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 for the enrollees breast cancer screening. Findings:  Three physician reviewers found that the patient was asymptomatic with respect to her breasts. She underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breast tissue was described as heterogeneously dense. The patient requested reimbursement for digital breast tomosynthesis. The Health Plan denied reimbursement for digital breast tomosynthesis indicating that the service at issue 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.  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. Therefore, digital breast tomosynthesis performed was likely to have been of greater benefit than 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision Dx melanoma gene assay for evaluation of the enrollees melanoma of the left upper arm.Findings:  Three physician reviewers found that Decision Dx examines has shown some accuracy in thin melanomas like in this case. However, what to do with the results of the test are indeterminate at this point. The treatment of this patient would not change based on the results of the exam. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. There is a lack of medical literature to support its use in the care of patients with thin melanomas to effect health outcomes. Final Result: Three physician reviewers determined that the testing 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 physician reviewers are board certified in dermatology 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 breast cancer.Findings:  Two physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone.Final Result: Two 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services for treatment of the enrollees temporomandibular joint (TMJ) dysfunction. Findings: The physician reviewer found that a review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. There is peer-reviewed literature supporting the utility of acupuncture for the treatment of the patients medical condition. A study evaluated short-term pain reduction from acupuncture in chronic myofascial pain. The researchers concluded that Pain tolerance in the masticatory muscles increased significantly more with acupuncture than sham acupuncture. In addition, another study evaluated the effectiveness of acupuncture in treating symptoms associated with myofascial pain of the jaw muscles. The researchers found that a single acupuncture session significantly reduced most myofascial pain endpoints when compared to sham acupuncture. In this case, the patient has difficulty opening her mouth with jaw locking and limited jaw opening. She underwent treatment with muscle relaxers, steroids and physical therapy with limited improvement. Based on the support in the peer-reviewed literature and limited improvement with prior conservative treatment, acupuncture services are supported as medically necessary for treatment of the patients medical condition.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program (PHP) treatment provided from 3/14/16 through 4/8/16. Findings:  The physician reviewer found that upon presentation, the patient identified significant anxiety and depressive symptoms. It appeared that bereavement contributed to, if not fueled, this patients acute-on-chronic symptom complex. However, she had no suicidal ideation. There was no report of psychosis, aggressive behavior or prior treatment in a more restrictive level of care. There was no psychiatric evaluation or mental status examination. She had a supportive family.  She had a strong faith-based system. She had safe housing. She had many activities of interest. She was well-educated and had no substance use history.  In sum, the patient was not experiencing an acute psychiatric syndrome and her prognosis was good. However, the patient had failed treatment in the outpatient setting. Thus, a higher level of care at the time was reasonably expected to improve the patients condition and prevent a more serious episode of illness at the time. Considering the relevant variables, an intensive outpatient program (IOP) would have been safe and appropriate. 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 physician reviewer is board certified in psychiatry 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 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 breasts.  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 performed was likely to have been of greater benefit than other available methods of evaluation. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa 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 limited life expectancy due to non-liver-related conditions. Per the guidelines, Epclusa is recommended as first line therapy for treatment naive, genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa. These trials showed superiority of Epclusa to Sovaldi with ribavirin. Moreover, a delay in treatment may result in decreased survival. For these reasons, Epclusa 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the surgery performed by an out-of-network provider for treatment of the enrollees right upper lobe lung nodule suspicious for non-small cell lung cancer.Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. There is a lack of compelling evidence in the peer-reviewed literature to suggest robotic minimally invasive technique is superior to video-assisted thoracic surgical lobectomy. A study found that robotic lobectomy and wedge resection have longer operating times without any differences in adverse events. In this case, in-network providers were available to perform the procedure, including a minimally invasive procedure without utilizing the robotic technique. 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 physician revieweris board certified in thoracic 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an increased dosage of buprenorphine/naloxone to three tablets per day for treatment of the enrollee, who has a history of chronic lumbar spine. Findings: The physician reviewer found that the medical literature does not support the requested increased medication dosage in this clinical setting. Chronic pain that is unable to be cured can be considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in the documentation available for review, there are no clear objective functional goals for the requested dose escalation. Moreover, multiple minimal requirements to justify a dose escalation have not been performed.  For these reasons, an increased dosage of buprenorphine/naloxone to three tablets per day is not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication dosage 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 in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the cell function assay with stimulation blood test performed for evaluation of the enrollees dilated cardiomyopathy status post heart transplant. Findings:  2/3 of the physician reviewers found that based on the records provided, the patient is status post cardiac transplantation who is documented to be clinically stable. In this setting of prior cardiac transplantation periodic monitoring for rejection is reasonable, appropriate, and considered standard accepted practice in the medical community. Standard monitoring for rejection includes periodic clinical evaluation, periodic echocardiographic evaluation, periodic endomyocardial biopsy and/or gene expression profile testing in lieu of endomyocardial biopsy in stable patients. In this circumstance, additional monitoring with immune cell function assay testing has not been shown to be of incremental clinical outcome benefit in any adequately controlled trial. Current guidelines that are endorsed by several national organizations also do not recommend routine surveillance with immune cell function assay testing to assess cell mediated immunity in post heart transplantation recipients. For the reasons provided, cell function assay with stimulation blood test 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 testing 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 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.Physician reviewer number two 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.Physician reviewer number three 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 breast cancer screening. Findings:  Three physician reviewers found that tomosynthesis is rapidly becoming a standard tool in evaluating dense breasts or suspicious calcifications. In this case, the patient 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 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. Accordingly, 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 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 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 Epclusa for 12 weeks. 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. Patients with cirrhosis are high priority for treatment. This patient failed an eight week course of Viekira Pak, but that is not a recommended treatment course for genotype 6 hepatitis C. As a complete course of treatment has never been used, the patient should be considered treatment-naive. Per the guidelines, Epclusa is recommended as first-line for treatment-naive genotype 6 patients, based on the ASTRAL-1 trial clinical trial showing a 100% cure rate. For these reasons, the request for Epclusa 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.