Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation with an orthopedic surgeon for evaluation of the enrollees left knee and right hip pain. Findings: The physician reviewer found that based on the available documentation, the requested consultation with an orthopedic surgeon is medically necessary and appropriate for further evaluation and treatment of this patients hip condition. The provider reports that the patient has longstanding symptoms interfering with daily activities and sleep despite routine symptomatic treatment including extensive independent exercise and stretching and supervised physical therapy as well as chiropractic care. Evaluation has included multiple sets of x-rays. With the presence of longstanding and limiting symptoms around a major joint, consultation with an orthopedic surgeon after failure of initial treatment directed by the primary care provider is medically necessary and appropriate. Final Result: The reviewer determined that the referral is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an male enrollee has requested authorization and coverage for circumcision for treatment of the enrollee, who presented for circumcision. Findings:  The physician reviewer found that the American Academy of Pediatrics (AAP) recently published a policy statement regarding circumcision, supporting the procedure. The AAP has determined that the benefits of circumcision outweigh the risk, recommending circumcision for any neonatal infant in whom there are no medical contraindications, accept for family preference. The Center for Disease Control (CDC) has taken this stance even further, recommending discussion with adolescent and adult men regarding benefits and risks of circumcision surgery. The benefits include prevention of urinary tract infection, acquisition of human immunodeficiency virus, transmission of some sexually transmitted infections, and penile cancer. Based on these current recommendations, circumcision should no longer be considered a cosmetic procedure after the neonatal period. Instead, the current medical literature supports this procedure as medically necessary and appropriate for infants. Therefore, based on current evidence, circumcision is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested procedure 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 pediatrics with sub-specialty certification in pediatric critical care 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 authorization and coverage for Sovaldi and Daklinza for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. In treatment naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based on the ALLY-3 study for Sovaldi and Daklinza which showed a cure rate of 97%. Delay in treatment may result in decreased survival. For these reasons, Sovaldi and Daklinza for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen 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 reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Two physician reviewers found that in a medical literature, the researchers found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: The 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: The 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for 12 weeks. 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. The guidelines recommend that non-cirrhotic genotype 1a patients who have failed peg-interferon and ribavirin should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 94% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a dermatology consultation for evaluation of the enrollees rosacea. Findings:  The physician reviewer found that Rosacea is a common chronic inflammatory disorder of the facial skin characterized by periods of exacerbation, remission and possible progression. The major subtypes include erythemato-telangiectatic rosacea and papular-pustular rosacea. Individual subtypes are likely a result of different pathogenic factors and respond best to different therapeutic regimens. Rosacea is a polymorphic disease precipitated by many causes including genetic, vascular, immune-mediated, emotional, environmental, and infectious factors. The non-pharmacologic approach to therapy is adequate skin care, trigger avoidance and photo-protection. In addition, there are several topical, herbal, systemic and light based therapies available. Since biopsy of a typical untreated lesion may be required to differentiate rosacea from seborrheic dermatitis, the referral to a dermatologist was appropriate. Final Result: The reviewer determined that the service at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology 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 authorization and coverage for Viekira Pak for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  This recommendation applies regardless of fibrosis stage.  Per the guidelines, treatment-naive, genotype 1b patients should be treated with Viekira Pak for 12 weeks.  This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and safety.  This medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.F inal Result: The reviewer determined that the requested medication regimen 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 reimbursement for breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Two physician reviewers found that this revealed no evidence of cancer.  The Health Plan has denied reimbursement for breast tomosynthesis. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. 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 for evaluation of the enrollees risk for breast cancer. Findings:  Two physician reviewers found that digital 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, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved since the patient does not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. A routine mammogram would have been sufficient. 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 has been no change when compared to multiple prior mammograms. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent for treatment of the enrollees dyslipidemiaFindings:  The physician reviewer found that this patient has marked elevation of cholesterol and LDL, which is consistent with heterozygous familial hypercholesterolemia. Treatment with statins has not been tolerated and has not been effective in lowering the patients cholesterol to a goal level. The U.S. Food and Drug Administration (FDA) approval recommends Praluent as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease, who require additional lowering of LDL cholesterol. Due to the high baseline of this patients LDL, the patient has a genetic disorder and would likely benefit from use of Praluent. 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 cardiovascular 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. 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, by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, the presence of breast implants is not an indication for tomosynthesis. However, she has breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically this type of patient with 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. Final Result: The 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: Reviewers 1, 2 and 3 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 reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. 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, by separating the various layers of breast tissue, one can better detect abnormalities. This patient has breasts that have been described as being dense. It is specifically this type of patient with 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. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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 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 reimbursement for 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, the records document dense breast tissue.  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. Thus, digital breast tomosynthesis was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. 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 reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Three physician reviewers found that the enrollee was asymptomatic with respect to her breasts.  She has a history of having had a prior cyst aspiration of her left breast, and a core biopsy of her right breast.  She also has a family history of breast cancer in her mother.  The current images were compared to prior mammograms, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breast tissue was described as dense.  The Health Plan has denied reimbursement for digital breast tomosynthesis. 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, the records document dense breast tissue.  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.  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.