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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Oncotype DX colon cancer assay.Findings: Two of the three physician reviewers found that the Oncotype DX colon cancer assay was not indicated under these circumstances. It has not been established if molecular markers are useful in treatment determination (predictive markers) and prognosis in patients with colon cancer. None of the five commercially available assays, including the 12-gene recurrence score (Oncotype DX colon cancer test), has specific U.S. Food and Drug Administration (FDA) approval for use in stage II colon cancer. Furthermore, none of these assays has been able to predict which patients with stage II disease could benefit from adjuvant therapy. It is important to note that the 12-gene recurrence score (RS) was created as a prognostic marker. While it may have the ability to better estimate a patient's risk of recurrence, whether such increased risk can be overcome by adjuvant chemotherapy is not clear. A December 2012 technical brief on gene expression profiling for predicting outcomes in stage II colon cancer prepared for the United States Agency for Healthcare Research and Quality concluded that the clinical utility of all of the gene expression assays, including the 12-gene recurrence score, was uncertain, and that information was lacking about the extent to which assay results do or do not classify patients into distinct groups with clinical relevance. ASCO guidelines do not address use of this assay. NCCN guidelines state that there are insufficient data to recommend the use of multi-gene assays, such as the Oncotype DX colon cancer assay, to determine adjuvant therapy. Therefore, the requested Oncotype DX colon cancer assay is not likely to be more beneficial than any available standard therapy for the patients medical condition.Final Result: Two of the three reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in internal medicine, with subspecialty certifications in medical oncology and hematology, and all three 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 reimbursement for genetic testing. Findings:  Two of the three physician reviewers found that the medical evidence supports cystic fibrosis carrier screening for all women of childbearing age. With regards to fragile X testing, according to the American College of Medical Genetics, if a woman has ovarian failure before the age of 40, DNA testing for pre-mutation size alleles should be considered as part of the infertility evaluation and prior to in vitro fertilization. This patient required in vitro fertilization to conceive. Given the history of fertility issues, fragile X testing was appropriate. With regards to spinal muscular atrophy, carrier testing should be offered to all couples regardless of race or ethnicity. In the absence of a significant family history, carrier screening of more than 200 conditions (in addition to conditions described above) was not indicated. The value of this screening is uncertain and is not standard of care. Thus, fragile X, cystic fibrosis and spinal muscular atrophy testing were standard of care and were likely to be of greater benefit than other methods of evaluating this patient. However, the superior effectiveness of the remaining of the services at issue has not been established.Final Result: The reviewers determined that a portion of the services 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 partially overturned.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in clinical biochemical genetics and are actively practicing. Physician reviewer 3 is board certified in clinical cytogenetics and genomics and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lower back fusion surgery with related hospital stay. The submitted documentation does not support that the requested services are medically necessary. American Association of Neurological Surgeons (AANS) criteria and National Imaging Associates (NIA) criteria for lumbar fusion identify a number of indications for which lumbar spinal fusion is appropriate, none of which are presented in this case. AANS guidelines further note that there is currently a lack of high-quality Level I evidence to support the use of lumbar fusion for patients with chronic low back pain without stenosis or without spondylolisthesis. In this case, the patient has chronic low back pain but no symptoms or signs of a lumbar radiculopathy. He has no localizing features to his pain and he has no symptoms or signs to implicate the L4-5 level as his pain generator, nor any level of his spine. The patients MRI shows no evidence of adjacent segment disease nor of nerve root compression. Furthermore, there is no documentation of failed conservative management such as physical therapy, injections, analgesics, a back brace, cognitive therapy, or activity modification. There is no correlation of his imaging with his clinical condition. Under these circumstances, lower back fusion surgery with a related hospital stay are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services 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 neurological surgery. 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: The parent of a male enrollee has requested authorization and coverage for in-home applied behavioral analysis (ABA) services for three hours per day, five days per week. Per a study, patients receiving center/community-based ABA services (CBS) had mastered significantly more exemplars and achieved 100% more learning per hour than those receiving home-based ABA services (HBS). The theory in favor of HBS that parents or caregivers are more likely to participate in treatment sessions if the sessions are located in their home. No evidence supporting this theory; rather, the study notes that CBS may provide more structure and a more intentional environment for parents and caregivers to be trained within. [CBS] may allow for more control over the environment and therefore result in a decrease in potential distractors, which may facilitate increased rates of learning.Here, no argument has been presented for why HBS would be more appropriate for this patient than the approved CBS. There are, however, reports from previous HBS providers documenting a need for CBS in order to establish instructional control, reduce disruptions or distractions and to better structure family involvement in sessions. This recommendation is consistent with the above referenced literature. Therefore, the requested in-home ABA services are not medically necessary for treatment of the enrollees condition.Final Result: The reviewer determined that the services at issue 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 psychology, is a board-certified behavioral analyst, 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 reimbursement for residential treatment center services. The submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association guidelines noted that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, who lack sufficient social and vocational skills, and who lack substance-free social supports to maintain abstinence in an outpatient setting. Based on the submitted records, this applies to this patient. Patients require safe and stable living environments in order to develop recovery skills. In this patients case, residential treatment was in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. Thus, residential treatment center services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Otezla. This patient has a history of chronic plaque psoriasis, and the records document that she has tried and failed therapy with topical steroids. The Health Plan requires that the patient first try the preferred formulary agents, including methotrexate, cyclosporine, acitretin, PUVA and UVB light therapy, or two other drugs that include Enbrel, Humira and Cosentyx, prior to covering Otezla. The medical records fail to indicate a treatment trial or any contraindications or adverse effects from the use of the preferred agents. The formulary agents are medically appropriate and are likely to be as effective as the requested medication. Therefore, Otezla is not medically necessary for the treatment of this patient.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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxycodone. The submitted documentation does not support that the requested medication is medically necessary. Medical literatures have concluded that patients with chronic low back pain who use chronic opiates have much poorer outcomes. In addition, clinical practice guidelines from the Centers for Disease Control (CDC) do not support the use of opiates for this patient. In this case, the patient had an aberrant urine toxicology with hydrocodone detected on one screening, then THC on another screening. The patient had stated that she used another persons oxycodone. These circumstances are red flags. At this time, the patient has an appointment with pain management in the near future. Under these circumstances, the request for oxycodone is not medically necessary for treatment of the patients medical condition.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 reviewer is board certified in anesthesiology, with subspecialty certification in pain management. 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 Xultophy. The submitted documentation does not support that the requested medication is medically necessary. Xultophy is a combination of Tresiba (Deglutec) and Liraglutide. In this case, the patient had intolerance to Metformin therapy and intolerance to Levemir insulin. There is no documentation of his current hemoglobin A1c results. The submitted documentation does not reflect that the patient has tried and failed other treatment options including non-metformin first-line oral diabetic agents, and basal insulins other than Levemir and GLP-1 agents, prior to being started on the requested medication. A trial of such step therapy alternatives would be consistent with the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) Comprehensive Type 2 Diabetes Management Algorithm. Accordingly, the requested for Xultophy is not medically necessary for treatment of the patient's medical condition.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 reviewer is board certified in internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism. 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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for testosterone transdermal gel (one percent) 50 milligrams per 5 grams. The submitted documentation does not support that the requested medication is medically necessary. In this case, the patient has a prolactin secreting pituitary tumor and currently is on cabergoline therapy with prolactin levels decreasing. Although the patient was seen to have multiple testosterone levels which were below the normal reference range, there was no time stamp for the lab draws, and the lab draws do not reflect if the reported testosterone levels were done in the morning. Accordingly, the submitted laboratory documentation is not sufficient to establish the diagnosis of hypogonadism at this time. Under these circumstances, the request for testosterone transdermal gel (one percent) 50 milligrams per 5 grams is not medically necessary for treatment of the patients medical condition.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 reviewer is board certified in internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism. 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 Dupixent (dupliumab) injections. Atopic dermatitis (AD) is a common itchy inflammatory skin disease characterized by immune activation, marked epidermal hyperplasia, and defective barrier function, reflecting underlying alterations in keratinocyte differentiation. Much effort has recently been placed on the development of new treatment strategies for this increasingly common illness. Treatment of AD usually starts with topical agents, such as corticosteroids as well as phototherapy, including broad-band UVA (UVB-BB), UVA with psoralen, and UVA-1. More recently, narrow-band UVB has emerged as an effective treatment modality. Skin inflammation in atopic dermatitis results from inherited and acquired insults to the skin barrier, and agents that normalize the skin barrier reduce the dependence on topical steroids. Tacrolimus ointment and pimecrolimus cream are the topical calcineurin inhibitor approved for clinical use and has been demonstrated to be safe and effective in the treatment of patients with AD. Dupixent is a fully human Ig4 monoclonal antibody directed against the interleukin-4 receptor subunit a (IL-4Ra) of IL-4 and IL-13 receptors. Recent studies have all demonstrated how Dupixent can significantly reduce the molecular signature in the skin of patients with AD and significantly reduce the clinical manifestations of moderate to severe AD. It also significantly reduces the pruritus of moderate to severe AD, thus improving patients quality of life. Dupixent is administered by subcutaneous injection every other week. It was approved by the FDA in March 2017 for the treatment of moderate to severe AD.Althought the provider used the term `intrinsic allergic eczema` for the patients skin disease it is medically synonymous to atopic dermatitis. The patient has tried and failed multiple conservative treatments, including topical corticosteroids, phototherapy and several other topical agents. For this patient with atopic dermatitis, Dupixent injections represent a reasonable and evidence-backed next step in the plan to treat this patients condition. Therefore, the requested Dupixent injections are medically necessary for treatment of the patients condition.Final Result: The reviewer determined that the services at issue 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for inguinal hernia surgery using a robotic surgical system. In this case, the patients symptoms are noted to be functionally impairing, and thus repair of his symptomatic groin hernias is warranted. However, use of a robotic surgical system is not supported in this clinical scenario. Robotic assistance during laparoscopic repair has not objectively been proven beneficial to surgical recovery or outcomes. A study found that, Specific published data regarding outcomes and cost analysis for robotic hernia is currently lacking. Further study of robotic hernia repair is needed prospectively as its use increases to delineate the true benefits. Therefore, in this case, the use of robot assistance for laparoscopic inguinal hernia repair would not be considered medically necessary. Accordingly, the requested inguinal hernia surgery, using a robotic surgical system, is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested use of a robotic surgical system 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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 16-year-old male enrollee has requested authorization and coverage for a four (4) day inpatient stay for Thorazine infusions. Thorazine is a phenothiazine derivative which is primarily used for schizophrenia and occasionally for migraine. Per researchers, its mechanism of action as an analgesic in migraine is probably due to inhibition by Thorazine of the human pain threshold sodium channel. Medical literatures describe the use of Thorazine to abort migraine in children and adults in the emergency room. Researchers performed a retrospective cohort study of patients 12-21 years of age treated for migraine headache in their emergency department. Their study found that the most common adverse effect was hypotension (12%). The patient has tried and failed several treatments for chronic migraines. Records from the patients therapist indicate that the untreated pain has negatively impacted his mental health, with resulting conditions including depression and suicidal ideation. The treating pediatric headache specialist has now prescribed Thorazine injections. As noted above, Thorazine is indicated for treatment of migraines. Moreover, the four-day inpatient admission is necessary because the treating physician plans to administer Thorazine intravenously every 8 hours. This regimen would not be feasible in an infusion center, which would be closed at night. Additionally, due to the risk of hypotension, cardio-respiratory monitoring is necessary throughout the Thorazine administration. Thus, the requested four (4) day inpatient stay for Thorazine infusions is medically necessary for treatment of this patients chronic migraine headaches.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 neurology with a special qualification in child 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.