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 FoundationOne gene testing.Findings:  Three physician reviewers found that FoundationOne is a 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 guide the clinician as to which chemotherapeutic agent would be useful. However, at this time, there is a lack of convincing evidence that the assay adds to the decision making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the value of molecular profiling, none of which have been convincing as to the efficacy of these analyses. A study did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. Additionally, finding a mutation does not guarantee that a treatment directed at it will produce a clinically meaningful response. Therefore, FoundationOne gene testing was not likely to have been of greater benefit than other methods of evaluating this patient. 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 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 authorization and coverage for topical ketamine with lidocaine, baclofen, gabapentin, and cyclobenzaprine.  Findings:  The physician reviewer found that There is a lack of scientific data to support the efficacy of topical ketamine for CPRS (Harden; Abdi, et al). Further, this patients records provided for review do not document treatment with sympathetic blocks, spinal cord stimulation, or other standard therapies which have support of efficacy in the peer-reviewed medical literature. Given these findings, the requested topical ketamine with lidocaine, baclofen, gabapentin, and cyclobenzaprine is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested topical ketamine with lidocaine, baclofen, gabapentin, and cyclobenzaprine is 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 requested topical ketamine with lidocaine, baclofen, gabapentin, and cyclobenzaprine is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with subspecialty certification in pain 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laser therapy (CPT code 17106). Rosacea is a common chronic disorder characterized by periods of exacerbation, remission and possible progression. In rosacea, the non-pharmacologic approach to therapy is adequate skin care, trigger avoidance, and photoprotection. In addition, there are several topical, herbal, systemic and light based therapies available. Further, the US Food and Drug Administration (FDA) has approved treatments include topical metronidazole and azelaic acid. Laser treatment can be used in combination with medical and topical treatments. Since this patient has failed many standard treatments, a multifaceted approach to therapy that includes laser treatment was an appropriate treatment option. Accordingly, the laser therapy was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the laser therapy was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in dermatology and is actively practicing.  All three 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 parent of an enrollee has requested authorization and coverage for once-per-week psychological therapy services. Researchers have noted that outpatient therapy is effective for childhood OCD and should be used when patients have not improved enough with medication treatment alone. Literature indicates that psychotherapy is typically used to help persons with depression, anxiety, and posttraumatic stress disorder, among other diagnoses. Researchers observe that there is a need for treatment planning as well as treatment goals in psychotherapy that would typically include symptom reduction of some type. In this case, it is apparent that the patient has anxiety symptoms that have continued over several months and years. While the patient has been receiving medication treatment, this alone has not been sufficient to treat the patients OCD and anxiety. Under these circumstances, once-per-week psychological therapy services are medically necessary for treatment of the patients medical condition.Final Result: The reviewer 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: The reviewer is board certified in psychiatry, with subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for arthroplasty (total joint replacement) of the right ankle. Nationally recognized evidence based medical guidelines recommend total ankle replacement surgery only for very limited indications. This patient presents with constant right ankle pain, grade 3/10 at rest and grade 8-10/10 with weight bearing. Pain interferes with activities of daily living and work ability. Clinical exam findings have documented painful limited range of motion and crepitus consistent with x-ray findings of end-stage post-traumatic right ankle osteoarthritis, reportedly bone-on-bone. He has had worsening pain despite long-term conservative treatment. The patients body mass index is 31. There are no guideline contraindications documented in the medical records. Current evidence based medical guidelines for total joint replacement in the ankle have been met. Therefore, the requested arthroplasty (total joint replacement) of the right ankle is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for progesterone suppositories and two Insulin Potentiation Therapy (IPT) treatments. The National Comprehensive Cancer Network (NCCN) standard preferred therapy for advanced staged III and IV and unresectable uterine cancer is chemotherapy with Platinum/Taxane therapy. Upfront surgery is very often necessary to make the diagnosis. However, while the estrogen receptor is prognostic in uterine cancer and presents an avenue for hormonal manipulation with progestational agents, the patients intermediate grade makes a response to such therapy less likely. In this setting of adjuvant therapy with gross residual disease, the likelihood of a meaningful response to progesterone suppositories does not justify that progesterone suppositories are medically necessary. In addition, there is no data to support the use of Insulin Potentiation Therapy (IPT) treatments in hormonal blocking therapy. Accordingly, progesterone suppositories and two Insulin Potentiation Therapy (IPT) treatments 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 obstetrics and gynecology, with subspecialty certification in gynecologic oncology. 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 transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous, with distal embolic protection (CPT code 37215). Findings: Three of the three physician reviewers found that the medical literature and submitted medical documentation support the present request. Internal carotid artery dissection is a major cause of acute ischemic stroke in the young and is responsible for 1025% of all strokes occurring in this population. Anticoagulation is the mainstay of treatment, but in patients who fail anticoagulation or have contraindications to anticoagulation, intervention is often considered. Open surgical repair had historically been the traditional therapy of choice, but percutaneous therapy with stent placement has become increasingly commonplace. No randomized trials exist regarding optimal surgical management of carotid artery dissection. Current literature supports both open and endovascular treatment as safe and effective for carotid artery dissection. In this patient with recurrent strokes, failure of anticoagulation, and a very high lesion not amenable to surgery, stenting is an appropriate option. Therefore, transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous, with distal embolic protection (CPT code 37215) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is 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 reviewer number one is actively practicing and is board certified in diagnostic radiology and interventional radiology. Physician reviewer number two is actively practicing and is board certified in surgery and vascular surgery. Physician reviewer number three is actively practicing and is board certified in diagnostic radiology. 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 reimbursement and prospective authorization and coverage for outpatient therapy services, once per week. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes do not include a description of the exact symptoms that are being treated in therapy. The patient has several issues of stress in life, including marital stress and parents illness. However, it is unclear as to whether the enrollees symptoms are improving or worsening. There is no description of exact therapeutic techniques, such as cognitive behavioral therapy or other forms of evidence-based mental health treatment. There is no clear description of treatment goals for the patients therapy. The DSM-5 indicates that functional impairment must be present in order for a set of symptoms to classify as a mental illness. The progress notes do not detail any functional impairment, as they are simply lists of problems that the patient is experiencing. Based on the documentation provided for review, there is no clinical indication that this patients therapy needs to occur on a weekly basis. Therefore, outpatient therapy services, once per week, were not and are not medically necessary for the treatment of this patient.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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for shoe insert (custom molded orthotics). The Health Plan has denied this request indicating that the requested devices are not medically necessary for treatment of the enrollees rheumatoid psoriatic arthritis. A review of the record indicates that the enrollee has been diagnosed with rheumatoid arthritis, psoriatic arthritis and capsulitis of the first metacarpophalangeal joint (MPJ). The provider note reported the enrollees old orthotics have bottomed out and no longer offer utility. The provider reported the enrollee is in need of new orthotic appliances because of their arthritic status and chronic pedal pain. The provider reported the enrollee has had these devices previously approved and will return to the office for orthotics casting pending approval. The submitted documentation supports the medical necessity of the requested devices. It is established in the progress note that the patient suffers with psoriatic and rheumatoid arthritis to bilateral feet as well as capsulitis to the first metatarsophalangeal joint on the left side. Orthotics are commonly utilized to combat foot pain caused by arthritic conditions. Functional custom molded orthotics provide significant support to otherwise unstable or painful joints that help reduce pain. Custom molded orthotics may also incorporate certain pads and fabrications in order to accommodate pain below the first metatarsophalangeal joint. Therefore, the requested custom orthotics are medically reasonable and necessary for treatment of this patient.Final Result: The reviewer determined that the requested devices are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tymlos 80 mcg injection or Forteo 20 mcg injection. The patient has severe osteoporosis of the spine that has caused multiple compression fractures requiring multiple vertebroplasties and back surgery. Unfortunately, because of the compression fractures, the patient is in pain. Just by the fact that she has had compression fractures, the patient's risk for additional compression fractures is very high. Miller notes, `Whether symptomatic or asymptomatic, they (vertebral fractures) both represent a high risk for not only vertebral but also nonvertebral fractures in untreated populations. This high risk of future fracture after a VCF (vertebral compression fracture) is independent of the T-score because bone strength is a combination of bone mineral density and bone quality. VCFs are the single greatest risk for future fractures at all other skeletal sites in untreated populations, including hip fractures. It is therefore important for a patient with compression fracture(s) to receive the most efficient therapy in the correct sequence to optimize healing and decrease the risk of additional fractures. Additional compression fractures of the spine or a hip fracture will significantly add to the already sick patient with multiple aliments. The Health Plan is requiring the use of an antiresorptive agent, denosumab (Prolia), prior to the approval of an anabolic agent, Tymlos or Forteo. Cosman and colleagues have documented that the treatment sequence matters and the use of an anabolic agent such as teriparatide and now the abaloparatide in the same family, followed by an antiresorptive agent will be the most efficient way to treat this patient. Iwata and colleagues indicate teriparatide has been shown to optimize healing of vertebral fractures. Miller and colleagues note a recent study has shown that abaloparatide had greater response rate than teriparatide in increasing bone mineral density. This patient needs Tymlos or Forteo urgently to continue her treatment with this anabolic agent given her history of severe osteoporosis. Once the treatment cycle with Tymlos or Forteo is completed, she should be transitioned to an antiresorptive agent to prevent loss of the gains in strength and bone density. Treatment with Tymlos or Forteo is medically necessary for this patient at this time, and must be completed prior to the antiresorptive therapy. Final Result: The reviewer 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: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Testopel 75 mg and prospective authorization and coverage for Testopel 75 mg, quantity of 12.Findings:  Two of the three physician reviewers found Low testosterone can lead to complications such as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue. For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL. The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal, and the dose of testosterone replacement therapy should be adjusted accordingly. Testopel slowly releases testosterone over the course of three to six months. The medical evidence supports the medication at issue in this clinical setting. Therefore, the medication at issue was and is likely to be of greater benefit than other treatment options.Final Result: The reviewers determined that the medication at issue was and is 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. In the medical literature, the largest studies reporting on the outcomes of multigene testing indicate that among female patients tested in clinical settings, about 5-10% have a BRCA1 or BRCA2 mutation, and about 4-7% have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer, or a mutation in a newer gene that may be associated with increased risks for these cancers. Panel testing is now considered a standard of care in this clinical setting. This patient has three close relatives with malignancies that could be familial and suspicious for a BRCA mutation on the paternal side. This meets the National Comprehensive Cancer Network (NCCN) guidelines for BRCA testing. Panel testing is now considered within the standard of care. Accordingly, the genetic testing genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the genetic testing genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service 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:  One reviewer is board certified in genetics and is actively practicing. One Reviewer is board certified in genetics and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three 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.