhibitor (PPI) therapy showed rapid and complete control of all acid reflux such that the patient cannot be considered medically refractory to acid blocker drugs. Accordingly, the requested LINX is not likely be more beneficial for treatment of the patients medical condition than available conventional medical therapy.Final Result: Two reviewers determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in 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 tumor necrosis factor (TNF) antagonists lab testing for evaluation of the enrollees Crohns disease. Findings: Two reviewers found that the Prometheus Anser ADA test is a quantitative measurement of serum adalimumab (ADA) and anti-ADA antibodies. Some evidence exists that low serum levels of adalimumab and/or the presence of antibodies to adalimumab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of adalimumab or the presence of ADA antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well controlled clinical trials to confirm that use of the Anser ADA testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). Given the paucity of data demonstrating improved health outcomes with use of the Anser ADA test in this clinical setting, the TNF antagonists lab testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the testing at issue is 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested intravenous immunoglobulin (IVIG) for treatment of the enrollees systemic lupus erythematosus (SLE).  Findings: Three physician reviewers found that Scleromyxedema is a rare disorder that mimics scleroderma. Currently, there are no guidelines or clinical trials addressing the proper treatment for this disease. Blum and colleagues found that systemic manifestations of the disease are common and often mimic those seen in systemic sclerosis. Eight of the 10 patients were treated with IVIG with a 100% complete or partial response rate. Treatment was initiated at a dose of 2 g/kg (total dose, divided over 2-5 days) for six months of initial therapy. In each case where IVIG was used, maintenance infusions are required to preserve disease control. In this case, the biopsy and laboratory studies do not support the diagnosis of scleromyxedema. There is atrophy and mucin deposits on the pathology, but there is no documented evidence of the triad of mucin deposition, fibrosis, and fibroblast proliferation. Also, the patients laboratory work-up does not show evidence of monoclonal gammopathy and her serum protein immunoelectrophoresis does not demonstrate the presence of a serum paraprotein (usually 7S-IgG) with a prevalence of lambda light chains over kappa (4 to 5:1). Instead, her evaluation suggests SLE and scleroderma. Although there is evidence that IVIG is effective in scleromyxedema, the records fail to confirm this diagnosis. Further, this patient has not been treated with other more standard therapies for scleroderma such as corticosteroids, mycophenolate mofetil, cyclophosphamide or azathioprine. IVIG is reserved for refractory cases of scleroderma. Thus, the requested IVIG is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in rheumatology 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 evaluation of the enrollee, who presented for an annual breast screening examination. Findings: All three physician reviewers found that the patient underwent a routine screening mammogram consisting of a combination two dimensional and three dimensional digital breast tomosynthesis examination.  In addition, the patient had an automated whole breast sonogram examination.  The current images were compared to prior mammograms and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  The breast sonogram noted multiple bilateral sub-centimeter breast cysts.  Her breast tissue was described as being extremely dense. The Health Plan has denied reimbursement for digital breast tomosynthesis used.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, the patients breast tissue has been described as being heterogeneously dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For these reasons, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are 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.