Persius/hicric huggingface dataset:
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 performed for evaluation of the enrollee, who was asymptomatic. Findings:  The 3 physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  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 compared to two-dimensional imaging alone.  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 3 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollees risk for breast cancer. Findings:  2/3 of the 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. 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. The 2D images were reconstructed from the primary tomosynthesis acquisition, thus 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 over 12 years. For these reasons, 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: 2/3 of the reviewers determined that the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for bilateral breast tomosynthesis performed. Findings:  The physician reviewer found that the patient reported a family history of breast cancer. The patient underwent a routine screening mammogram consisting of a synthetically reconstructed two dimensional views with three dimensional tomosynthesis study. 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 breasts were described as being dense. 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 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 particular patient, the patients breast tissue was described as being dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense tissue that can benefit most from digital breast 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. board certified in diagnostic radiology and is actively practicing. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400 mg-100 mg for 24 weeks, in combination with ribavirin for treatment of the enrollees hepatitis C virus (HCV). Findings:  The physician reviewer found that according to 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 nonliver-related conditions. The guidelines state that patients with liver transplant are highest priority for treatment. In genotype 3 patients who have had a liver transplant, therapy is recommended with Sovaldi, Daklinza, and ribavirin for 12 weeks or Sovaldi and Daklinza for 24 weeks. This is based on the ALLY-1 study, which showed a high cure rate in liver transplant patients, and other studies showing high cure rates.  However, the guidelines also state that Epclusa is never recommended in liver transplant patients, stating that based on the lack of real-world experience of the pharmacokinetics of sofosbuvir/velpatasvir in liver-transplant recipients and because alternatives with similar projected efficacy are available for which interactions with immunosuppression agents have been reported, we do not recommend the use of velpatasvir in transplant recipients at this time. Final Result: The reviewer determined that the requested medication regimen 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 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 authorization and coverage for BRCA1 and BRCA2 sequence and deletion/duplication for evaluation of the enrollees risk of breast cancer. Findings:  The 3 physician reviewer found that the patient with a history of an ovarian polyp and right partial breast surgery for a benign radial scar. Her maternal grandparent had leukemia. Her parents have a history of colonic polyps. Her sister had a non-melanomatous skin cancer. The patient has requested authorization and coverage for BRCA1 and BRCA2 sequence and deletion/duplication. The Health Plan has denied this request as investigational. Per the National Comprehensive Cancer Network (NCCN) guidelines BRCA testing is indicated for an individual that has a personal history of any neoplasm, and has a first, second or third degree relative with breast, ovarian, pancreas or prostate cancer. The patient fails to meet this criteria. In addition, the U.S. Preventative Services Task Force recommend against routine testing unless there is a family history breast, ovarian, tubal or peritoneal cancer. For the reasons provided, the request for BRCA1 and BRCA2 sequence and deletion/duplication is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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 digital breast tomosynthesis for the enrollees breast cancer screening. Findings:  The 3 physician reviewers found that the patient was asymptomatic with respect to her breasts.  She underwent a routine screening mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination. The current images were compared to a prior mammogram and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as being heterogeneously dense. The Health Plan has denied coverage for the digital breast tomosynthesis portion of the examination, stating that digital breast tomosynthesis was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography 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 particular patient, her breast tissue was described as heterogeneously dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, digital breast tomosynthesis was likely to have been of greater benefit than other modalities for evaluation of this patient. Final Result: The 3 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for hypoglossal nerve stimulator surgery. Findings:  The physician reviewer found that the patienthas a history of obstructive sleep apnea (OSA). He was treated with continuous positive airway pressure (CPAP) but he became intolerant to the therapy. The patient reported daytime somnolence. The patients provider recommended a surgical implantation of hypoglossal nerve stimulator. The Health Plan denied the requested services as investigational for the treatment of this patient. The hypoglossal nerve stimulator can be an effective therapy for certain patients diagnosed with OSA. However, in this patients case, the procedure is not likely to be superior to other methods of treatment for his medical condition. Although this patient has failed CPAP therapy, there was no documentation of nonconcentric airway collapse confirmed by sleep endoscopy.  As such, while hypoglossal nerve stimulator can be effective therapy for certain OSA patients, the requested services are not effective for this patient. Therefore, the requested hypoglossal nerve stimulator is not likely to be superior to other available modalities for treatment of this patient. Final Result: The 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 physician reviewers are board certified in otolaryngology and 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 Synvisc injection of the left knee for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  Evidence-based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  Viscosupplementation has been found to be safe and effective and allow for delay of knee replacement.  In this case, the patient presents with debilitating left knee pain impairing her ability to walk and be active.  Clinical examination findings are consistent with radiographic evidence of left patellofemoral arthritis.  There is evidence of significant prior benefit with viscosupplementation that allowed for sustained improvement in her functional mobility.  She is currently not a surgical candidate. Therefore, the requested Synvisc injection of the left knee is medically necessary 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 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: An enrollee has requested authorization and coverage for Epclusa 400mg/100 mg and ribavirin 200 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus.Findings:  The physician reviewer found that according to 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 nonliver-related conditions. All patients should be treated, regardless of fibrosis stage.  Per the guidelines, in patients who have failed Sovaldi and ribavirin, treatment is recommended with Epclusa and ribavirin for 12 weeks, based on clinical studies. This applies regardless of the results of any resistance testing. Due to the patients prior severe side effects with ribavirin, this regimen is more appropriate than alternatives requiring longer duration of ribavirin treatment. Final Result: The reviewer determined that 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections in both knees for treatment of the enrollees knee pain. Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  Evidence-based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement.  In this case, the patient has been diagnosed with bilateral severe knee osteoarthritis.  He presented with worsening knee pain.  He has been treated with anti-inflammatory medications, with mild relief.  He has undergone prior series of Euflexxa injections, with reported significant sustained pain relief.  These injections have been recommended to delay total knee arthroplasty.  The medical evidence supports the requested services in this clinical setting.  All told, the requested Euflexxa injections are 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 physician 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: An enrollee has requested authorization and coverage for the medication Avastin used in combination with Cytoxan for treatment of the enrollees recurrent ovarian cancer. Findings:  The physician reviewer found that the medical literature supports the requested medical regimen in this clinical setting. The paclitaxel/platinum combination has proven to be better than single agent platinum therapy in several clinical trials and is considered the standard for patients who relapse. Phase II studies with Avastin have shown promise in patients with platinum-refractory disease, as in this patients case. Reviewing the case file and the impressions of the oncologist, it does not appear that the original course of Avastin was aborted due to tumor progression. There were other toxicities that were due to carboplatin. Thus, the medication regimen requested is medically indicated for this patient. Moreover, there is medical evidence supporting the use of Avastin for treatment of patients diagnosed with recurrent ovarian cancer. Avastin has been successfully combined with cyclophosphamide. Therefore, Avastin used in combination with Cytoxan is medically necessary for the treatment of this patient. 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-certification in hematology and medical oncology 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.