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 laparoscopic LINX procedure. Findings:  Two of the three physician reviewers found the LINX device has been approved for patients with gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux. This patient has symptoms consistent with gastroesophageal reflux. However, it appears the patient's reflux is neither advanced, as there was no endoscopic or histologic evidence of esophagitis, nor has the lower esophageal sphincter been demonstrated to be dysfunctional. The patient cannot be considered medically refractory to acid blocker drugs since the records document only a small dose of ranitidine. Additionally, the implantation of LINX in this setting must be approached with caution given the documented complaint of dysphagia. As such, the requested laparoscopic LINX procedure is not likely to be superior over other treatment options. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified 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: 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 400 hours of private duty nursing in the home setting. Children with special needs frequently require equipment at home to allow for safe and effective care. Such equipment may facilitate feeding and eating, toileting, bathing, safe sleeping, and mobility, as well as offer opportunities to achieve functional skills. This patient has a number of skilled nursing needs and requires constant supervision, monitoring, and skilled intervention should he develop respiratory distress, signs and symptoms of aspiration, or seizures. This is not something that can be safely managed by layperson caregivers, such as parents, around the clock. Thus, the requested 400 hours of private duty nursing in the home setting 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 pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the transcranial magnetic stimulation (TMS). As noted in the medical literature, 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 30-40 sessions over four to six weeks. Researchers noted that controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. The researchers also noted 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 the records provided for review, the patient had already utilized this additional time frame. Given the lack of adequately powered, controlled studies showing the benefit of longer courses of TMS therapy, the TMS therapy services provided on were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay performed for evaluation of the enrollees malignant melanoma. Findings:  The physician reviewer found that DecisionDx-Melanoma assay tests the tissue genetics of the melanoma and can stratify whether a melanoma is high risk for metastasis or not. The test examines gene markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some accuracy determining risk of metastasis; however, decision-making based on the results of the test is indeterminate at this time. There is limited scientific evidence permitting conclusions concerning the effect of this test on health outcomes and there is not enough published data to support its routine use. The treatment of this patient would not change based on the results of the examination. Moreover, the test is not considered standard of care for treatment of patients in this clinical setting. Formal standard procedures or precautions that would be changed in light of the data is lacking. The current standard of care would be to perform a wide local excision. Since this test does not provide a superior benefit over established tests in terms of outcomes, DecisionDx-Melanoma test gene assay was not likely to have been more beneficial for the evaluation of this patients medical condition than any available standard modalities. Final Result: All three reviewers determined 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 dermatology 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: An enrollee has requested authorization and coverage for the delivery of the enrollees unborn child at a tertiary hospital that has a level III or level IV neonatal intensive care unit (NICU) equipped with extracorporeal membrane oxygenation (ECMO) system. The Health Plan has denied this request indicating that the requested services are not medically necessary for delivery of the enrollees unborn child.Findings: Congenital diaphragmatic hernia (CDH) occurs in one out of 2500 live births and is characterized by incomplete closure of the diaphragm, usually on the left side, which allows abdominal organs to enter the chest, pushing the heart to the right and compressing the lungs.  This can lead to pulmonary hypoplasia and impaired oxygenation at birth.  The degree of pulmonary compromise can be predicted by the lung head ratio.  Patients with ratios less than 1 have the worst prognosis and the greatest risk of need for ECMO.  ECMO has been shown to improve survival in CDH patients who are most severely affected. However, systematic reviews are unclear as to the benefits of ECMO in treating CDH patients with less severe prognosis. In this case, the documentation indicates this patient has a relatively good prognosis. Additionally, the consultation record indicates that delivery can be safely performed at a level III neonatal intensive care unit even if they do not have ECMO available. In sum, the delivery of the patients unborn child at a tertiary hospital that has a level III or level IV NICU equipped with ECMO system is not medically necessary.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 obstetrics and gynecology with sub-specialty certification in maternal and fetal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 testing (genetic testing). The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees recurrent breast cancer.Findings:  Three physician reviewers found that understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise but is not yet ready for routine clinical use.  Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible in both a timely and cost-achievable manner, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. As such, Guardant360 testing (genetic testing) was not likely to have been superior over the available standard techniques for the evaluation of this patients medical condition.Final Result: All three reviewers determined 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (methylenetetrahydrofolate reductase (MTHFR) for evaluation of the enrollees risk factors for mild to moderate hyperhomocysteinemia.  Findings:  The physician reviewer found that this patient presents with some cardiovascular risk. In this clinical circumstance, 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 cardiovascular risk including genetic testing such as MTHFR 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. Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are no controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Given these findings, the gene test 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 test MTHFR (CPT code 81291) 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 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

Nature of Statutory Criteria/Case Summary: A 63-year-old male enrollee has requested authorization and coverage for Repatha 140 mg/mL syringe. Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or documented atherosclerotic heart disease who require additional lowering of LDL cholesterol despite of maximally tolerated standard therapy. This patient does not meet these criteria. Based on the records provided for review, the patient presents with a documented coronary disease and dyslipidemia. However, there is no documentation of heterozygous familial hypercholesterolemia. In addition, there is a lack of documentation that the patient has tried and failed Zetia, a medication that has been shown to be safe and effective at lowering cholesterol and is associated with improved cardiovascular outcome. Moreover, the records document a minimal increase in CK without a documented baseline value and without documented myalgia symptoms while on rosuvastatin. Mild asymptomatic CK elevation alone is not considered an indication to discontinue statin therapy. Given these findings, the Repatha 140 mg/mL syringe is not 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for duplex ultrasound of the lower extremity and physiologic testing of the lower extremity. The documentation submitted does not support that the diagnostic studies were done for a symptom of claudication. The definition of intermittent claudication is a reproducible discomfort of a defined group of muscles that is induced by exercise and relieved with rest. There is no documentation of any lower extremity pain with exertional activities and improved with rest. There is no documentation of non-healing arterial ulcers or abnormal arterial pulses. The diagnosis of peripheral arterial disease is typically made based on a history of risk factors or symptoms of claudication combined with abnormal physical examination findings. For patients with an abnormal physical examination consistent with significant stenosis and risk factors for peripheral artery disease, ankle brachial index should be performed.  Screening for asymptomatic peripheral artery disease is recommended for patients who are less than 50 years of age with diabetes and an additional cardiovascular disease risk factor, patients who are 50 years of age or older with a history of smoking or diabetes, or patients who are greater than 65 years of age. In this case, the patient does not meet criteria for asymptomatic screening of peripheral artery disease. The documentation does not support that she has clinical signs or symptoms that would be concerning for peripheral artery disease. As the physical examination was normal and there were no reported symptoms consistent with claudication, duplex ultrasound of the lower extremity and physiologic testing of the lower extremity were not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia. According to the ASA guidelines for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care is more likely necessary in patients with failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, pregnancy, increased aspiration risk, ASA class 3 or higher, or morbid obesity. Therefore, the submitted records do not support the medical necessity of monitored anesthesia care in this case. Thus, anesthesia performed 10/12/17 was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a computed tomography (CT) scan of the heart. Findings:  Three physician reviewers found that based on the records provided for review, this patient presents with some coronary risk but no symptoms or objective findings suggestive of coronary ischemia. In this circumstance, guidelines for evaluation and management of cardiovascular risk are available and do not recommend routine screening with cardiac CT scanning. Moreover, cardiovascular outcomes have not been shown to be incrementally improved from treatment based on routine screening cardiac CT scan results compared to treatment based on standard clinical risk profiling and standard lipid measurements alone. Specific guidelines endorsed by several national organizations also do not consider a screening CT scan appropriate in this setting. All told, the requested CT scan of the heart is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.For these reasons, the requested diagnostic procedure is not likely to be more beneficial for evaluation of your medical condition than any available standard therapy.Final Result: The reviewers determined that the requested diagnostic procedure is not likely to be more beneficial for evaluation of your medical condition than any available standard therapy.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Genotropin. The submitted documentation demonstrates the medical necessity of the requested medication. The records document short stature. To the extent that the question of Hashimoto thyroiditis and hypothyroidism arises as possibly causal for the short stature, it is noteworthy that the patients elevation of thyroid stimulating hormone was so mild has to preclude the possibility of lasting clinical consequence of hypothyroidism on stature specifically. Ongoing therapy with growth hormone is warranted in this context. The patients annualized velocity on growth hormone has improved, indicating a positive response, which warrants continued therapy. Therefore, Genotropin is medically necessary 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 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.