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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast cancer index testing for evaluation of her breast cancer.   Two physician reviewers found that hormone receptor-positive breast cancer responds to adjuvant anti-estrogen therapies such as aromatase inhibitors and tamoxifen.  These drugs are usually administered for five years after mastectomy.  However, patients are at risk for recurrence at about 2% per year, nearly 15 years after diagnosis and initial surgical resection.  Thus, a biomarker may help providers identify those patients at higher risk, making them candidates for extended anti-estrogen therapy.  The breast cancer index is a gene expression test that generates a risk for five-year recurrence.  The test was studied retrospectively on paraffin embedded material from patients on the TransATAC study. In this well-controlled clinical study, the breast cancer index was a good prognostic marker of breast cancer recurrence and performed better than the Oncotype DX gene expression test.  Therefore, breast cancer index testing was likely to have been more effective than other methods of evaluating this patient.   Final Result: Two 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:   One reviewer is board certified in internal medicine and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a sleep study for evaluation of her medical condition.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The purpose of a CPAP titration study is to determine the optimal setting of CPAP treatment for those patients who have met criteria for treatment with CPAP.  The diagnostic study in the patients record had a normal apnea-hypopnea index.  The usual criteria for treatment with CPAP include an apnea-hypopnea index of 15 or greater.  In this patients case, her apnea-hypopnea index was 3.8, which is normal.  For patients with heart disease or hypertension, the criteria for CPAP include an apnea-hypopnea index of 5 or greater.  This patient did not meet standard criteria for the medical necessity for CPAP.  Therefore, a sleep study was not medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested testing for drug metabolism for evaluation of her medical condition.  Three physician reviewers found that the current medical evidence does not support the services at issue in this clinical setting.  There is a lack of clinical benefit for genetic testing for drug metabolism in this patients case.  The patient is not being prescribed medications with a narrow therapeutic dose range, and her response in terms of adverse effects can be monitored in the clinical setting.  All told, the superior efficacy of genetic testing for drug metabolism has not been established.  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 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 specialized thyroid gene testing for evaluation of her thyroid follicular lesion. Two physician reviewers found that since the chances of cancer in this patients category was 10-30%, it was reasonable to submit the specimen for genetic analysis. The National Comprehensive Cancer Network (NCCN) guidelines support the Afirma Fine Needle Aspiration (FNA) genetic analysis as one option for immediate genetic testing in this clinical setting. The testing allows the patient and provider to be reassured regarding the patients chance of malignancy. If the result had been suspicious, the chances of malignancy would support an indication for surgery. Thus, the specialized thyroid gene testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two 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: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in endocrinology and metabolism 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 provided during a colonoscopy for evaluation of her abdominal pain, diaphoresis, and loose stools.   The physician reviewer found that this patients records do not document any of the serious risk factors or medical conditions that would warrant monitored anesthesia care. There is no evidence of serious airway issue, cardiopulmonary disease, craniofacial issue, or evidence of high dose opioid use that would necessitate anesthesia as opposed to conscious sedation. All told, monitored anesthesia care provided during a colonoscopy was not medically necessary for evaluation of this 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 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 12 weeks for treatment of her chronic hepatitis C virus genotype 1b.  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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. In treatment naive genotype 1 patients, therapy is recommended with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Additionally, treatment of patients before they progress to cirrhosis is advantageous. Lower sustained virologic response rate has been reported with Harvoni in patients with cirrhosis. Treatment with Harvoni resulted in a 66% reduction of overall liver disease related complications when patients were treated at fibrosis score F2 versus F3-F4, and 82% reduction in complications with treatment at F0-F1. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, the requested Harvoni for 12 weeks is medically necessary for treatment of this patients medical condition.  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 Harvoni for 12 weeks for treatment of her chronic hepatitis C virus genotype 1a.  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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage. Patients without cirrhosis who have failed prior therapy with interferon regimens are recommended to be re-treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. In the ION-2 trial, non-cirrhotic patients who had failed peginterferon regimens demonstrated 94% sustained virologic response with Harvoni. Additionally, treatment of patients before they progress to cirrhosis is advantageous. A prospective study of 820 F0-F1 patients reported 93% 15-year survival in treated F0-F1 patients versus 88% in untreated patients. This patient is ineligible for alternatives that require high daily pill count due to pill dysphagia. For these reasons, the requested Harvoni 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 acupuncture for treatment of her lower back pain. The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Acupuncture is recommended as an option for chronic low back pain using a short course of treatment in conjunction with other interventions. Acupuncture has also been found to be more effective than no treatment for short-term pain relief in chronic low back pain ). According to the documentation submitted for review, the patient has not been treated with an acupuncture trial for her chronic lower back pain. Given the patients continued severe symptoms despite previous treatments including multiple surgeries, multiple injections, oral medication and self-care the requested services are supported by the peer review literature as medically necessary. Based on the reasons provided, acupuncture is medically necessary for treatment of the patients chronic low back pain. 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 oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested  Nuvigil for treatment of her fatigue associated with multiple sclerosis.  The physician reviewer found that Nuvigil is widely used by MS specialists to combat MS related fatigue. These drugs enhance alertness and in some patients improve MS related fatigue. Providers that treat MS use a variety of stimulants including various amphetamines, Ritalin, and Nuvigil. While the literature is mixed, the use of Nuvigil is supported in the peer-reviewed literature. Lange and colleagues investigated the effects of modafinil on focused attention, motor function and motor excitability in patients MS and fatigue. The authors found that compared to placebo, modafinil improved fatigue, focused attention and dexterity and enhanced motor cortex excitability. The authors concluded that modafinil may be helpful in MS patients with fatigue to improve cognitive and motor abilities. Given that the patient has tried and failed multiple other stimulants, Nuvigil is medically necessary in this clinical setting.   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 neurology 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 chiropractic services for treatment of her neck, hip, and back problems.  The physician reviewer found that the records indicate that this patient had an eight visit trial of chiropractic treatment. However, the submitted records for treatments in dispute do not document any type of subjective or functional improvement as a result of treatment. Chiropractic care may be appropriate after a trial of treatments based on documented improvement. Further, the provider has submitted diagnoses that are mild and should not require extensive treatment. Thus, the patient could have been well managed with the eight authorized visits over two months and should not require additional treatment. The provider has not documented any flare-ups or comorbidities that would justify continued treatment. For these reasons, the requested chiropractic services were not and are not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the services at issue were not and 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 chiropractic and oriental 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her breast cancer. Three 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, 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 the dense breast. Helvie noted that breast tomosynthesis technology has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies. Rafferty and colleagues concluded that, addition of tomosynthesis to digital mammography offers the dual benefit of significantly increased diagnostic accuracy and significantly reduced recall rates for noncancer cases. All told, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a clinical chemistry test for evaluation of her medical condition.  Three physician reviewers found that there is a lack of support for the services at issue in this patients case.  In the setting of worsening disease while on biologic therapy, there is a lack of controlled data supporting that testing for biologic drug levels is superior to good clinical judgment.  In this patient who is having a complication from her disease, a decision needs to be made using available clinical data including endoscopic and radiologic data.  An empiric increase in Humira to weekly can be tried if the flare is thought to be from increased inflammatory activity.  All told, a clinical chemistry test was not likely to have been of greater benefit than other available modalities. 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 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 digital breast tomosynthesis for evaluation of her fibrocystic breasts.  Two 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. Thus, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result:  Two 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 chiropractic for treatment of her myospasm, dorsal segment dysfunction, and rib subluxation.   The physician reviewer found that the records indicate that this patient has had extensive chiropractic treatment. The records from the patients chiropractic visits do not include documentation and examination findings that support the medical necessity of ongoing chiropractic treatment. There are no objective measures of improvement. In addition, the provider has submitted diagnoses that are mild and should not require extensive treatment and could have been well managed with the approved visits over two months. Chiropractic care is medically necessary after a trial of treatments based on documented improvement. When further clinical improvement cannot be reasonably expected and treatment becomes supportive rather than corrective in nature then the treatment is considered maintenance therapy. Given these findings, the chiropractic services were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 chiropractic and oriental 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.