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

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the DecisionDx-Melanoma Assay gene test for evaluation of the enrollees malignant melanoma. Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Assay gene test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two out of 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: Physician reviewer number one is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the sinus treatment (CPT codes 31296, 31296/50, 31297/51, 31295/51, 31295/50A and 31297/50) for treatment of the enrollees constant nasal congestion.Findings:  The physician reviewer found that at present, functional endoscopic sinus surgical techniques for the management of chronic rhinosinusitis refractory to medical management are still considered the surgical treatment of choice. However, this patient does not meet clinical medical criteria for surgical treatment of the paranasal sinuses based on the evidence reported in the medical reports. According to the medical reports submitted for review, this patient complained of nasal congestion but not recurrent acute of chronic sinusitis. The patient was shown to have enlarged inferior turbinates. However, there was no indication in the medical reports submitted that the patient had evidence of more than three months of continuous sinus disease other than nasal congestion. As such, the sinus treatment (CPT codes 31296, 31296/50, 31297/51, 31295/51, 31295/50A and 31297/50) provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three 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 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.Physician reviewer number two 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.Physician reviewer number three 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for emergency medical services.Findings:  The physician reviewer found that the psychiatric services provided were not necessary for treatment of a psychiatric emergency medical condition. The patients post-acute withdrawal symptoms were mild to moderate. The patient was not a danger to self or others, and the patient displayed no self-harming behaviors. There were no emotional, behavioral, cognitive, or impulsive symptoms that supported a psychiatric emergency medical condition. The patient had no comorbid medical conditions, and was psychiatrically stable. The patient was not manic or psychotic. The patient was assessed as a mild safety risk. The patient was motivated and actively engaged in working the program. The patient was developing insight and coping skills. The patient had no acute symptoms placing the patients health in jeopardy, causing impairment, or serious dysfunction. The patient had no psychiatric emergency medical condition as the patient was not a danger to self or others. For the reasons provided, the patient did not receive psychiatric emergency medical services on the dates of service at issue. FFinal Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Lyrica for treatment of the enrollees thoracic outlet syndrome. Findings:  The physician reviewer found that Lyrica is supported for the treatment of seizure disorder and neuropathic pain. Lyrica is recommended for use after failure of first-line agent such as gabapentin. Current peer-reviewed medical literature has demonstrated that Lyrica is effective for treatment of patients with neuropathic pain. The medical records report this patient has a neuropathic pain condition of thoracic outlet syndrome. The records report previous treatment and failure with gabapentin. Thus, Lyrica is medically necessary based on the records provided for review.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 neurology 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: The patient has requested authorization and coverage for Jakafi 10 mg for treatment of the enrollees graft versus host disease (GVHD). Fulfills requirements of (1374.33) (h)(1)(A), (B), and (C). Findings:  The physician reviewer found that patients who have undergone allogeneic hematopoietic stem cell transplant (allo-HSCT) are at risk for acute graft versus host disease (GVHD) (Flowers, et al). Immunosuppressive therapy is indicated and Jakafi is increasingly being recognized as a potent agent for use in this clinical setting. Jakafi is an ATP-competitive inhibitor of Janus kinases 1 and 2. In a retrospective survey of multiple transplant centers, Jakafi was effective in controlling steroid refractory GVHD in 80% of patients .  There is sufficient medical evidence to show that Jakafi has a role in patients who have exhausted standard treatment. As this patient has exhausted standard treatment, the requested Jakafi 10 mg is supported as medically necessary for treatment of this patients GVHD. Fulfills requirements of (1374.33)(h)(1)(H) and (K).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. Fulfills requirement of 1374.33(h)(1)(I) Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology 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. Fulfills requirement of (1374.33)(h)(1)(G)
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Forteo injection 20 mcg for treatment of the enrollees osteoporosis. Findings:  The physician reviewer found that There is support in the medical literature for the requested medication in this clinical setting. The Fracture Risk Assessment Tool (FRAX) guidelines state the following, Teriparatide (Forteo) is an anabolic agent that stimulates bone formation and has been approved by the [U.S. Food and Drug Administration] FDA for treatment of osteoporosis. There are many studies in the medical literature that support the use of teriparatide to stimulate healing in nonunions, like in this patients case.  The literature is vast in favor of the positive effects of teriparatide and osteoporotic fracture healing and nonunion or delayed union healing of bone after surgery. In this case, the prescribed trial of Forteo for this patient with a high risk for fracture and a nonunion ankle bone fusion, is medically necessary. The patient had the initial ankle fusion procedure in 2015 with failure to heal. The patient had a revision in 2016 that also failed to demonstrate healing. Computed tomography scan has demonstrated only 5% bridging, and the patient is not responding to bone stimulation therapy. The patient is at high risk for hip fracture and according to the FRAX calculation, therapy for osteoporosis is indicated. Additionally, the patient has reported that the patient is in pain. Based on the evidence in the literature about the benefits of bone formation and fracture and nonunion healing, there is sufficient evidence to use Forteo for the purposes of stimulating bone formation, bridging and healing of the failed fusion, as well as to decrease the patients risk of hip fracture. For all these reasons, Forteo is medically necessary for the treatment of this patients medical condition. )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 endocrinology, diabetes and metabolism 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:The physician reviewer found that Hunter syndrome, or mucopolysaccharidosis type II, is a lysosomal storage disease caused by a deficient (or absent) enzyme, iduronate-2-sulfatase. It is an X-linked recessive disease, leading to progressive accumulation of glycosaminoglycans in nearly all cell types, tissues and organs.  Characteristic features of mucopolysaccharidosis type II include coarsened facial features, an enlarged head, an enlarged tongue, hypertrophic tonsils and adenoids, irregularly shaped teeth, recurrent otitis media, a distended abdomen due to hepatosplenomegaly, abdominal and/or inguinal hernias, thickened pebbled skin, and short stature. Although the specific combination of signs and symptoms may vary considerably between individuals, the presence of any of the features listed may be suggestive of mucopolysaccharidosis type II. The gold standard for the diagnosis of mucopolysaccharidosis type II is demonstration of deficiency of iduronate-2-sulfatase enzyme activity. Genetic testing of iduronate-2-sulfatase to confirm the diagnosis may be useful in patients with an unusual phenotype or in whom the results of iduronate-2-sulfatase testing are inconclusive.  In this patients case, the iduronate-2-sulfatase activity was zero and other enzyme activity was normal. This, along with the characteristic physical examination features, is diagnostic of mucopolysaccharidosis type II, Hunter syndrome.  In sum, the requested gene testing is not likely to be of greater benefit than other methods of evaluating this patient.  Final Result: The reviewers determined that the requested service are 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 pediatrics and clinical biochemical genetics] 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 pediatrics 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 pediatrics 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: The patient has requested reimbursement for the magnetic resonance imaging (MRI)of the enrollees lumbar radiculopathy status post lumbar fusion. Findings:  The physician reviewer found that while the patient continues to report low back pain and right radicular symptoms the provided records do not document an adequate trial of conservative management after the removal of the lumbar screws from the patients prior fusion. The provider indicates that anterior lumbar interbody fusion (ALIF) has been considered since the patient has not significantly improved following the screw removal. However, the patient does not have a history of fever to indicate infection, or neurological deficit or other red flag to support an indication for immediate imaging with MRI. Overall, the criteria for the lumbar spine MRI rendered was not medically necessary for evaluation of this patients medical condition absent a trial of conservative management. Final Result: The reviewer determined that the diagnostic procedure at issue was 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 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 reimbursement for substance use residential treatment center servicesfor treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the services at issue in this clinical setting. The patients comorbid anxiety and depression were well controlled on medication. The patient did not have a psychiatric condition or medical illness that required treatment at the residential level of care. The patient was motivated in his quest for sobriety. The patient was employed and had safe housing.  At the time of discharge from detoxification treatment, the patient was improved and motivated for recovery. It was recommended that he have a follow up visit with the patients community provider in six weeks. During the episode of illness, the patient had no history of chemical dependency treatment such as community programming, outpatient counseling, anticraving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment. The medical literature recommends treatment in the community as outcome measures and therapeutic gains are optimized in this environment. Additionally, the patient previously achieved sobriety after a week long admission followed by Alcoholics Anonymous. There was no evidence to suggest that similarly comprehensive, evidence based services provided in a less restrictive treatment setting would have been insufficient or inadequate at the time in this patients case.  Although addiction specialty services were indicated, the clinical documentation does not demonstrate the medical necessity of treatment in a 24 hour supervised setting during the disputed timeframe.  Therefore, the substance use residential treatment center services were not medically necessary for the 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 reimbursement for FoundationOne gene testing services for treatment of the enrollees breast cancer. Findings:  The physician reviewer found that molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful.  However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician, nor yields a result that is reliably clinically beneficial to the patient. There are various nonrandomized studies exploring the value of molecular profiling but these studies are not convincing.  A randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. Some recent studies have expressed serious reservations about this approach in general. Therefore, the FoundationOne gene testing provided on 10/26/16 was not likely to have been more effective than other methods available for the evaluation of this patients medical condition.Final Result: The reviewers determined that the 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.