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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prometheus Anser ADA testing. There is insufficient medical evidence to support the effectiveness of Prometheus Anser ADA testing compared with conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies. It is possible that active disease results in low adalimumab levels due to loss of adalimumab, rather than low adalimumab levels resulting in loss of disease control.  Additionally, controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management.  For these reasons, Prometheus Anser ADA testing was not likely to have been of greater benefit than other methods of evaluating this patient. Findings:  Three physician reviewers found 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.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: A enrollee has requested reimbursement for the transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that TMS provided a reduction of headache days from baseline. Early treatment of migraine with aura by TMS resulted in increased freedom from pain at two hours compared with sham stimulation, and absence of pain was sustained 24 hours and 48 hours after treatment. The records document that this patient has tried multiple abortive and prophylactic treatments for her migraine headaches. Thus, the TMS was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Krystexxa. A study noted that the current guidelines recommend having a uric acid level <6 ml/dL. In patients who have had reactions to allopurinol, If allopurinol toxicity does occur, alternative urate lowering treatments may be employed. As discussed in proposition 2, nonpharmacological approaches such as education, weight loss, reducing alcohol consumption, and dietary modification should always be considered. However, if urate lowering drugs are required, the current alternatives are other xanthine oxidase inhibitors or uricosuric agents. Several RCTs have shown that xanthine oxidase inhibitors other than allopurinol (for example, the metabolites of allopurinol, oxipurinol, tisopurine, and febuxostat) are effective in reducing SUA.81,82,83,84,85,86,87,88 However, their safety in patients who previously have developed AHP has not been established. Clinically, up to 40% of patients show cross reactivity between allopurinol and oxipurinol89,90; the nonpurine xanthine oxidase febuxostat is not reported to cause severe skin reactions and might be expected to have less cross reactivity than oxipurinol (though this has not been studied directly). Alternatively, as discussed in proposition 10, uricosuric agents may be considered. Although metabolites of allopurinol may be effective, there is up to a 40% chance of reaction due to cross-reactivity to allopurinol. A recent study demonstrated uric acid lowering in patients refractory or intolerant to allopurinol. Among patients with chronic gout, elevated serum uric acid level, and allopurinol intolerance or refractoriness, the use of pegloticase 8 mg either every 2 weeks or every 4 weeks for 6 months resulted in lower uric acid levels compared with placebo. Given the patients elevated uric acid, tophi and active arthritis, treatment is necessary. Given the risks of possible cross-reactivity with allopurinol and possible reaction to colchicine, the request for Krystexxa is medically necessary.Final Result: The reviewer determined that the requested medication Krystexxa 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 orthopedic 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: A 53-year-old female enrollee has requested authorization and coverage for ondansetron 8 mg dispersible tablets. Findings:  The physician reviewer found that long-term ondansetron use is effective for the treatment of multiple etiologies of intractable and ongoing long-term nausea, as it addresses the symptom regardless of the underlying cause.  Doses of up to 24 mg daily have been studied for ongoing use. The half-life of ondansetron is below six hours, so dosing three times daily is appropriate. This patient has failed alternatives, has experienced nausea chronically without an established cause, and has had improvement with ondansetron. Thus, the continuation of ondansetron 8 mg three times daily is supported as medically necessary for the treatment of the patients chronic nausea.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 Synvisc One injections, series of two. The submitted documentation supports the medical necessity of the requested services. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Per the authors, the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function. The authors noted that viscosupplementation has a good safety profile. The medical evidence supports the requested services in this clinical setting. Therefore, Synvisc One injections, series of two is medically necessary for the treatment of this patient. 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 orthopedic 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 an enrollee has requested authorization and coverage for 40 hours per week of one-to-one applied behavior analysis (ABA) therapy, four hours per week of case management and one hour per week of parent training. The submitted documentation supports the medical necessity of the requested services. ABA therapy has been identified as the most evidence-based treatment for patients with autism. The Behavior Analyst Certification Board (BACB) notes that patients with autism spectrum disorder who have deficits across multiple skill domains that jeopardize health or safety should receive comprehensive ABA interventions at high intensity. Although 40 hours or more is commonly recommended for younger children, the BACB indicates that comprehensive interventions may also be appropriate for older patients with autism spectrum disorder who exhibit severe deficits or behavioral excesses across environments. A direct assessment of the complexity, severity, and nature of individual needs should be used to determine the scope and quantity of ABA interventions. In this patients case, the records document a variety of complex medical, behavioral, and developmental needs that require ongoing intensive intervention. Specifically, the patient presents with deficits in functioning that are substantially below age level and problematic behaviors that continue to require careful monitoring and intervention. Therefore, 40 hours per week of one-to-one applied behavior analysis (ABA) therapy, four hours per week of case management and one hour per week of parent training are medically necessary for the treatment of this patient. 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 board certified behavior analyst and licensed psychologist 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 advanced lipoprotein testing.  Findings:  The physician reviewer found that 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, genetic testing 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. Although 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, advanced lipoprotein testing was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: Two of 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that the parent of an enrollee has requested authorization and coverage for Saizen (5 mg vial, daily). Based on the available documentation, this patients height is not more than two standard deviations (SDs) below the mean for age and gender, his bone age is not significantly delayed, and his growth velocity is normal. Moreover, the patients growth factors are normal, and there is no known morphological abnormality of the pituitary gland. While the patients adult height prediction is more than two SDs below the genetic target height, it is still within normal limits for U.S. adult males and not short enough to warrant a trial of growth hormone therapy for treatment of idiopathic short stature. Growth hormone treatment for idiopathic short stature was approved for males with adult predicted height of less than 63 inches, and this patient does not meet standard criteria for a trial of growth hormone therapy. All told, the requested Saizen (5 mg vial, daily) is not supported as medically necessary for treatment of this 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 has requested authorization and coverage for a special ortho position seat (tomato seat). Based on the available documentation, the requested special ortho position seat (tomato seat), is medically necessary for treatment of the patients medical condition. The patient has developmental delay due to his chromosome disorder as well as hypotonia and hyperlaxity of most joints. He is unable to hold up his head when sitting or crawling for more than a few minutes. Photographs of the patients back show bruising over the spinous processes due to pressure from his current chair. He has a history of aspiration pneumonia and gastroesophageal reflux. In the medical literature, Ryan and colleagues noted that the introduction of adaptive seating devices for young children who need support to sit had a meaningful, positive impact on child and family life. Rigby and colleagues reported that children were more able to engage in self-care and play activities when provided with appropriate seating. Overall, the data suggests that appropriate adaptive seating can significantly improve the quality of life for children with developmental and physical disabilities who are unable to sit without support. Given these findings, the requested special ortho position seat (tomato seat) is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device 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 pediatrics and neurology with 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 55-year-old male enrollee has requested authorization and coverage for Orthovisc injections.  Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Thus, the requested Orthovisc injections are supported as medically necessary for treatment of this patients bilateral knee osteoarthritis. 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 orthopedic 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene mutation testing (methylenetetrahydrofolate reductase (MTHFR)). MTHFR gene is a B vitamin gene involved in the folate/homocysteine metabolism pathway. Genetic variations in the MTHFR gene have been associated with a number of psychiatric conditions such as depression, schizophrenia, autism, bipolar disorder and dementia. However, there have been conflicting reports on its clinical utility (Wu, et al; Roberts, et al). Mitchell and colleagues reported that, diverse clinical studies have revealed weak and in some cases inconsistent associations of cognition, mood, and neurodevelopment disorders to genes involved in B vitamin metabolism. Based on current medical literature, the gene mutation testing (MTHFR) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Findings:  Three physician reviewers found the gene mutation testing (MTHFR) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the gene mutation testing (MTHFR) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in psychiatry 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 Anser VDZ. Findings:  Three physician reviewers found that the medical evidence does not support the superior effectiveness of Anser VDZ in this setting. The published studies including the use of anti-Entyvio antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment response and the presence of anti-Entyvio antibodies. Additionally, the antibodies can be transient. Controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management. Thus, the superior effectiveness of Anser VDZ has not been established.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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.