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 Decision Dx Melanoma Gene assay performed for evalualtion of her melanoma.  Findings:  Three physician reviewers found that The National Comprehensive Cancer Network guidelines indicate that genetic testing such at the Decision Dx Melanoma Gene Assay should not be used outside of clinical trials. In addition, it is not clear that results of this assay would change treatment recommendations in this patients case. The testing at issue is not considered to be standard of care in the treatment of the patients melanoma. Therefore, the Decision Dx Melanoma Gene assay performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in dermatology 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: An enrollee has requested authorization and coverage for hyperbaric oxygen chamber and oxygen concentrator for treatment of the enrollees tinnitus. Findings:  The physician reviewer found that the request for hyperbaric oxygen chamber and oxygen concentrator are not medically necessary for treatment of the patients medical condition. The medical literature does not demonstrate any longstanding clinical benefit utilizing hyperbaric oxygen therapy for the treatment of subjective tinnitus. The data reports a modest degree of improvement of symptoms of sudden hearing loss when the treatment is initiated shortly after the development of the hearing loss. In this case, the patients trauma occurred more than one year ago. In addition, colleagues state that For people with acute [idiopathic sudden sensorineural hearing loss] ISSHL, the application of [hyperbaric oxygen therapy] HBOT significantly improved hearing, but the clinical significance remains unclear. The authors further reported that the effect of HBOT could not be assessed on tinnitus by pooled analysis. The authors concluded that There is no evidence of a beneficial effect of HBOT on chronic ISSHL or tinnitus and we do not recommend the use of HBOT for this purpose. Given the lack of benefit of the use of hyperbaric oxygen therapy for the treatment of tinnitus, the requested services are not medically necessary for treatment of 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 otolaryngology 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 intravenous chelation services for treatment of the enrollees medical condition. Findings:  The 3 physician reviewers found that this patient has a history of multiple sclerosis which was documented as stable. The patient received multiple treatments of intravenous chelation for the treatment of toxic effect of unspecified metals which is documented as improved. Multiple sclerosis is most common immune-mediated inflammatory demyelinating disease of the central nervous system.  The current medical evidence does not support intravenous chelation services in this clinical setting. There is a lack of evidence to support chelation therapy over the disease-modifying agents. For patients with an acute multiple sclerosis exacerbation that results in neurologic symptoms and increased disability or neurologic deficits, high dose glucocorticoids is the recommended treatment. In this case, the patient is documented as being stable, without decline in function. There is no other medical condition documented that would benefit from chelation treatment.  All told, intravenous chelation services provided were not likely to have been of greater benefit than other treatment options.  Final Result: The 3 reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for the Foundation One test provided for evaluation of the enrollees breast cancer with bone metastases. Findings:  2/3 of the physician reviewers found that Foundation One is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the Foundation One assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment. A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the Foundation One test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center level of care services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the services at issue.  This patient had a very serious poly-addictive illness complicated by a co-occurring post-traumatic stress disorder and bipolarity.  She had been using substances for many years, and she had no significant periods of sobriety.  Prior to admission, the patient was consuming multiple substances on a daily basis and had overdosed twice on heroin to the point where naloxone rescue was necessary. Her extensive drug use dominated all domains of her existence and more than likely undermined her self-esteem and the developmental task of identity formation. She did not have the resiliency or an experiential foundation to draw upon in negotiating intrapsychic and interpersonal stressors.  Further, she had failed treatment in a less-restrictive setting during the episode of illness and was at high-risk for a poor outcome in the absence of appropriately matched care. It appears that the patient was engaged in active care throughout the admission, including modification of her psychotropic medication. Based on the longitudinal history and medical documentation, the patient had not consolidated the treatment gains necessary to succeed in a less restrictive setting and was likely to have promptly relapsed in the absence of residential programming had she been discharged. Both the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment for a case of this severity aligned with community standards. All told, residential treatment center level of care 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene test for treatment of the enrollee's uterine leiomyosarcoma. Findings: Three physician reviewers found that currently, therapy and achieved outcomes for metastatic uterine leiomyosarcoma are not based on panel testing. To demonstrate the clinical utility of panel genetic testing, such as FoundationOne, prospective randomized clinical trials are needed to compare the strategy of targeted treatment based on panel results with standard of care and currently there is a lack of such trials. The available literature as to its clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. As such, this evidence is not sufficient to make any conclusions as to its efficacy in this clinical setting. In addition, there is potential for harm if ineffective therapy is given based on test results, because there may be adverse effects of therapy in absence of a benefit. Accordingly, the use of expanded mutation panel testing for targeted treatment in cancer is considered investigational and should only be conducted in the setting of a clinical trial. Therefore, the FoundationOne gene test performed was not likely to have been more effective than the available options for the evaluation of this patients medical condition.Final Result: The reviewers determined that the services at issue were not 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 upheld. Credentials/Qualifications: All three reviewers 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: An enrollee has requested reimbursement for the platelet-rich plasma (PRP) injection for treatment of the enrollees neuroma of the left foot. Findings:  The 3 physician reviewers found that There is a paucity of information available in the literature concerning the effectiveness of PRP injection for treatment of neuroma pain. PRP provides a promising alternative to surgery or other invasive treatment modalities.  However, authors conclude that there are too few controlled trials and sample sizes are too small. Therefore, authors conclude that more large controlled studies are needed. In sum, there are a lack of controlled trials to conclude that PRP is better than any other standard treatment for musculoskeletal conditions. Therefore, the PRP injection provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service at issue was 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 reviewer number one is board certified in podiatry 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.Physician reviewer number two is board certified in podiatry 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.Physician reviewer number three is board certified in podiatry 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 panel of gene tests for evaluation of the enrollees malignant melanoma.  Findings:  The 3 physician reviewers found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers that can help guide therapy decision making. Per the National Comprehensive Cancer Network guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis. Gene expression profiling for melanoma could be a valuable contribution to understanding the biology of the disease. However, the difficulty of embracing gene expression profiling as an independent predictor of outcome is illustrated by the inconsistency of results across studies aimed at defining the most predictive gene sets for melanoma. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. As FoundationOne provides genetic testing to guide therapy and this is the subject of an ongoing phase II trial, it would be considered investigational/experimental for this patient. In addition, the records do not show that this patient has received standard treatment for metastatic melanoma. As such, the panel of gene tests performed were not likely to have been more effective than the standard of care for the evaluation of this patient. Final Result: The 3 reviewers determined that the services at issue were not 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 upheld.  Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical 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: 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 the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The 3 physician reviewers found that In the medical literature, genetic testing for medication guidance has not been demonstrated to result in improved health outcomes when used to direct treatment. Sufficient high-quality, replicated, and controlled studies demonstrating that pharmacogenetics and pharmacogenomics reliably improve health outcomes are not yet available. Genetic testing may not be reporting relevant clinical information. Although there are some circumstances that genetic testing may be indicated, there is a lack of scientific data supporting the use of the genetic testing performed in this case. Thus, the genotype testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross-linking for treatment of his keratoconus. Findings:  Three physician reviewers found that treatment for this patients condition with corneal collagen cross-linking was appropriate and consistent with current medical guidelines. Based on the patients diagnosis and progression, cross-linking was indicated as the most effective treatment option available. Although there are deficiencies in the individual studies on corneal collagen cross-linking, there is data available to support cross-linking as a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. Furthermore, corneal collagen cross-linking for corneal ectasias fulfills an unmet need. There is no other treatment option available to slow or halt disease progression. Given this support, the corneal collagen cross-linking provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Review: Three reviewers determined that the service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in ophthalmology and are actively practicing. The reviewers are 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.