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 her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in patients with heterogeneously or extremely dense tissue.  This new method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested gene testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that metastatic triple negative breast cancer is a very aggressive disease with few standard treatment options. Most patients are treated with off-label therapies. Von Hoff and colleagues reported on a study of 86 patients where the progression-free (PFS) survival on a regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors found the regimen selected by molecular profiling offered a 27% survival advantage. In addition, recent data on breast cancer also supports the use of Foundation One testing (Parker, et al). Given the support above, the testing at issue 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 testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and 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. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis  was likely to be more beneficial than any available standard therapy. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

 Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient presents with a history of a lumpectomy for right-sided breast cancer, followed by radiation therapy. In this clinical setting, the addition of tomosynthesis was the diagnostic procedure to detect recurrence. The study by Mansour and colleagues evaluated the impact of adding digital breast tomosynthesis (DBT) to full field digital mammography (FFDM) in the detection and diagnosis of breast lesions. The study demonstrated that screening sensitivity of full field digital mammography was increased from 60% to 94%, and specificity increased from 20.7% to 74% when DBT was applied. In addition, DBT allowed unnecessary biopsy to be avoided in 37.3% of patients (Mansour, et al). Based on the support in the peer-reviewed literature, breast tomosynthesis 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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Three physician reviewers found that  peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and 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. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial than any available standard therapy.  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 reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested insertion of two Mobi-C artificial intervertebral discs for treatment of her medical condition. Findings: Three physician reviewers found that this patient has widespread pain, numbness, and tingling involving the top of her head, right face, neck, and right upper extremity and is awakened with bilateral upper extremity tingling and numbness. Her provider reports myotomal symptoms and findings of right C6 and C7 radiculopathies. However, there is a lack of documentation by history and neurological examination of dermatomal and myotomal symptoms and findings consistent with cervical radiculopathies (Corey and Comeau). In addition, she does not have a cervical myelopathy and there is no correlation of her imaging with her clinical examination. The U.S. Food and Drug Administration (FDA) have approved the Mobi-C for two level disc replacements. However, the FDA has also required a seven-year post approval study to determine the long-term safety and effectiveness of this device. This study is ongoing. There are some promising studies of small and of short duration, but no large, controlled, and randomized studies to show long-term safety and effectiveness. All told, the requested insertion of two Mobi-C artificial intervertebral discs is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.  Final Result: Three 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 orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested corrective surgery and removal of a clamp of the enrollees genitalia for treatment of his medical condition. Findings: The physician reviewer found that according to the documentation submitted for review, the patient underwent bilateral orchiopexy surgery for testicular torsion. In this surgical setting, there was no clamp or synthetic material which could have caused a shortening of the penis. In addition, reversing the surgery would not affect penile length. In sum, the requested corrective surgery and removal of a clamp of the patients genitalia is not medically necessary for treatment of the patients medical condition.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 urology 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 breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that the patient has a significant family history of breast cancer and ovarian cancer. Breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography (FFDM, 2D) alone. Recall rates are reduced by 15-17%: 3D allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries). Studies have also shown that there has been an increase in cancer detection by 33-53%: cancer detection increased from 6 cancers/1000 women screened with 2D to 8 cancers/1000 women screened with 3D. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening.  Final Result: Two reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three physician reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco for treatment of his medical condition. Findings: The physician reviewer found that not all non-opioid treatment options have been utilized. Behavior therapy has not been done despite much research to support its use (Lee, et al). In addition, optimization of all non-opioid medications has not been documented (Mendlik and Uritsky). Chronic pain that has no hope for a cure can be considered palliative in nature and treatment. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting (Raffa and Pergolizzi). Since non-opioid options for pain relief have not been exhausted, the requested Norco is not medically necessary for treatment of this patients medical condition.  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.  Qualifications/Credentials: The physician reviewer is certified in anesthesiology with sub-specialty certification in pain 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested lymphatic sparing liposuction surgery for treatment of her medical condition. Findings: The physician reviewer found that the request for lymphatic sparing liposuction surgery for both arms is not medically necessary for treatment of the patients medical condition. The patient presents with well-documented evidence of lipedema which has affected her function with chronic pain and difficulty with ambulation. However, this has mainly affected her lower extremities. The patient had undergone water-assisted liposuction of the lower extremities on two separate occasions. The second surgery was complicated by deep vein thrombosis and pulmonary embolism. She is noted to have received significant functional improvement following these procedures with decreasing size in the lower extremities, resolved chronic pain and improvement in her mobility. The photographs provided for review show a severe condition of the lower extremities, but not the upper extremities. The previous physical examination noted less involvement of the upper extremities as compared to the lower extremities. Overall, the significant functional deficit of this patient appears to be related to the lower extremities. In addition, it is unclear if the conservative management employed for the lower extremities was also attempted for the upper extremities. Her functional deficits specifically related to the upper extremities has not been well-documented. In sum, the current medical documentation does not support lymphatic sparing liposuction surgery for both arms as a clear functional deficit has not been adequately defined and standard conservative management has not been well-documented.  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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his behavioral health condition. Findings: The physician reviewer found that TMS is endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population. The general treatment course for TMS includes 30-40 sessions delivered over a course of 4-6 weeks. In cases where a positive response is achieved, oral medication and psychotherapy are typically utilized to maintain remission.  In this case, the patient had a positive response to an adequate course of TMS and was tapered from the intervention. The patient was not prescribed oral prophylactic psychotropic medication aside from an antianxiety agent.  The records do not document that the patient was active in psychotherapy. The patient reported increased anxiety, and vomiting in the morning because of his anxiousness. Although he denied depression, TMS was resumed at a frequency of 1-2 times per month. The medical records do not demonstrate that standard therapies have been exhausted. Considering that TMS is not approved for anxiety and the standard remission enhancing strategies of pharmacotherapy and psychotherapy were not employed, the medical evidence does not support the medical necessity of TMS therapy.  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 reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested applied behavior analysis (ABA) services for treatment of his autism.  Findings: Two physician reviewers found that there is sufficient support for the requested services in this patients case.  The requested ABA services are medically necessary for modification of this patients autism spectrum disorder.  The requested number of hours of ABA services are well within the guidelines of best medical practice.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, exists and can be utilized to improve overall neurologic health.  ABA therapy can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to the developmental delays and social disconnection associated with autism spectrum disorder.  In sum, the requested services ABA services are medically indicated for the treatment of this patient.  Final Result: Two reviewers 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:  One reviewer is actively practicing and is board certified in neurology with special qualification in child neurology.  One reviewer is actively practicing and is board certified in neurology with special qualification in child neurology.  One reviewer is actively practicing and is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus genotype 1a.  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 (Kowdley, et al; Afdhal, et al). Moreover, the AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.