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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (molecular profiling) performed.  Findings:  The physician reviewer found that the patient is diagnosed with lung cancer. She presented with a right mediastinal mass that proved to be lung adenocarcinoma. She had superior vena cava syndrome and extension of tumor to critical vasculature as well as formation of a fistula. A tumor sample was submitted for Guardant360 mutational testing. The patient requested reimbursement for the gene test (molecular profiling) performed. The Health Plan denied reimbursement for the services at issue stating that the gene testing was investigational for the evaluation of this patient. Recent medical evidence demonstrates the superior efficacy of the services at issue in this clinical setting. The Guardant360 test is a liquid biopsy that analyzes patient plasma for mutations in a panel of 70 genes. Recently, a clinical study directly compared the use of targeted agents with conventional chemotherapy approaches. A study involved 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has very significant results for patients with stage IV tumors.  Invariably, this patient will be offered something off-label or a phase I/II clinical trial but the results from molecular profiling offers a rational selection of the next regimen. The therapy for advanced non-small cell lung adenocarcinoma (NSCLC) has been revolutionized by the finding of epidermal growth factor receptor gene (EGFR) mutations in certain adenocarcinomas.  The mutations are more common in those who have never smoked. Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of NSCLC has significantly expanded in the past two to three years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. Furthermore, the American Society of Clinical Oncology issued guidelines include EGFR testing. All told, gene test (molecular profiling) performed was likely to have been superior over the standard options available for the evaluation of this patients medical condition. The reviewers determined that the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: A 54-year-old female enrollee has reimbursement for advanced lipoprotein testing (CPT 83704). Findings:  Three physician reviewers found that the documentation provided does not support the services at issue in this clinical setting. There is no history of known coronary artery disease in this patients case. The records note that she was undergoing preventive screening and underwent advanced lipoprotein profile testing. In this patients case, advanced lipoprotein testing would not add significant information to what is available from a fasting lipid panel.  The patient has only a single risk factor for coronary artery disease, namely well controlled hypertension. The documentation notes that she is asymptomatic and presented to her provider for preventive examination. Her hemoglobin (Hgb) A1C is within normal range with no history of diabetes and she is not a smoker. 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: Reviewers 1, 2, and 3 are 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 authorization and coverage for estrogen Femring 0.10 mg for treatment of her menopausal symptoms. Findings:  The physician reviewer found that menopausal symptoms vary from patient to patient and their treatment often requires a tailored approach. Multiple treatment routes are available, including oral, transdermal, transvaginal. The treatment route depends on the patients tolerance, reaction and medical history, and is tailored to provide the least risk profile. In this case, the patients provider reports that she needed increasing doses of Estrogel in order to control her symptoms. In order to decrease her hormone exposure and decrease her symptomatology, she was changed from a gel formulation to the ring. However, the documentation does not support that any other medications were tried on the formulary before switching from the gel to the ring. Given that there is no documented intolerance or contraindication to the formulary preferred medications, the request for estrogen Femring 0.10 mg 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 obstetrics and gynecology 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 residential treatment center (RTC) services for treatment of the his alcohol abuse. Findings:  The physician reviewer found that the records provided for review document that this patient had minimal post-acute withdrawals. He was not a danger to himself or others and he was medically and psychiatrically stable. His medication management did not require RTC level of care. There were no emotional, behavioral, cognitive, impulsive, psychotic, or manic concerns which would have precluded stepping him down to a lower level of care. He has been motivated and engaged in treatment. He is future oriented, becoming increasingly aware of his triggers and the behavior patterns that drive his addiction. He has been utilizing coping skills. His family is supportive and his living environment is conducive to recovery. He has improved and there is a lack of evidence that he would deteriorate if stepped down to a less restrictive level of care. Although he had issues of shame, guilt, and self-identity due to retirement, these could have been addressed in psychotherapy at intensive outpatient program (IOP) level of care, in conjunction with additional community based Alcoholics Anonymous, along with help from his sponsor. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty certification in addiction 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 authorization and coverage of Sovaldi with ribavirin for a duration of 24 weeks. 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 (AASLD/IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions regardless of fibrosis stage. Per the guidelines, patients with cirrhosis are high priority for treatment.  The guidelines do not recommend Harvoni as a treatment for genotype 3, hepatitis C as its ledipasvir component does not have sufficient activity against this genotype. Therefore, the patient has never received an effective treatment for hepatitis C, and should be considered treatment naive.  For treatment naive, genotype 3 patients, the guidelines recommend two effective regimens, but no longer recommend Sovaldi with ribavirin as primary or re-treatment therapy for genotype 3 hepatitis C due to lower efficacy. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) (CPT code 73721). Findings:  The physician reviewer found that According to the medical literature MRI of the knee is not medically necessary in the absence of a detailed physical exam or in the absence of a supervised four week trial of conservative treatment, including analgesics, bracing, and physical therapy. In the absence of a detailed physical examination and documentation showing failure of conservative treatment. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: the physician reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for proton beam therapy. There is a lack of medical evidence to suggest that treatment with proton beam radiation offers a clinical benefit when compared to conventional radiation therapy techniques for breast cancer. There is scant data in the medical evidence that suggests that treatment with proton techniques will be able to improve sparing of the skin, heart, and/or lungs compared to standard intensity modulated breast radiation with photon techniques. Accordingly, consensus group guidelines do not support the use of proton beam therapy in this setting (National Comprehensive Cancer Network guidelines). In the vast majority of cases, intensity modulated radiation or three dimensional conformal techniques with photons is able to achieve an acceptable cardiac and lung dose in left sided breast cancer. Also, level I evidence is lacking to support the use of proton beam therapy for the treatment of left breast cancer. 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 radiation oncology 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 and prospective authorization and coverage for skilled nursing level of care. Findings:  The physician reviewer found that  The patient does have a programmable shunt placed due to hydrocephalus.  Programmable shunts may potentially provide some benefits to avoid some of the mechanical complications associated with fixed rate shunts.  Generally, there are no set adjustment protocols for patients who have shunts with programmable valves, and this management is clinically determined.  There is a lack of objective indications in the records documenting that the patients shunt requires close monitoring in a hospital setting on an ongoing basis.  Based on the available records, skilled therapy and nursing services on an inpatient level would not be reasonably expected to impart a marginal benefit on the patients health or functional outcomes or clinical course in comparison to a basic restorative nursing program for range of motion, strengthening and activities at a custodial level of care. Final Result: The reviewers determined that the services at issue were not and are 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 physical medicine and rehabilitation 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 Norco for treatment of his pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has not followed the requirements of the opiate maintenance agreement and is not following the recommendations of his treating providers. Opiate therapy has been associated with an increased risk of fracture, as in this case. It is not medically appropriate to prescribe opiates to a patient that is not following the agreement and attending recommended consultations. The current medical evidence does not support the use of Norco in this clinical setting. 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 sub-specialty certification in pain 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier tablets for 12 weeks for treatment of her chronic hepatitis C virus (HCV) genotype 1a. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: The parent of an enrollee has requested authorization and coverage for in-home private duty nursing. Findings:  The physician reviewer found that the records document that this patient has multiple medical problems due to his CHARGE syndrome and intellectual disability. The documentation provided indicates that he is not medically stable as he is immunosuppressed, and has had at least one inpatient hospitalization for pneumonia and streptococcal pharyngitis. He requires constant adult supervision due to his intellectual disability, as he can become agitated during interventions. The patient has obstructive sleep apnea, asthma and congenital airway abnormalities requiring him to wear CPAP. He also requires gastrostomy bolus feeds and diaper changes. These treatments require 24-hour monitoring to prevent him from removing the device. His two primary caregivers are in poor health, and it is unrealistic for them to provide constant 24-hour nursing care for the patient. In the medical literature, the complexities and difficulties faced by families caring for chronically ill children, and describe the importance of the provision of in-home nursing care. Recommendations for in-home nursing care for chronically ill children are also outlined in the position statement issued by the American Academy of Pediatrics. Although the providers recommendation for 16 hours per day of in-home private duty nursing is not medically necessary, the medical records support 10 hours per day of in-home private duty nursing seven days per week. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology with special qualification in child neurology and sub-specialty certification in hospice and palliative 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 genotype testing for evaluation of her behavioral health conditions. Findings:  Three physician reviewers found that in general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization, may well become a valuable tool in the treatment armamentarium for those plagued with psychiatric illness.  However, despite its promise, pharmacogenetics is not yet ready for mainstream clinical application.  Indeed, trusted psychiatric reference texts do not recommend genetic testing for cases involving routine medication management.  Further, the American Psychiatric Association (APA) did not endorse such testing in a recent official statement or its most current clinical practice guidelines. There is a lack of well-designed or adequately powered studies illustrating consistent and reproducible results that provide clinically useful information pertaining to genomic testing and its relationship to specific pharmacologic interventions.  In this patients case, there was no clinical data provided to support genetic testing.  Notably absent was a psychiatric evaluation and/or interpretative summary addressing the longitudinal illness burden and extent of impairment, family history, psychosocial stressors, substance use history and possible medical comorbidities. There was no discussion of prior interventions used to treat the depression, intrusive thoughts and repetitive behaviors. 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: Reviewers 1, 2, and 3 are board certified in psychiatry 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: The parent of an enrollee has requested reimbursement for the mental health residential treatment center (RTC) services provided.Findings:  The physician reviewer found that the records provided for review document that by  the date of dispute, the patient had excellent insight. The providers indicated that the patient had no suicidal or homicidal ideation or evidence of psychosis and no significant symptoms of eating disorders or of problems sleeping. She was noted to have met all treatment goals and no longer required 24-hour supervision and monitoring. Given the patients presentation on the date of dispute, she was a candidate for treatment at a less restrictive level of care. Thus, the mental health RTC services provided  were not supported as medically necessary for treatment of this patients behavioral health issues.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 with sub-specialty certification in child and adolescent 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.