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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a gene analysis blood test for treatment of her medical condition. Findings:  Three physician reviewers found that the testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is a lack of peer-reviewed literature that demonstrates better outcomes of treatment or a clinically relevant change in planned treatment in a patient with known Factor V Leiden deficiency who is not pregnant and currently has no deep venous thrombosis or other hematological problems. For the reasons provided, the services at issue were 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 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:   One reviewer is board certified in vascular and interventional radiology and is actively practicing. One reviewer is board certified in clinical genetics and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 proton beam radiation therapy for treatment of her medical condition. Findings: Three physician reviewers found that the requested services are not likely to be more beneficial for treatment of the patients medical condition than standard available therapies. The theoretical advantage of proton therapy is that it has a Bragg peak, resulting in decreased dose before and after the peak. This translates into a decrease in exposure of normal tissue in the low- to intermediate-dose range, but not in the high-dose range, in comparison with photons. Data is lacking on comparison with photon-based treatments. Phase I data showed similar local control rates, but worse cosmetic outcome with regards to long-term telangiectasia, skin color changes, and skin toxicities. Given the low overall clinical toxicity of breast radiation with photons, the improved dosimetry with protons has not yet been demonstrated to translate into decreased clinical side effect.  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 radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a liver transplant candidacy evaluation for treatment of her liver disease.  Findings:  The physician reviewer found that in order to be referred for liver transplant candidacy evaluation, an individual must be deemed eligible for liver transplantation. Thus, acceptance as a potential liver transplant candidate is essential to establish the medical necessity of the requested liver transplant candidacy evaluation, as the evaluation serves the purpose of determining whether a potentially good candidate for liver transplant remains fit for such after medical and psychosocial evaluation. In this patients case, she has been diagnosed with liver disease with documented recent drinking and subsequent hospitalization.  The patient has had alcoholic liver disease-related presentations previous to her most recent admission and has, per the record, failed to successfully abstain from alcohol through various treatment programs. Thus, the patient does not meet the entry criteria for liver transplant candidacy evaluation given evidence of continued alcohol use and failure to actively participate in an alcohol treatment program despite previous similar decompensation. These factors are considered a major contraindication for liver transplantation and evaluation for such. For the reasons stated above, the requested referral for a liver transplant candidacy evaluation 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 internal medicine with sub-specialty certification in gastroenterology and transplant hepatology 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 a Euflexxa injection for treatment of his shoulder pain. Findings:  Three physician reviewers found that evidence based medical guidelines and peer-reviewed literature do not support the use of hyaluronic acid injections, such as Euflexxa, for shoulder osteoarthritis. Kwon and colleagues conducted a randomized controlled trial and concluded that there was no statistically significant difference in outcomes comparing sodium hyaluronate injection with saline injection for glenohumeral osteoarthritis. This patient presents with chronic left shoulder pain and stiffness with functional difficulty in lifting and overhead activities. There is imaging evidence of severe shoulder osteoarthritis with humeral head deformity and large osteophytes. There is documentation that corticosteroid injection has failed to improve symptoms; however, detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure have not been submitted. There is no compelling evidence provided to support that this requested service is likely of more benefit than standard therapy. Therefore, in the absence of evidence based peer reviewed support, the requested services are 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 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 laboratory testing to measure serum levels of Remicade (infliximab) for treatment of her medical condition.  Findings:  Three physician reviewers found that the use of measure serum levels of infliximab to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear infliximab levels been established (Steenholdt, et al). Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing (Vande Casteele, et al). A systematic review reported that future prospective controlled studies are needed, especially considering anti-tumor necrosis factor (TNF) levels are influenced by several variables that can fluctuate over time and among individuals (Yarur, et al). Based on the clinical literature, the requested services remain controversial and have not been established as 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 services are 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 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 a Body Buoy specially designed custom body vest or functionally equivalent specially designed custom body vest for treatment of her medical condition.  Findings:  Three physician reviewers found that the medical evidence has not established the superior effectiveness of the requested equipment.  The Body Buoy serves as minimal posture corrector during sleep or during very active physical activities. There is a lack of evidence-based criteria to indicate that the Body Buoy improves pain or function in controlled studies.  Therefore, the requested equipment is not likely to be of greater benefit than other treatment options. Final Result: Three reviewers determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in neurology and are 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 continuous positive airway pressure (CPAP) equipment for treatment of her medical condition.   Findings:  The physician reviewer found that there is a lack of support for the requested equipment in this patients case.  There is no documentation that this patient has obstructive sleep apnea.  Also, daytime hypersomnia is a cornerstone of a diagnosis of suspected obstructive sleep apnea, and her Epworth Sleepiness score was normal.  All told, the requested CPAP is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 internal medicine with sub-specialty certification in pulmonary disease 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 a breast ultrasound for evaluation of her medical condition.  Findings:  The physician reviewer found that the request for a breast ultrasound has not been established as medically necessary for evaluation of the patients medical condition. Ultrasound to screen for breast cancer has been shown to be a valuable adjunct to mammography, especially in patients with dense breasts, which is not present in this case. A majority of the peer reviewed literature references the additive benefits, and does not support the use of ultrasound as the primary screening modality. As noted by Berg and colleagues The addition of screening ultrasound or [magnetic resonance imaging] MRI to mammography in women at increased risk of breast cancer resulted in not only a higher cancer detection yield but also an increase in false-positive findings. Chae and colleagues concur stating, Supplemental screening whole-breast sonography increases the cancer detection yield by 2.391 cancers per 1000 women with dense breast tissue over that of mammography alone. It is beneficial for increased detection of breast cancers that are predominantly small and node negative; however, it also raises the number of false-positive results. While screening ultrasound may mildly increase the number of cancers detected, there are numbers of false positives. In conclusion, while breast ultrasound is a useful adjunct to mammography, its diagnostic accuracy alone is relatively poor, and it is not recommended as a screening modality.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 her hepatitis C virus.  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. Per the guidelines, non-cirrhotic genotype 1 patients who have failed interferon-based therapy should be treated with Harvoni for 12 weeks; these guideline recommendations are based on multiple randomized clinical trials (Afdhal et al; Lawitz et al). AASLD/IDSA guidelines cite data showing decreased 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.
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 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, there has been an interval change in her right breast when compared to multiple prior mammograms.  Breast tomosynthesis has been shown to better separate out superimposed tissues.  Areas of architectural distortion may be a sign of an invasive carcinoma.  In this patients case, breast tomosynthesis is likely to have been superior over other methods of evaluating this patient. Final Result: Three reviewer 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 monitored anesthesia care (MAC) during a colonoscopy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. Colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with propofol. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. Given the above, the services at issue were not medically necessary for treatment of the patients medical condition. 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 anesthesiology with sub-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 advanced lipoprotein testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that per the submitted documentation, this patient had increased coronary risk but no documented history of coronary disease.  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, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, 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.  All told, advanced lipoprotein testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were 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 internal medicine with sub-specialty certification in cardiovascular 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 custom orthotics for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  There is a lack of support in evidence-based, peer-reviewed literature demonstrating the effectiveness of custom orthotics over pre-fabricated orthotics in the treatment of plantar fasciitis.  In this case, the patient has been prescribed a conservative treatment trial, including over-the-counter orthotics.  The medical records do not document that he has failed to improve with the use of pre-fabricated orthotics to support the medical necessity of custom orthotics at this time.  Therefore, the requested custom orthotics are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 orthopedic 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.