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 enrollees breast cancer screening.  Findings: Three physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as heterogeneously dense. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  In addition, the calcifications can be better characterized with tomosynthesis. 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: 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: Two physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. In this case, the patient has heterogeneously dense breasts. 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. Therefore, the digital 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 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: 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, 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 breasts were described 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.  In sum, 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein for the evaluation of the enrollees risk of heart disease.  Findings: Two physician reviewers found that the patient has a history of gastroesophageal reflux and dyslipidemia. Coronary calcium scoring and revealed coronary calcium score of 38. A clinic note documented no cardiac symptoms during active exercise and a normal cardiovascular physical exam. The provider recommended advanced lipoprotein testing for this patient. The test included lipid subfractionation. The Health Plan denied reimbursement for the advanced lipoprotein testing as investigational and experimental for treatment of this patient. In this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, insulin, insulin resistance testing, fibrinogen, genetic testing and homocysteine.  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.  Although 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.  All told, advanced lipoprotein testing was not likely to have been superior over other methods of evaluating this patient. Final Result: Two reviewers determined that the service 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested hyaluronan injections for treatment of the enrollees hip pain.  Findings: Three physician reviewers found that this patient is requesting authorization and coverage for hyaluronic acid injection for treatment of left hip pain attributed to osteoarthrosis. Viscosupplementation with hyaluronan is performed frequently for painful knee osteoarthritis, but the benefits are limited. The hyaluronan injection treatment proposed is approved by the Food and Drug Administration for treatment of painful osteoarthritis of the knee and injection in the hip is an off label usage. However, there have been very limited studies as to the superior efficacy of hyaluronic injections for treatment of hip pain related to hip osteoarthritis. The study by Qvistgaard and colleagues compared the effects of corticosteroid, hyaluronic acid and saline (placebo control) injections for hip osteoarthritis and no beneficial effects of the hyaluronic acid injection were shown. Most studies for treatment of hip symptoms include small numbers of patients and are uncontrolled with no comparison to more established treatment options such as corticosteroid injection. Therefore, the requested hyaluronic injections are not likely to be more effective than other available standard options for the treatment of this patient.  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. 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 of Zepatier for 12 weeks. Findings:  The physician reviewer found that according to the 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. The guidelines recommend that treatment naive genotype 1a patients can be treated with Zepatier for 12 weeks when NS5A resistance is not found, as in this case. These guideline recommendations are based on clinical trial results.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine 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: The parent of a pre or very early adolescent enrollee has requested Nutropin AQ NuSpin for treatment of the enrollees idiopathic short stature.  The submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting. Per the records, the patient has normal bone age, normal growth factors, normal peak GH response to provocative testing, and no known morphological abnormalities of the pituitary gland or midline brain structures. Thus, these measurements do not support that he demonstrates classic GH deficiency.  Using the Bayley-Pinneau height prediction method, the estimated adult height for this patient is within two standard deviations of his genetic target height and not short enough to warrant a trial of GH therapy for idiopathic short stature. Moreover, the Pediatric Endocrinology Society guidelines (Wilson, et al) state that a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency.  However, this patient does not meet most of these criteria. All told, the requested Nutropin AQ NuSpin 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 bilateral breast tomosynthesis for the enrollees breast cancer screening.  Findings: Three physician reviewers found that the patient has a family history of breast cancer. The patient underwent a routine screening mammogram consisting of a combination two dimensional (2D) and three dimensional (3D) tomosynthesis examination. The report noted that this study was the patients baseline mammogram, and no prior mammograms were available for comparison.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  The patients breasts were described as being heterogeneously dense. The Health Plan has denied reimbursement for bilateral 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 patients case, she has breasts that were described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For these reasons, bilateral breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three physician reviewers have 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis. Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. However, in this case there were no problems to be resolved. The patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there have been no changes when compared to prior studies over nine years. Final Result: Two reviewers determined that the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: 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 authorization and coverage for wireless capsule endoscopy.  Findings:  Two physician reviewers found that in this case there is a concern that Crohns disease is affecting the small intestine and caused the patients obstruction.  However, Crohns disease is one possible cause for obstruction in this case, rather than the established cause.  Upper endoscopy would reach minimally into the small intestine, not deep enough to evaluate a jejunal or ileal stricture, and colonoscopy did not find a stenosis that would cause a bowel obstruction.  Wireless capsule endoscopy evaluates the small intestine and has proven useful for detection of occult 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.  The use of a patency capsule  is beneficial in patients with risk for bowel obstruction due to the capsule, as in this case of a patient with prior obstruction.  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 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 Harvoni 90/400 for treatment of the enrollees hepatitis C virus. 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 90/400 tablets for eight weeks is 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.
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 is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. This particular patient was noted to have breasts that are heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically this subset of 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 addition, the findings of nodules and cysts seen on the whole breast automated sonogram can be further evaluated by tomosynthesis, though, as in this patient, a targeted sonogram is also of value. Thus, in this clinical setting, the use of 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.