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 test. Findings: Two of the 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 in determining which chemotherapeutic agent would be useful. 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 varieties of non-randomized studies exploring the value of molecular profiling, none of which have been convincing as to the efficacy of these analyses. A randomized trial by researchers 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 test was not likely to have been more efficacious 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 reimbursement for Genova Diagnostics testing.Findings:  Three physician reviewers found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Multiple evidence based studies have demonstrated that IgG testing to foods is an unproven method of testing for food intolerances as well as food allergy. The Guidelines for the Diagnosis and Management of Food Allergy in the United States, published by the National Institute of Allergy and Infectious Diseases (NIAID), specifically lists allergen-specific IgG4 testing among tests that are unproven and nonstandardized, and therefore not recommended. IgG antibodies are proteins produced by the immune system in response to exposure to external triggers, like pollens, foods or insect venoms. Their presence reflects exposure to these triggers, not disease that results from exposure. IgG antibodies to food are commonly detectable in healthy adult patients and children, whether food-related symptoms are present or not. There is no credible evidence that measuring IgG antibodies is useful for diagnosing food allergy or intolerance, nor that IgG antibodies cause symptoms. The only exception is that gliadin IgG antibodies can be used to monitor the success of avoiding gluten in people with proven celiac disease. The Genova Diagnostics IgG testing performed for the patient therefore was not likely to be more beneficial than any available standard therapy for the patients medical condition.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any other 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 allergy and immunology and internal medicine. Physician reviewer number two is actively practicing and is board certified in allergy and immunology. Physician reviewer number three is actively practicing and is board certified in allergy and immunology and internal medicine. 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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for the medication Myrbetriq 25mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees urinary incontinence; urinary urgency; voiding dysfunction; pelvic floor dysfunction; and overactive bladder.At issue in this case is whether the requested Myrbetriq 25mg is medically necessary for treatment of the enrollees medical condition.Fluid management behavioral therapy is the primary treatment for patients with symptoms related to overactive bladder. However, patients often require additional therapy with pharmaceuticals. The American Urological Association guidelines regarding treatment of overactive bladder suggest treatment of symptoms of overactive bladder with antimuscarinics and/or Beta 3 agonist. These medications are often used in conjunction with primary treatment options. Researchers concluded that mirabegron (Myrbetriq) 50mg had similar efficacy to most antimuscarinics and lower incidence of dry mouth, the most common adverse event reported with antimuscarinics and one of the main causes of discontinuation of treatment. Beta 3 agonist Myrbetriq is approved for treatment of symptoms related to overactive bladder. Treatment of this patients symptoms with Myrbetriq is indicated. Therefore, Myrbetriq 25mg daily is medically necessary.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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Coflex spinal spacers.Findings:  Two of the three physician reviewers found this patient presents with persistent chronic low back pain with radicular symptoms, including numbness and tingling in her left leg. She had associated significant functional limitations in activities of daily living. There is reported imaging evidence of moderate spinal stenosis at the L3-4 and L4-5 levels and grade 1 spondylolisthesis. Evidence of long-term comprehensive nonoperative treatment has been submitted. The current evidence-based literature supports the use of Coflex interlaminar stabilization with decompression as a safe and efficacious alternative to decompression and/or lumbar fusion for the treatment of lumbar spinal stenosis at one to two levels. Therefore, the requested Coflex spinal spacers are likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested devices are 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Optune Tumor Treatment Fields Therapy and prospective authorization and coverage for future Optune treatment.Findings:  Three physician reviewers found that the services in issue were and are likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. In 2011, the U.S. Food and Drug Administration (the FDA) approved the Optune portable medical device for the treatment of recurrent glioblastoma. The Optune device generates low-intensity alternating electric fields, or tumor treatment fields (TTF). Approval was based on results of a clinical trial that randomly assigned 237 patients to either TTF therapy or chemotherapy. Similar survival was observed in the two groups, and TTF therapy was associated with lower toxicity and improved quality of life. A subsequent open-label randomized trial in patients with newly diagnosed glioblastoma showed prolonged progression-free and overall survival in the group assigned to TTF therapy when used in combination with post-radiation temozolomide. Consensus-based guidelines published by the National Comprehensive Cancer Network (NCCN) include alternating electric field therapy as a treatment option for patients as adjuvant therapy in combination with temozolomide or with recurrent glioblastoma. It has been used alone as well as with other standard therapies such as Avastin, where it is felt to enhance efficacy. Therefore, under the present circumstances, Optune Tumor Treatment Fields Therapy was and 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 services in issue were and are likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with subspecialty certification in medical oncology, and they 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 authorization and coverage for pembrolizumab and paclitaxel. Findings:  Two of the three physician reviewers found that there is sufficient support for the requested medications in this clinical setting. Second-line chemotherapy for squamous cell non-small cell lung cancer often includes paclitaxel chemotherapy. There is increasing interest in combining chemotherapy with immunotherapy drugs, especially pembrolizumab. A recent study demonstrated that adding pembrolizumab to chemotherapy increased progression-free survival and overall survival. Therefore, pembrolizumab and paclitaxel are likely to be more efficacious than other available treatment options. Final Result: The reviewers determined that the requested medications are 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pre-surgical electrical stimulation therapy. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees scrotal pain.At issue in this case is whether the requested pre-surgical electrical stimulation therapy is medically necessary for treatment of the enrollees medical condition.It is unclear if the prosthesis is causing the patients symptoms. There is no evidence in the literature to suggest treatment of chronic scrotal pain with electrical stimulation therapy followed by prosthetic surgery is beneficial in alleviating symptoms. Therefore, electrical stimulation therapy would not be indicated and is not medically necessary.Final Result: The reviewer determined that the requested treatment 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for molecular pathology procedure level 2 gene test. Findings: Three physician reviewers found that in this case, the records document persistent atrial fibrillation and non-ischemic cardiomyopathy which improved while on medical therapy. In this case, medications are dosed based on blood levels or on hemodynamic response and tolerance (in the case of other medications) regardless of results of genetic testing. Genetic testing to assess for variants of drug metabolism was not likely to have altered treatment since this patients drug dosing was already being appropriately guided by blood levels and hemodynamic response. In addition, genetic testing to assess for variation in drug metabolism is not considered standard accepted practice in the medical community. Thus, molecular pathology procedure level 2 gene test 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 cardiovascular disease 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 balloon ostial dilation maxillary sinuses (code 31295).Findings:  Two of the three physician reviewers found that at this time, the medical evidence has not demonstrated the superiority of balloon ostial dilation over functional endoscopic sinus surgery for recurrent acute sinusitis. In this patient with recurrent acute sinusitis, balloon ostial dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, such as functional endoscopic sinus surgery. Alternative treatment options include oral antibiotics of two to four weeks duration for patients with chronic sinusitis or multiple one-week to three-week courses for patients with recurrent acute sinusitis, systemic and/or topical steroids, saline irrigations, topical and/or systemic decongestants, and treatment of concomitant allergic rhinitis, including avoidance measures, pharmacotherapy, and/or immunotherapy. Therefore, balloon ostial dilation maxillary sinuses (code 31295) is not likely to be superior over other available treatment modalities. Final Result: The reviewers determined that the requested services are 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.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychotherapy services. The patient is variously diagnosed with major depression, recurrent, generalized anxiety disorder, obsessive compulsive disorder (OCD), BPAD unspecified, with impulsivity, risky behavior, and paranoid thinking. He also has a reported seizure disorder. By his own report, the patient had abused alcohol but had been sober for several months before receipt of the services at issue. He also reported having strained family relationships and stress at home. Upon referral from a Licensed Clinical Social Worker (LCSW) therapist to services elsewhere, the therapist wrote that the patients OCD had improved, that he had decreased impulsivity, and that he had no suicidal or homicidal ideation. The patient received psychotherapy services from a clinical psychologist who was located near the patients school during the period in question. The submitted documentation includes notes from six psychotherapy appointments. In this case, the submitted documentation does not reflect that the patient had a psychiatric emergency medical condition during the period that he received the services at issue. At the time of the patients referral to the clinical psychologist, the LCSW therapist indicated that the patient was not experiencing suicidal or homicidal ideation and did not present a risk of harm to himself or others. Furthermore, there is no indication in the psychotherapy notes for the initial appointment that the patient was either an immediate danger to himself or to others. In addition, there is no indication in the submitted documentation that the patient was unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder during the relevant period of time. During this period, the patient was either living at home or attending school successfully. The patients needs for food, clothing, and shelter were provided. Finally, there is no indication that any of the services at issue relate to a screening that was provided to determine whether a psychiatric emergency medical condition existed. Under these circumstances, the psychotherapy services provided to the patient on the dates of service at issue did not constitute psychiatric emergency services as defined by California law.Final Result: The reviewer determined that the services at issue were not psychiatric emergency services. Therefore, the Health Plans denial should be upheld.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: A male enrollee has requested authorization and coverage for the medication, Stelara injection, 90mg/ml once, every four weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Crohns disease.Current medical literature supports dose escalation of Stelara in this case. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohn's disease that was resistant to anti-tumor necrosis factor therapy, which this patient has failed.   A study showed dosing at 90 mg every 4 weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every 4 weeks. Multiple other studies have shown that dosing intensification (to 90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response. Additionally, in this case, alternative therapies are limited, several other conventional and biologic therapies for Crohns disease have failed. For these reasons, Stelara injection, 90mg/ml once, every four weeks is supported as medically necessary for the treatment of this patients Crohns disease.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 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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a female enrollee has requested authorization and coverage for vertebral body tethering fusion-less spinal surgical procedure.Findings:  Two of the three physician reviewers found that in this case, the records document congenital vertebral anomalies and infantile scoliosis. The provider has requested fusion-less vertebral body tethers to correct the severe curve which measures 67 degrees at this time. Compression-based fusion-less tethers are an alternative to conventional surgical treatments of pediatric scoliosis. Anterior approaches place an anterior tether on the anterolateral convexity of the deformed spine to modify growth. Posterior tethers have also been performed. Anterior vertebral body tethering is a promising new technique for correction of the curve. It is a growth modulation technique, which utilizes the patients growth to attain progressive correction of the scoliosis. In this patients case, vertebral body tethering is likely to be a less risky alternative than other treatment options. Therefore, vertebral body tethering fusion-less spinal surgical procedure is likely to be more efficacious than other treatment options.Final Result: The reviewers determined that the requested services are 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.