Persius/hicric huggingface dataset:
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 her risk for breast cancer with previous abnormal screening mammogram. 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 medically necessary for evaluation of the patients medical condition. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Three 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. Given this support, the requested 12 week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.   Final Result: Three 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. 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 Soma, Norco 10 mg, cough syrup with codeine and Ativan 10 mg for treatment of her knee pain and migraine headaches. The physician reviewer found that the requested medications are not medically necessary for treatment of the patients medical conditions. In this case, the patient presents with chronic low back pain, shoulder pain, knee pain and headaches. The patient also has a diagnosis of bipolar disorder including recent substance abuse and manic episodes. According to the documentation submitted for review, the patient has been non-compliant in psychological treatments and tested positive for methamphetamine, cocaine, and marijuana. In addition, the medications in question are notable for the fact that all of the requested medications are Schedule II or III medications. Based on the documentation submitted for review, given the patients recent substance abuse, manic episodes and non-compliance of me psychological treatments the requested medications are not medically necessary. Final Result: The reviewer determined that the requested medications 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested fistula plug surgery for treatment of her anal fistula. Two physician reviewers found that while placement of an anal fistula plug is an accepted U.S. Food and Drug Administration (FDA) approved option in the management of complex fistula-in-ano as a second-stage procedure, it is not more likely to be successful than other surgical procedures. Currently, most studies reveal a success rate of 20-40%. The ligation of intersphincteric fistula tract (LIFT) or mucosal advancement flap (MAF) procedures are both safe procedures and have a higher rate of long-term success reported at 60-90%. Thus, the requested fistula plug surgery is not likely to be more beneficial than the LIFT or MAF procedures in treating this patients medical condition.  Final Result: Two reviewers determined that the requested surgery 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: One reviewer is board certified in general surgery with sub-specialty certification in colon and rectal surgery and is actively practicing. One reviewer is board certified in general surgery and is actively practicing.  One reviewer is board certified in general surgery and critical care surgery and is 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 epidural steroid injections for treatment of her back pain.  Three physician reviewers found that criteria for the use of epidural steroid injections indicates that radiculopathy be documented by physical examination and corroborated by imaging studies and/or electrodiagnostic testing. In this case, there are no reported symptoms of radicular pain which is defined as pain in dermatomal distribution. There are no long tract signs that suggest thoracic myelopathy. There is also no electrodiagnostic testing reported and imaging findings do not describe neural compromise that would corroborate a diagnosis of thoracic radiculopathy. For the reasons provided, the requested thoracic epidural steroid injections are 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 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: One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in spinal cord injury and pain medicine and is actively practicing. One reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing.  One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is 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 risk for breast cancer.  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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for eight weeks for treatment of her hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The requested medication is likely to prevent further development of fibrosis and prevent potential complications of advanced liver disease.  Therefore, Harvoni for eight weeks is medically indicated for the treatment of this patient. 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. 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 the Prostatic Urethral Lift for treatment of his benign prostatic hyperplasia (BPH).  Two physician reviewers found that although UroLift received U.S. Food and Drug Administration (FDA) approval, long-term studies and comparative studies with transurethral resection of the prostate (TURP) have not been completed. It is unlikely that the UroLift procedure will provide sufficient relief in this patient with such severe obstruction. All told, the requested Prostatic Urethral Lift is 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: 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested incontinence supplies (disposable liners, reusable underpants and large disposable under pads) for treatment of her urinary incontinence.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. According to the documentation submitted for review, the patient presents with a symptom-based diagnosis of stress incontinence. The documentation submitted does not include a detailed work-up or evaluation of urinary incontinence. In addition, there is no documentation to support the cause of incontinence. Thus, the request for incontinence supplies (disposable liners, reusable underpants and large disposable under pads) is not medically necessary for treatment of the patients medical condition. 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 12 week course of Harvoni for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that Harvoni is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic hepatitis C genotype 1 infection in adults. It was reported that Harvoni was associated with a high rate of sustained virologic response among previously untreated patients with hepatitis C virus genotype 1 infection without cirrhosis. Given the current medical literature, the requested 12 week course of Harvoni is medically necessary for this patient status post liver transplant. Final Result: Three 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. 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 water circulating cold pad with pump (CPT E0218) for treatment of his medical condition.  The physician reviewer found that the patient underwent left knee arthroscopy with extensive tricompartmental debridement, partial medial and lateral meniscectomies, and patellofemoral chondroplasty.  Evidence-based medical guidelines and peer-reviewed literature generally support the use of cryotherapy in the postoperative period following knee arthroscopic surgery.  However, there is a lack of large volume, long-term studies evidencing significant overall outcome differences with regards to continuous flow cryotherapy versus standard cold packs, in surgeries of this type. Therefore, the water circulating cold pad and pump was not likely to have been more beneficial for the treatment of the patients medical condition than standard cold packs. Final Result: Three reviewers determined that the device at issue was 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the water circulating cold pad with pump (CPT code E0218) for treatment of the enrollees knee pain status post total knee arthroplasty.  Three physician reviewers found that cooling is commonly recommended after surgery to diminish pain and swelling, but can be accomplished with readily available materials such as a bag of ice. Currently, there is a lack of scientific evidence of improved functional outcomes with the use of commercial cooling units and as a result, such units are not included in evidence based treatment algorithms. Adie and colleagues conducted a systematic review and concluded there is insufficient evidence of benefit to recommend the use of commercial cooling units after knee replacement surgery. Su and colleagues found a paucity of data demonstrating functional benefit of a cryopneumatic device after knee arthroplasty. All told, there is a lack of scientific evidence to support the use of commercial cooling units after knee arthroplasty and no evidence the use of such devices improve patient outcomes. Thus, the water circulating cold pad with pump (CPT code E0218) was 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 device at issue was 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  The proposed treatment is considered the standard of care for the treatment of the patients with hepatitis C, genotype 1 infection.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic hepatitis C should be treated with antiviral therapy regardless of fibrosis score.  The medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient.  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.  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 risk for breast cancer.  Three physician 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested authorization and coverage an ear, nose and throat (ENT) consultation (CPT code 99243) for treatment of her temporomandibular joint (TMJ) syndrome.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested service. According to the documentation submitted for review, the patient presents with TMJ dysfunction. The American Association of Oral and Maxillofacial Surgeons (AAOMS) indicate that conservative therapy is the mainstay in treating TMJ pain and disorders. Per AAOMS conservative therapy includes behavioral change, oral medications for pain, anti-inflammatory injections, and orthotic devices. In this clinical setting, standard non-surgical treatments and an assessment of treatment outcomes are indicated prior to a referral to an ENT specialist. Therefore, the request for an ENT consultation (CPT code 99243) is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 otolaryngology and head and neck 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.