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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Forteo for treatment of her medical condition.   Findings: The physician reviewer found that this patient has severe osteoporosis and is young for this condition. Her provider has noted concern with her very low bone mineral density and T-score at her age and has recommended an anabolic agent. Since the patients bone mineral density is in the severe osteoporotic range, and she has sustained fractures, the requested Forteo is medically necessary for treatment of the 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 endocrinology and metabolism 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 Zepatier for treatment of her hepatitis C.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load.  The current guidelines recommend that treatment-naive genotype 4 patients should be treated with Zepatier for 12 weeks.  The guidelines cite data showing decreased survival with delay in therapy.  All told, Zepatier is medically indicated for the treatment of this patient.  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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. In addition, 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 (Skaane, et al). Given the support above, 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that the problem of evaluating dense breasts or suspicious calcifications is a major issue faced by interpreting providers. In addition to the dilemma of evaluating dense breasts, there is a question of whether tomosynthesis is warranted in the general population as a screening tool. Friedewald and colleagues reported that the addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate. However, in this case, 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. 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 have been no changes when compared to prior studies without dense tissue that could obscure an abnormality. Thus, the addition of three dimensional digital breast tomosynthesis was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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:   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 use of a computer-assisted device during surgery for treatment of his medical condition. Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this patients case.  Evidence-based medical guidelines and peer-reviewed literature indicate that there is inadequate data to permit scientific conclusions regarding computer-assisted surgery.  Additionally, there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of computer-assisted navigation in the specific treatment of wrist fracture dislocations.  Therefore, the use of a computer-assisted device was not likely to have been superior over other treatment options.  Final Result: Two reviewers determined that the services at issue were 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: All three reviewers are board certified in orthopedic surgery 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 gene testing for evaluation of his drug metabolizer status.  Findings:  Three physician reviewers found that in the documentation available for review, no rationale was given for the testing at issue. The peer-reviewed medical literature suggests that it is premature to recommend routine therapy adjustment for oxycodone on the basis of CYP2D6 genotype. Additional studies state that the need to test for NSAID tolerance before prescribing has not been established in the medical literature. All told, the requested gene testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three 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 anesthesiology with sub-specialty certification in pain 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi, Daklinza and Ribasphere for treatment of his 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 non-liver-related conditions. The guidelines state that patients with cirrhosis are high priority for treatment. The guidelines recommend that cirrhotic patients with genotype 3 hepatitis C who have failed treatment with Sovaldi and ribavirin should be treated with Sovaldi, Daklinza, and ribavirin for 24 weeks if ineligible for peg-interferon. This is based partially on the results of the ALLY-3 study, which demonstrated poor cure rates (only 71%) after 12 weeks of therapy (Nelson, et al). The guidelines cite study data reporting that delay in treatment may result in decreased survival (Jezequel, et al). In this case, the patient is interferon-ineligible because interferon regimens can exacerbate depression, and can induce major depression in 25% of patients (Udina, et al). For these reasons, the requested treatment with Sovaldi, Daklinza, and Ribasphere is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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: The parent of an enrollee requested 20 hours per week of in-home applied behavioral analysis (ABA) services for treatment of the enrollees medical condition. Findings: Two physician reviewers found that according to the documentation submitted for review, the patient was diagnosed as autistic at the age of five, based on formal psychological testing. The diagnosis of autism by the psychologist is strong evidence that supports the patient as autistic. In addition, the school districts IEP describes the patient with many autistic features such as lack of eye contact and avoidance of social peer relationships. Given the confirmation of autism supported by the psychological testing and school district IEP, 20 hours of in-home ABA therapy is medically necessary in this clinical setting. Final Result: Two 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:  One reviewer is board certified in pediatrics and child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing.  One reviewer is board certified in child neurology and is 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 proton beam therapy for treatment of her medical condition. Findings: Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional photon radiation.  The data regarding central nervous system tumors treated with proton beam radiation therapy is limited to retrospective series, with a lack of evidence of long-term clinical outcome compared to conventional intensity modulated radiation therapy.  There is insufficient published clinical outcome evidence of proton beam radiation therapy for ependymoma from well-controlled studies in peer-reviewed medical literature.  Thus, the requested proton beam radiation is not likely to be of greater benefit than other treatment options. Final Result: Three 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:   All three reviewers are board certified in radiation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested advanced lipoprotein testing for evaluation of his medical condition. Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this patients case.  Guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.   For example, randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits.   Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  Thus, the superior efficacy of advanced lipoprotein testing 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 with sub-specialty certification in cardiovascular disease 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 breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. It is specifically those patients who have dense breasts that benefit most from tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For the reasons provided, 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:  The parent of an enrollee has requested Elidel cream for treatment of the enrollees eczema.  Findings:  The physician reviewer found that Protopic and Elidel are the first two non-steroidal drugs approved for the treatment of atopic dermatitis. Patients with atopic dermatitis have decreased quality of life, leading to distress, anxiety, and sleep disturbance. Both medications have shown significant positive effects in the treatment of atopic dermatitis without adverse effects seen with corticosteroid therapy. Elidel 1% applied twice daily for three to six weeks is effective at controlling the signs and symptoms of atopic dermatitis in patients with predominantly moderate disease, using atopic dermatitis severity scores as end points. In long-term studies of up to one year, Elidel 1% applied twice daily as needed for initial symptoms of atopic dermatitis, reduced atopic dermatitis flares, and thus the need for topical corticosteroids. Protopic has also been shown to be an effective treatment for moderate-to-severe atopic dermatitis in adults and children in multiple clinical trials up to two years in length. Protopic and Elidel are macrolactams with immunosuppressive characteristics. Both exert their immunosuppressive effects by inhibiting the activation of T-lymphocytes, thereby decreasing the release of the various proinflammatory cytokines. Thus, both medications work at the same disease pathway with equal efficacy. Given these findings, the requested Elidel cream is not supported as medically necessary in this patient who is already being treated with Protopic.  Final Result: The reviewer determined that the requested medication is 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested artificial cervical total disc arthroplasty for treatment of his medical condition.  Findings:  Two physician reviewers found that the request for artificial cervical total disc arthroplasty is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is sufficient support for the requested services in this clinical setting. Davis and colleagues evaluated the safety and effectiveness of two-level total disc replacement using a Mobi-C cervical artificial disc at 48 month follow-up. The authors concluded that total disc replacement is a safe, effective, and statistically superior alternative to anterior cervical discectomy and fusion for the treatment of degenerative disc disease at two contiguous cervical levels. In addition, Rao and colleagues performed randomized controlled trials with a total of 4,061 patients. The results of the meta-analysis indicated that cervical disc arthroplasty was superior to anterior cervical discectomy and fusion with better neurological success, greater motion preservation at the operated level, fewer secondary surgical procedures, and lower rates of adverse events. In light of the support in the peer-reviewed literature, the request for artificial cervical total disc arthroplasty at two levels is supported as superior to anterior cervical discectomy and fusion.  Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment 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 orthopedic surgery 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 CHEK2 genetic testing for evaluation of his medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  CHEK2-1100delC mutation appears to be associated with an increased risk for colorectal cancer, particularly in the setting of a family history of colon cancer.  Studies have also found that CHEK2 carriers have increased risks for male breast cancer, as well as stomach, prostate, kidney, and thyroid cancer and sarcoma.  If this patient is CHEK2 negative, his risk for the above cancers would be that of the general population.  If he is CHEK2 positive, then he would be recommended for increased screening for certain cancers, especially those that run in his family.  Therefore, CHEK2 genetic testing was likely to have been superior over 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:   All three 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.