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 DecisionDx-Melanoma testing.Findings:  Three physician reviewers found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system. Mitotic index may also add to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the risk of metastasis over five years. A study reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma testing classification, in patients undergoing sentinel node sampling. However, it is not clear how the five-year DecisionDx-Melanoma testing data compares to the ten-year data. Furthermore, it is not known if DecisionDx-Melanoma testing can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing was not likely to have been more effective 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that this enrollee has been diagnosed with multiple sclerosis (MS). The enrollee was started on Copaxone 20 mg/mL and that it was well tolerated and without side effects. The provider recommended Copaxone 40 mg/mL for the treatment of the patients multiple sclerosis. The provider then noted that the patient has remained stable on his current therapy since 2012. The provider noted that a discontinuation of this medication could lead to a deterioration of the insureds condition.The submitted documentation supports the medical necessity of the requested medication. Researchers conducted a systematic review of the clinical effectiveness of glatiramer acetate (Copaxone) and found that Copaxone has a lesser side effect profile and a demonstrated benefit in the treatment of Multiple Sclerosis. Researchers have also noted that Copaxone is an effective treatment for multiple sclerosis with a side effect profile that is better than comparable treatments for multiple sclerosis. In this case, the records reflect that the patient has failed one therapy for Multiple Sclerosis. The patient has noted concern for the side effect profiles such as potential end organ damage with other first line therapies supported by the Health Plan. As noted above, Copaxone has been identified as having a side effect profile that is better than comparable treatments for multiple sclerosis. Copaxone is an FDA approved treatment for MS and may be used when other treatment has failed. Under these circumstances, Copaxone 40 mg/mL is 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for letermovir (Prevymis). As noted in the medical literature, cytomegalovirus (CMV) keratouveitis is well recognized clinical entity which is often present along with high eye pressure. In this case, PCR results and the patients response to valganciclovir confirm this diagnosis. However, since the patient has developed side effects due to valganciclovir, it is no longer a viable treatment option. Prevymis is a new medication for the management of systemic CMV infection. Based on the scientific data demonstrating its efficacy against CMV, Prevymis is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in ophthalmology 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 a Bioness L300 Go Plus Brace System for the calf and thigh with electrodes and Bioness L300 Go Plus replacement electrodes. Findings:  Three physician reviewers found that there is limited high-quality peer-reviewed literature available on functional electrical stimulator (FES) devices for gait with incomplete spinal cord injury, including FES for treatment of gait instability with foot drop. Existing studies discuss promising initial results. However, these studies have been small and any findings require confirmation through further research. There is insufficient published research at this time to support this treatment to be established as more effective than standard therapy. All told, the Bioness L300 Go Plus Brace System for the calf and thigh with electrodes and Bioness L300 Go Plus replacement electrodes were not likely to be more beneficial for treatment of the patients medical condition than any available medical therapy.For these reasons, the Bioness L300 Go Plus Brace System for the calf and thigh with electrodes and Bioness L300 Go Plus replacement electrodes were not likely to be more beneficial for treatment of the patients medical condition than any available medical therapy.Final Result: The reviewers determined that the Bioness L300 Go Plus Brace System for the calf and thigh with electrodes and Bioness L300 Go Plus replacement electrodes were not likely to be more beneficial for treatment of the patients medical condition than any available medical therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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: The parent of an enrollee has requested authorization and coverage for vision therapy with a developmental optometrist. Findings:  Three medical professional reviewers found that there is sufficient support for the requested services in this patients case. The Convergence Insufficiency Treatment Trial showed that office-based vision therapy is an effective treatment for convergence insufficiency. Long-term findings post therapy showed that patients maintained improvements after one year. Guidelines of the American Optometric Association state numerous studies have shown that vision therapy is the treatment of choice for convergence insufficiency. Per the guidelines, lenses alone are not sufficient to eliminate an accommodative spasm. In this case, the patient has symptoms consistent with convergence insufficiency and accommodative dysfunction. Office-based vision therapy has been demonstrated to be beneficial and is a recognized standard treatment in this clinical setting. Therefore, vision therapy with a developmental optometrist is likely to be more effective 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: Medical professional reviewers 1, 2 and 3 are board certified in optometry 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 parent of a 10-year-old male enrollee has requested authorization and coverage for a computed tomography (CT) scan for treatment of the enrollees costochondritis and mild persistent asthma. Findings:  The physician reviewer found that Hussain and colleagues note that chest pain is a reasonably common complaint in the pediatric population. In terms of referral to pediatric cardiology, it ranks second only to heart murmurs. The most common cause is idiopathic, occurring in up to half of cases. Other causes include pulmonary, musculoskeletal, gastrointestinal, and psychological. Actual cardiac causes are present in less than five percent of cases. Most children have normal physical exam findings. Interventions depend upon etiology: bronchodilators for reactive airways disease, anti-reflux medications for gastroesophageal reflux, and non-steroidal anti-inflammatory medications for musculoskeletal pain. When cardiac cause is suspected, a reasonable evaluation would include comprehensive history and complete physical examination, selective laboratory studies including metabolic studies and indicators of cardiac stress, electrocardiogram, chest x-ray, and echocardiogram. In some cases, a period of cardiac monitoring may be indicated. Other patients may benefit from a Holter 24-hour monitor or an event monitor. In this childs case, he initially presented with chest pain that began during physical education, and with subsequent onset of dry cough. He was evaluated multiple times by all pertinent specialists, with normal testing throughout and examination consistent with costochondritis. Ultimately he was also diagnosed with habit cough after completing a course of prednisone and azithromycin. There is nothing in his history or the submitted documentation that would indicate that a chest CT would add any additional useful information. In weighing risk and benefit, the risk of radiation exposure from CT far outweighs any potential benefit given his symptomatology and low yield for diagnosis. Therefore the computed tomography scan is not medically necessary. Final Result: The reviewer determined that the requested service 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 pediatrics with subspecialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Magnetic Resonance Imaging (MRI) testing of the back, abdomen, and head. The Health Plan has denied this request indicating that the requested testing is not medically necessary for treatment of the enrollees headache, back pain, abdominal pain, and urinary tract infection. At issue in this case is whether the requested MRI testing of the back, abdomen, and head is medically necessary for treatment of the enrollees medical condition. Chronic daily headache is characterized as headaches for at least 15 days per month. In this setting, without change in the characteristic of the headache or focal neurological findings, neuroimaging is usually not warranted according to some findings. In the setting of hematuria with or without flank pain, the standard first imaging examination is CT urography. Magnetic resonance urography is only recommended in the setting of indeterminate CT findings or in patients with a CT contrast allergy. According to studies found appropriateness criteria for the evaluation of uncomplicated low back pain, radiographs are the initial recommended imaging examination. MRI is considered usually not appropriate. In review of the patients medical records, the patients headaches do not qualify as chronic daily headache. She also had negative CT imaging. MRI is not currently indicated. The patient also has had negative abdominal CT scans. MRI of the abdomen would not add further information and is not indicated. Lumbar MRI is also not indicated, radiographs are first recommended as well as conservative therapy. In this patients case whole body MRI is not medically necessary. Therefore, the requested MRI testing of the back, abdomen, and head is not medically necessary.Final Result: The reviewer determined that the requested testing 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) scan. Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. This patient has a difficult tumor to manage and to image after surgery and chemotherapy. Due to the chemotoxicity of the drug epirubicin, it was imperative to determine if the benefits of the drug outweighed the toxic effects. Thus, it was important to quantitatively measure the tumor response to epirubicin prior to continuing treatment with this toxic agent. Due to the propensity for local and distant metastases of this aggressive tumor and the difficulty in assessing tumor recurrence after such extended surgical and chemotherapy, PET was the imaging procedure of choice. Conventional imaging does not allow for the physiologic measurement of tumor activity, which is crucial in the face of prior extensive treatment. Therefore, PET scan was 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 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 diagnostic radiology 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: A 55-year-old female enrollee has requested authorization and coverage for a gastrointestinal tract capsule endoscopy of the small bowel. The records document that this patient has had symptoms and elevated calprotectin with normal colonoscopy, suggestive of possible small intestinal Crohns disease rather than the current diagnosis of ulcerative colitis. Capsule endoscopy is useful for the diagnosis of Crohns Disease or determination of the extent of disease activity, and superior to radiographic imaging tests such as small bowel follow through. Capsule endoscopy has been demonstrated to be superior to all current forms of radiological testing of the small intestine in detecting the mucosal abnormalities of non-stricturing Crohns disease. Therefore, the test is supported by guidelines for the diagnosis of Crohns disease. For these reasons, a gastrointestinal tract capsule endoscopy of the small bowel is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that a gastrointestinal tract capsule endoscopy of the small bowel is not 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 requested service is 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System).Findings:  Two of the three physician reviewers found that there is sufficient support for the requested services in this clinical setting. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. A trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea. This trial demonstrated that the hypoglossal nerve stimulator was safe and effective in a small subset of patients with obstructive sleep apnea who had failed CPAP, had nonconcentric airway collapse, an AHI between 20 and 50, and a body mass index less than 32 kg/m2. A recent study supported effective outcome in patients with a higher body mass index and a broader AHI range. The requested services are an effective second-line treatment for moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with CPAP therapy. With a body mass index of 35.35 kg/m2, AHI of 63.2 and nonconcentric airway collapse, this patient meets the expanded criteria for implantation with a hypoglossal nerve stimulator. He has failed CPAP, which is the gold standard treatment for obstructive sleep apnea, and he has failed multilevel sleep surgery. He is at risk for untoward cardiac sequelae of untreated obstructive sleep apnea. Therefore, the requested hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System) is likely to be superior over other available 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 otolaryngology 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 authorization and coverage for Xeljanz. Alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of alopecia areata including eyebrows, eyelashes and facial hair. Some autoimmune diseases are also linked with alopecia areata. Treatment is challenging and aims at the regrowth of hair. Although alopecia areata is not life threatening or painful, its onset and erratic nature disturbs the lives of many. Alopecia areata can negatively impact a patients self-esteem, body image, and self-confidence. It has been also studied for treatment of psoriasis, inflammatory bowel disease, and other immunological diseases. Researchers found that Xeljanz is effective in alleviating alopecia universalis without significant side effects. Given this support, the requested Xeljanz is 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 requested medication 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: 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.