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

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for magnetic resonance spectroscopy (MRS) of the brain. Arginase deficiency is an inborn error of metabolism. Manias and Peet described that MRS is a novel advanced imaging technique used as an adjunct to MRI to reveal complementary non-invasive information about the biochemical composition of imaged tissue. The authors noted that, Inherited metabolic disorders demonstrate accumulation of neurotoxic metabolites visible on MRS. The technique has proved to be useful in detecting early metabolic abnormalities prior to clinical or MRI changes in children with rare metabolic diseases. For these reasons, the requested MRS of the brain is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested MRS of the brain is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be 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 reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is actively practicing. Physician reviewer 2 is board certified in neurology with special qualification in child neurology and is actively practicing. Physician reviewer 3 is board certified in neurology with special qualification in child neurology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for the DecisionDx-Melanoma gene test. This patients dermatopathology report demonstrated melanoma with a Breslow depth, non-ulcerated, stage pT2a. He underwent DecisionDx-Melanoma gene testing to assist in his treatment planning. The DecisionDx-Melanoma gene test analyzes the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The National Comprehensive Cancer Network (NCCN) guidelines do not endorse routine use of the DecisionDx-Melanoma gene test. Overall, there is a lack of published data to support its routine use in this clinical setting. All told, the DecisionDx-Melanoma gene test was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for epoprostenol (Veletri) infusions (HCPCS J1325). This patient has severe refractory Raynauds phenomenon with digital ischemia and ulcerations due to systemic sclerosis. The patient has failed multiple standard therapies and has digital ischemia with necrosis. Veletri has been demonstrated to be effective even in patients who have been refractory to other therapies. This patient has demonstrated a positive response to Veletri in the past. Cruz and colleagues reported that the available evidence supports intravenous (IV) Veletri for treatment of severe Raynauds phenomenon in patients refractory or intolerant to standard therapies. Given these findings, the requested epoprostenol (Veletri) infusions (HCPCS J1325) are medically necessary for 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 internal medicine with subspecialty certification in rheumatology 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 authorization and coverage for a positron emission tomography (PET) scan. The assessment of disease burden and therapeutic response in this patient with metastatic renal cell carcinoma is critical to her care and effective decision-making. The patient has extensive disease with soft tissue and bone lesions. She is not able to continue with contrast enhanced computed tomography (CT) imaging due to an iodine contrast allergy. CT imaging without contrast would not be useful for appropriate care of this patient. PET imaging has demonstrated effective detection of clear cell renal cancer metastases comparable or superior to contrast CT imaging. In one publication comparing PET/CT imaging to contrast CT imaging, PET detected all of the sites of distant metastasis revealed by CT, as well as eight additional metastatic sites, leading to an accuracy of 94% versus 89% for CT. All told, the requested PET scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested PET scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be 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 reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for the surgical procedure on the left toe. Clinical examination and operative findings were consistent with advanced hallux rigidus. She underwent placement of left first MPJ joint implant with complete resolution of her symptoms and functional restoration. The evidence-based medical literature supports the use of the joint implant as an option in this patients medical condition to maintain first MPJ motion. Given this patients age and desire to maintain first MPJ motion, the use of the implant was indicated over fusion. Therefore, the surgical procedure on the left toe was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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

The enrollee is requesting authorization and coverage for custom foot orthotics. The enrollee has plantar fascial fibromatosis. She also has left heel pain that has been unresponsive to anti-inflammatories, pain medications, shoe modification, over-the-counter orthotics, stretching, and ice. She reported her pain as throbbing and reported she was unable to walk. Her podiatrist recommended physical therapy and custom orthotics. This enrollees records show a three-month history of heel pain, and records support the enrollee experienced a similar issue in the past, which responded only to an injection. Medical records do not show the enrollee was offered a steroid injection. Although prescribed, the records do not support the enrollee completed a course of physical therapy. There is no evidence of a follow up with the provider to assess the enrollees response to the treatment plan. There is insufficient evidence to support the enrollee has performed and failed conservative measures. Literature indicates customized and prefabricated foot orthoses demonstrates a similar effect on pain relief, and were similar in their effect on function in the medium term. There is moderate-quality evidence that foot orthoses are effective at reducing pain in the medium term; however, it is uncertain whether this is a clinically important change. Research indicates there are no data on the efficacy of these devices as compared with placebo or no treatment.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in podiatric 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for lidocaine 5% patches (30 patches for 30-day supply).The submitted documentation does not support that the requested medication is medically necessary in this clinical setting. The manufacturer label for Lidoderm includes the following general precaution for Hepatic Disease, `Patients with severe hepatic disease are at greater risk of developing toxic blood concentrations of lidocaine, because of their inability to metabolize lidocaine normally.` Lidoderm patches are indicated for the treatment of post herpetic neuralgia for localized pain and not for either generalized osteoarthritis or inflammatory erosive systemic arthritis. In this case, the patient has a systemic inflammatory form of arthritis for which Plaquenil has been prescribed as well as multiple intraarticular steroids. The patient also has a history of chronic hepatitis related to alcohol use. The provider is concerned about hepatic issues, and the patient is already using lidocaine 4% over-the-counter. Under these circumstances, the requested medication lidocaine 5% patches (30 patches for 30-day supply) 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 internal medicine, with subspecialty certification in rheumatology, 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

An enrollee has requested authorization and coverage for MaterniT21 Plus. The use of a specific cell-free DNA test focuses on an individual patients needs as well as personal and family history. For detection of chromosomal aneuploidies 13, 18 and 21, MaterniT21 testing is indicated for this patient. The records document abnormal findings on ultrasound. The American College of Obstetricians and Gynecologists (ACOG) noted that cell-free DNA testing is not recommended as a routine, first-line test. However, given the presence of a higher risk of fetal aneuploidy in this case, the requested MaterniT21 Plus is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested MaterniT21 Plus is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be 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, and 3 are board certified in obstetrics and gynecology 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

The patient has requested reimbursement for residential mental health services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying the LOCUS guideline, this patient did not meet the criteria for the residential mental health services. The records provided for review document that the patient was at some risk of harm, as he had passive suicidal ideation without active urges or intent. The patient demonstrated some functional impairment to social isolation and inability to complete his graduate school studies. The patient had minor comorbidities, including neuropathic pain from lichen sclerosis for which he was taking gabapentin and Tylenol with codeine. The patient had minimal medication changes during his stay. The patients recovery environment was mildly stressful. The patient lived with his father, who was involved and supportive with his treatment. The patient initially demonstrated poor response to treatment, with improvement in mood and functioning by the end of his admission. The patient demonstrated optimal engagement as reported by the providers. The patients composite score is 13, which is consistent with recovery maintenance health management. Given these findings, the residential mental health services were not medically necessary for 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 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: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for a Holter monitor. The patients records show a diagnosis of arteriosclerotic heart disease; however, this condition was not noted in the progress notes. Diagnostics reports showed moderate left ventricular hypertrophy, and mild left ventricular diastolic dysfunction. The patient underwent a 24-hour Holter monitor test. Testing showed the patients average heart rate was 75 beats per minute. Occasional premature ventricular contractions were reported. The patients cardiologist recommended repeating the tests in one year. The cardiologist ordered a stress echocardiogram, echocardiogram, 24-hour Holter monitor, and a central venous pressure test, as one year has elapsed. Ambulatory electrocardiographic monitoring is useful to evaluate whether symptoms, such as palpitations, presyncope, or syncope, are the result of a ventricular arrhythmia. The main role of ambulatory electrocardiography is to detect and characterize the cardiac electrical activity during ordinary daily life activities. Ambulatory electrocardiographic monitoring is listed as a Class I recommendation by the American College of Cardiology/American Heart Association 2017 Guidelines and is supported by randomized trials. This patients medical record provided very little clinical information. An electrocardiogram report is not available and the progress notes do not show this patient has atherosclerotic heart disease. The records show the patient is overweight and describe his echocardiogram as having a normal ejection fraction with moderate left ventricular hypertrophy and mild diastolic dysfunction. However, no segmental wall motion abnormalities are noted. A Holter recording from 2018 showed normal sinus rhythm and occasional ventricular premature beats. Literature shows the Holter recording can assist in evaluating symptoms such as syncope, dizziness and palpitations and to evaluate a patients response with discontinuation from drug therapy. None of these indications is reported in this patients medical record.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal medicine and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for Prolia injections. The enrollee has a history of osteoporosis and gastroesophageal reflux disease. A bone density study showed the enrollees bone mineral density had declined. The enrollees endocrinologist recommended increased dosages of vitamin D and calcium supplements, and recommended the enrollee begin anti-resorptive therapy. The endocrinologist reported the enrollee is not a candidate for oral therapy due to her history of gastroesophageal reflux disease. The enrollee describes anxiety regarding intravenous infusion and the enrollee does not want Reclast. The enrollees spouse reports the enrollees vein swells, turns red and itches, for a duration of 15 to 30 minutes, when the enrollee receives infusions; even with saline infusions. A professional society recommends that clinicians offer treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis. The authors also indicate there is insufficient evidence to determine the comparative effectiveness or superiority of one medication over another, within the same class or among classes, for the prevention of fractures. Network meta-analyses demonstrate that, overall, there are no statistically significant differences among the medications. Medical records report this enrollee has a history of depression and anxiety. The notes also report she is fearful of medical treatment. Since there is no difference in effectiveness, the choice of therapy would depend upon the persons compliance with the regimen. If the enrollee refuses intravenous administration, then the use of Prolia, which is administered subcutaneously, becomes the clinical choice.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Lynparza (olaparib) 150 mg tablets, two tablets twice a day. Poly ADP ribose polymerase (PARP) inhibitors have shown promise for the treatment of certain cancers related to BRCA1 and BRCA2 mutations. There is a paucity of data in the current medical literature to support the use of PARP inhibitors, such as Lynparza, in the treatment of colon cancer. There are ongoing clinical trials evaluating the safety and efficacy of PARP inhibitors in combination with other drugs for the treatment of solid tumors. Although this patient has a somatic BRCA2 mutation, the available data do not support an indication for treatment with a PARP inhibitor. Based on these findings, the requested Lynparza (olaparib) 150 mg tablets, two tablets twice a day, is not medically necessary for treatment of this patient.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 subspecialty 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.