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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fractional laser resurfacing for treatment of the enrollees scarring. Findings:  The physician reviewer found that this patients scarring constitute an abnormal condition of the body.  Hypertrophic scars are considered to be abnormal wound healing responses to trauma or infection.  In this patients case, the hypertrophic scars resulted from persistent cystic acne, non-healing abscesses and surgical interventions to correct the inflammatory conditions.  The requested procedure is being performed to create a normal appearance to the best extent possible.  There is no documentation of any potential functional benefit.  However, the requested services are not likely to provide more than a minimal improvement in the appearance of the patient.  As the requested services are not expected to provide a functional benefit or more than a minimal improvement in the appearance of the patient, the requested fractional laser resurfacing is not reconstructive in nature.  All told, the requested services are not reconstructive in nature and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not reconstructive in nature and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  Physician reviewer number one 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 acupuncture.  Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  This patient has had acupuncture in the past which was beneficial in reducing his symptoms.  Therefore, since he was symptomatic, the patients provider recommended additional acupuncture.  The current medical evidence supports additional acupuncture treatment in this patients case.  Trinh and colleagues noted there is strong evidence suggesting that acupuncture is effective in the short-term relief of lateral epicondyle pain.  According to a study, studies suggest that acupuncture is more effective than sham acupuncture.  Final Result: The reviewers 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: Experimental/Investigational
Decision: Overturned 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 breast cancer screening. Findings:  The 3 physician reviewers found that the breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the diagnostic procedure at issue in this clinical setting. The study by colleagues assessed cancer detection rates, false-positive rates, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis in a large prospective screening trial. The authors reported that Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. The authors concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Given the diagnostic procedure at issue was 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 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: 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing performed for evaluation of the enrollees thyroid nodule. Findings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma Gene Expression Classifier testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. 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 physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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:  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 did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. 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. Given these findings, 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

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:  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. This 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 the 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, 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: 2/3 of 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: 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that there is sufficient support in the peer-reviewed literature for the diagnostic procedure at issue in this clinical setting. Colleagues performed a large prospective screening trial To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis. The authors concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Given the support in the medical literature, 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: 2/3 of 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: 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) treatments provided for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that TMS is a non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association (APA) for the treatment of acute phase depression in the adult population. A typical treatment course of TMS consists of 30 to 40 sessions spanning four to six weeks. Despite the findings from the articles referenced in the providers appeal letter, a group of TMS proponents arrived at a different conclusion regarding duration of care. According to colleagues The standard parameter setprovided clinical benefit in treatment courses up to 6 weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. The article did suggest that an extended treatment course of one to two weeks may be appropriate for patients who experience only partial improvement and the clinician believes that a clear plateau of benefit has not been obtained. However, based on a starting date, the patient had already received this treatment. There is a lack of adequately powered, controlled studies showing the benefit of longer courses of TMS therapy. Thus, the medical evidence does not support a reasonable expectation that additional TMS therapy as would have improved the patients condition or prevented a more serious episode of illness.  Further, the medical records failed to demonstrate that standard psychopharmaceutical strategies and non-pharmacologic interventions had been exhausted in this case. Thus, TMS services in dispute were not medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer number one 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 the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. Tomosynthesis allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in an increase in accuracy, increase in detection of small cancers and decrease in callbacks compared to when imaging is done using the two-dimensional technique only. Thus, the digital tomosynthesis was 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver related conditions. The guidelines recommend that treatment naive genotype 1b patients should be treated with Zepatier. These guideline recommendations are based on high-quality clinical trials. Per the AASLD/IDSA guidelines, they cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C with Zepatier 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 authorization and coverage for Mohs surgery for treatment of the enrollee who was diagnosed with a nodular basal cell carcinoma. Findings:  The physician reviewer found that there is support in the medical literature for the requested procedure in this clinical setting. The patient requested Mohs surgery for the treatment of a basal cell carcinoma which is located on the left side of her nose.  The guidelines indicate that Mohs surgery is recommended for treatment of basal cell carcinoma involving the head and neck, irrespective of the size of the lesion. The size of the biopsy specimen is not necessarily related to the size of the lesion. The pathology specimen was 2 mm (after shrinkage which occurs in the skin once removed from the body). The clinical record indicates that the lesion is 7 mm in size and not 2 mm in size.  Additionally, the location of the lesion is complicated because it is located in the alar groove. Given the diagnosis and location of the lesion, the recommended treatment for complete removal of this tumor is Mohs micrographic surgery. Therefore, the requested Mohs surgery is medically necessary for the treatment of this patients medical condition. 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 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.