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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H-Wave device. Findings:  The physician reviewers found that meta-analysis of the peer-reviewed literature regarding low back pain reveals multiple non-randomized or anecdotal studies/reports in the medical literature which report patients benefit from H-Wave. Also, comparative studies demonstrating a greater benefit from TENS versus other forms of passive treatment are lacking.  Overall, there is a lack of high-quality or peer-reviewed studies comparing H-Wave to standard treatment options.  In sum, H-Wave device is not likely to be more effective than other standard options for treatment of this patients medical condition. Final Result: 3 of 3 reviewers determined that the requested device is 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: All three physician reviewers are board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 12 additional days of intensive outpatient program (IOP) services provided for treatment of the enrollees major depressive disorder, social anxiety disorder, and attention deficit hyperactivity disorder (ADHD). Findings: The physician reviewer found that a review of the patients IOP records indicate that he did not report suicidal or homicidal ideation or psychosis. The patient has longstanding anxiety issues and was noted to make good progress in the IOP. He was cooperative, calm and engaged actively in the IOP. He was able to verbalize improvement in his relationships with family as well as his target symptoms. Outpatient treatment and least restrictive options are considered the first-line of care as referenced by The American Academy of Child and Adolescent Psychiatry (AACAP), which recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. Cognitive behavioral therapy as a mainstay for anxiety treatment and is effective on an outpatient basis. One study noted that the cognitive-behavioral treatment program was similarly effective in anxious children with and without comorbid disorders; both groups showed clinically significant reductions in pretreatment diagnoses and symptoms. Applying the Child and Adolescent Level of Care Utilization System (CALOCUS), this patients presentation a composite score of 14, which correlates with outpatient services given his lack of suicidal or homicidal ideation, some deterioration and expected level of functioning in relationships with peers, adults and family, lack of co-morbid medical problems or substance issues, and mild issues with family relationships, and a stable housing situation. Further, the patient has a highly supportive recovery environment with family that is actively involved in treatment and attends family therapy sessions on a regular basis. Moreover, the patient has demonstrated recent successful experience in treatment and has participated actively in therapy and as shown improvement. 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 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: 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 acute inpatient psychiatric treatment for treatment of his schizophrenia. Findings:  The physician reviewer found that based on the available documentation, the patient could have been treated in a lower level of care. The provider noted doubts regarding the patients primary diagnosis of schizophrenia, and it was indicated that the patients primary diagnosis was a substance use disorder. The patient denied any suicidal or homicidal ideation. There was no evidence that the patient was not compliant with medications or staff direction, the patient was medically stable, and there was no documentation that the patient was sleeping poorly or not eating. There had not been any medication changes with the patient for weeks. The patient continued to have poor insight, paranoia, and substance seeking behaviors, and continued to require treatment, but the patient was a candidate for treatment in a less restrictive setting. 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 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 Plegridy Pen for treatment of the enrollees relapsing multiple sclerosis. Findings:  The physician reviewer found that this patient has longstanding multiple sclerosis with mild disability and recent increase in disease activity. She discontinued one disease modifying therapy six years previously due to interferon side effects. It has now been recommended she use Plegridy, which is a pegylated interferon, every two weeks. As this is an interferon that is nearly identical to Rebif, it would be expected that the patient would have similar side effects. It has been the experience of many providers that Plegridy actually has more interferon related side effects than all of the other interferons. Plegridy offers no clear advantages over other interferons except for its biweekly dosing schedule. It is thus reasonable to use Avonex which is on the formulary and has efficacy and side effect profiles similar to Plegridy including low incidence of neutralizing antibodies, except it does not have injection site reactions due to its intramuscular route of administration. Currently, there is a lack of evidence that Plegridy has higher efficacy than the standard available therapies. 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 neurology 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 residential treatment services provided for treatment of the enrollees alcohol use disorder. Findings:  The physician reviewer found that based on the available documentation, the residential treatment services provided from were not medically necessary for treatment of this patients medical condition. The patient was not experiencing post-acute withdrawals, he was not a danger to himself or others, and there were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was medically and psychiatrically stable to the extent that he did not need residential level of care. Vivitrol could have been administered on an outpatient basis. He was engaged and participated in his treatment plan, was looking for a sponsor, and he was insightful. The issues he was working on in individual therapy that centered around his family relationships did not need to be addressed in residential treatment. His recovery could have continued on an ambulatory basis in a less restrictive treatment setting. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing to analyze how the body breaks down some drugs performed.  Findings:  The physician reviewer found that  genetic testing results may show if a patient is a normal responder of certain classes of medications, may be more or less likely to respond to certain medications, is at low risk of certain adverse events, at higher risk of others, or may have decreased activity of a certain enzymatic line. However, studies have shown that clinically useful predictors in genetic testing are limited for medication therapy, with results being inconsistent and only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability. Moreover, there is a lack of large randomized trials have been conducted supporting its use. The existing studies have also indicated that there was no significant correlation between either genotypes or medication serum concentration and response treatment. Current evidence does not support the use of genotyping when choosing a medication, and even less is understood about its use in treatment. It lacks evidence based research to show efficacy in guiding the clinician towards choosing a medication regimen. Given these findings, the genetic testing to analyze how the body breaks down some drugs performed on was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the 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 s 1, 2, & 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections. Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Treatment with viscosupplementation injections have been found to be safe and effective and allow for delay of total knee replacement . In this case, the patient has been diagnosed with advanced bilateral knee osteoarthritis. He has undergone previous viscosupplementation series with Synvisc with positive results documented in terms of pain reduction and improved function. The patient reports progressively worsening of his knee pain and difficulty maintain an active lifestyle. Therefore, the requested Synvisc injections are medically necessary for treatment of the patients medical condition. Final Result: The reviewers determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer is board certified in orthopedic surgery 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 nrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that ABA has been shown in the medical literature to be effective for children with autism spectrum disorders. A study found that early intensive behavioral intervention is effective to increase IQ, and improve communication and adaptive skills. In this case, the patient ABA therapy is medically necessary for the treatment of the patients autism including the adaptive delays. Moreover, the patients discharge report from ABA therapy does not adequately address the patients skills or provide sufficient evidence that he has met all of his goals. All told, ABA therapy has been established as medically necessary for treatment of the patients autism.  Final Result: The reviewers determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number two is board certified in pediatrics with sub-specialty certification in developmental-behavioral 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: Anenrollee has requested authorization and coverage for Harvoni for eight weeks. Findings:  The physician reviewer found that According to 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 applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, Harvoni for eight weeks is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx melanoma assay performed.  Findings:  The physician reviewer found that the DecisionDx melanoma assay tests the tissue genetics of an individual patients melanoma and can stratify whether a thin melanoma is high risk for metastasis. The DecisionDx has shown some impressive accuracy in melanomas like this patients tumor. However, there is a lack of data supporting treatment decision making based on the results of the test. Overall, there is a paucity of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. Further, the test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Given these findings, the DecisionDx melanoma assay performed on was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the 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 reviewers 1,2 & 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma gene classifier testing performed.  Findings:  The physician reviewer found that  the Afirma gene classifier testing performed on the date in question was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The cytopathology of the 2.8 cm thyroid nodule was consistent with AUS. The risk of malignancy is 5-15% in these types of nodules . The American Thyroid Associations guidelines state that for nodules with AUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. In this case, the benign result prevented the need of an additional biopsy or diagnostic surgery. This approach is supported by clinical studies and recommended for management and to avoid unnecessary procedures or diagnostic thyroidectomy). Therefore, the testing at issue has been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result:  All three (3) reviewers determined that the testing at issue was 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 & 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

Standard ReviewA transgender female enrollee has requested authorization and coverage for consultation with a plastic surgeon regarding facial feminization surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees gender dysphoria.Credentials/Qualifications: The reviewer is board certified in plastic surgery 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. Nature of Statutory Criteria/Case Summary: There is sufficient support for the medical necessity of the requested consultation with a plastic surgeon in this clinical setting. This patient has well-documented gender dysphoria which has been treated with hormonal therapy and counseling for over one year.  She is noted to have masculine features of the face that is contributing to her gender dysphoria. The provider noted that while the patient has been on hormone therapy for almost over one year, the patients facial features are more consistent with a male appearance. It is possible there are indications for surgical treatment to establish a female appearance in this patients case.  Thus, a plastic surgeon can adequately examine and evaluate the patient to determine the appropriateness of possible surgical treatment. Therefore, consultation with a plastic surgeon regarding facial feminization surgery is medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Myrbetriq 50 mg. Findings:  The physician reviewer found that there is a lack of documentation from the provider in the medical records reviewed that this patient has completed an adequate trial of oxybutynin. Currently, Myrbetriq is considered a second-line therapy for this patients progressive urinary frequency and incontinence. In the absence of records demonstrating that the patient has failed an adequate trial of a first-line therapy such as oxybutynin, the requested Myrbetriq is not supported as medically necessary. 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 urology 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.