Persius/hicric huggingface dataset:
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 breast cancer in the right breast. Three physician reviewers found that in the medical literature, Skaane and colleagues reported that 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. Thus, the literature does support the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate when used with standard mammographic imaging. Given these findings, 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 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 reimbursement for breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that in this patients case, the services at issue were likely to have been superior over other methods of evaluation.  Breast tomosynthesis has gained acceptance among radiologists due to a significant decrease in callbacks and increased detection of small cancers.  In a patient with heterogeneously dense breast tissue who is status post lumpectomy, as in this case, the technique is of added benefit due to the tomographic capability which helps to separate normal postoperative changes from potential cancer recurrence.  All told, breast tomosynthesis was likely to have been of greater benefit than other available modalities.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested BRCA1 and BRCA2 genetic testing for evaluation of her medical condition.  Three physician reviewers found that the requested testing is not likely to be more effective for this patient than other available options. The National Comprehensive Cancer Network (NCCN) guidelines state that testing criteria includes an Individual from a family with a known deleterious BRCA1/BRCA2 mutation. In this case, there is no documented family history of a known deleterious BRCA1/BRCA2 mutation or that her family members breast cancer was triple negative. There is also not a personal history of breast cancer. Thus, BRCA1 and BRCA2 genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result:  Three reviewers determined that the requested testing 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  Two reviewers are board certified 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bronchial thermoplasty for treatment of her chronic asthma.  Two physician reviewers found that bronchial thermoplasty is not generally accepted as the standard of care for the treatment of asthma. Thomson and colleagues studied the safety of bronchial thermoplasty and found that there was no difference in forced expiratory volume in 1 second (FEV1), emergency room (ER) visits or admissions between the bronchial thermoplasty group and the control group. Also, the clinical trial by Castro and colleagues evaluated the effectiveness and safety of bronchial thermoplasty versus a sham procedure in subjects with severe asthma who remain symptomatic despite treatment with high-dose inhaled corticosteroids and long-acting beta-agonists. In this trial there were 190 patients in the bronchial thermoplasty group and 98 patients in the sham group. The therapeutic effect of sham group was similar to bronchial thermoplasty. Actually, if you include adjustment for the patients who dropped out of the study before one year, the sham placebo group did better than the bronchial thermoplasty group. There was no adjustment for the greater number of the bronchial thermoplasty treated patients dropping out before one year compared to the sham group. In sum, there is a lack of support in the medical literature that the use bronchial thermoplasty would improve the long term functional outcome of the patients condition. All told, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 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 reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease 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 Subsys (fentanyl sublingual spray) for treatment of his chronic pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  The medical literature reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  The medical literature reported that prolonged use of high-dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, the requested Subsys (fentanyl sublingual spray) 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested a one-on-one visit with a nutrition specialist for medical treatment of her diabetes. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  This patient has a high BMI and has type 2 diabetes mellitus.  Lifestyle interventions and medical nutritional therapy are essential cornerstones of diabetes management.  It is standard of care that obese patients with diabetes be referred to individualized medical nutritional therapy as part of diabetes self-management education, especially if they have been unsuccessful in losing weight.  A patient with morbid obesity requires individualized medical nutritional therapy.  A weight loss of 5% or greater may have significant effect in the outcomes and improvement of diabetes and blood pressure control.  All told, the requested one-on-one visit with a nutrition specialist is medically indicated for the treatment of this patient.Final Result: The reviewer 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: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 requested Xiaflex for medical treatment of his Peyronies disease.   Findings:  The physician reviewer found that Xiaflex has been shown to have modest efficacy in clinical trials and is U.S. Food and Drug Administration (FDA) approved for use in patients with Peyronies disease with at least 30 degrees of curvature and a palpable plaque. In addition,  Xiaflex is the only FDA approved drug for Peyronies disease. This patient has failed conservative therapy and has or exceeds the other requirements for treatment with Xiaflex.  All told, the requested Xiaflex is supported as medically necessary for treatment of this patients Peyronies disease. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested cervical disc replacement (discectomy and arthroplasty) for medical treatment of her medical condition.  Findings:  Two physician reviewers found that in this case, the requested services are not likely to be more effective than other treatment options.  Cervical total disc replacement has been increasingly used as an alternative to fusion surgery in patients with pain or neurological symptoms in the cervical spine who did not respond to nonsurgical treatment.  Although the available data shows promising results, it is not currently considered to be the standard of care for the treatment of cervical degenerative disorders.  In this case, there is no indication that the patient has completed all conservative treatments prior to the request for surgical intervention.  Therefore, per the peer-reviewed literature, the requested cervical disc replacement (discectomy and arthroplasty) would not be more beneficial for treatment of the patients medical conditions than any other available standard therapy.  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: Reviewers 1, 2, and 3 are board certified in orthopedic surgery and is actively practicing. The reviewers are 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 requested Xiaflex (clostridial collagenase histolyticum) injections for treatment of his Peyronies disease.  Findings:  The physician reviewer found that the current medical evidence supports Xiaflex in this clinical setting.  This patients condition has a psychosocial impact and affects his well-being and quality of life.  The use of Xiaflex is standard of care for the treatment of this condition.  All told, the requested Xiaflex injections are medically indicated for the treatment of this patient. 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 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 three dimensional (3D) breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Three reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited. All told, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that in this patients case, the superior efficacy of the services at issue has not been established.  There is a lack of peer-reviewed literature that supports the use of digital breast tomosynthesis compared to currently available techniques in this clinical setting.  Although breast tomosynthesis may be a promising technique, its superior clinical efficacy has not been substantiated in the peer-reviewed literature.  Therefore, digital breast tomosynthesis was not likely to have been superior over other methods of evaluation.  Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested partial hospitalization level of care for treatment of the enrollees behavioral health conditions.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was ruminative regarding suicidal ideation but without intent or plan.  Thus, her suicidal ideation was passive in nature.  She was not functionally impaired and did not have medical comorbidity.  Her psychiatric diagnoses were unchanged, as was her medication regimen, and she suffered no side effects.  Her recovery environment was moderately stressful in that she was still exposed to a social circle of friends who were active substance users.  The patients family participated in family sessions and her mother actively worked with her on her treatment plan.  She had a moderate response to treatment, and was beginning to recognize the need to develop internal motivation, recognize triggers, and avoid substance using friends and associated situations.  Overall, she no longer needed the structure of partial hospitalization program level of care.  All told, partial hospitalization level of care was not medically indicated for the treatment of this patient.  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 child and adolescent 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 Harvoni for treatment of his chronic hepatitis C virus genotype 1a. Findings: Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Therefore, the requested Harvoni is supported as medically necessary for treatment of this patients chronic hepatitis C virus.  Final Result: Two reviewers 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 three 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 an oral appliance for treatment of his obstructive sleep apnea.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested device in this patients case.  An oral appliance is an appropriate therapy for patients with mild obstructive sleep apnea.  There is sufficient support for an oral appliance in this clinical setting.  The requested device is an appropriate treatment for this patient.  All told, the requested oral appliance is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested device 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 pulmonary disease and sleep 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.