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 the heart monitor (implantable ambulatory event monitor) for treatment of the enrollees chronic cardiac rhythm.Findings:  Two physician reviewers found that based on the records provided the patient has PVCs and NSVT associated with symptoms that are reported to be continuous and without associated syncope. In this circumstance arrhythmia assessment should be able to be adequately obtained using serial Holter monitoring or external event recording. External event recording previously used adequately identified the patients dysrhythmia. Implantable loop recorders are not clinically indicated in this setting, and are generally reserved for infrequent dysrhythmias or symptoms that would not be expected to be identified on shorter term monitoring devices. Implantable loop recorders are typically used in the evaluation of palpitations or syncope of undetermined etiology when symptoms are infrequent, usually less than once per month and/or other ambulatory monitoring has been inconclusive. Final Result: Two reviewers determined that the device at issue was 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 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: A female enrollee has requested reimbursement for the computed tomography (CT) scan of the heart without contrast for evaluation of the enrollees elevated cholesterol. Findings:  The physician reviewer found that based on the records provided, the patient presents with some coronary risk but no history of coronary disease. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia are available and do not recommend performing coronary calcium scanning in this setting. Screening coronary calcium scoring is not considered the standard of care. Specifically, there is a lack of controlled evidence that treatment based on screening coronary calcium scanning provides outcome benefit that is incremental compared to treatment based on standard risk factor profiling and basic lipid analysis alone. Finally, though this patient has a mildly elevated total cholesterol it is largely due to a high HDL cholesterol. All told, the CT scan of the heart without contrast was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the service 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 number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 46-year-old male enrollee has requested authorization and coverage for Medtronic 670G insulin pump for treatment of the enrollees type I diabetes mellitus. Findings:  The physician reviewer found that Multiple studies have referenced meta analyses on insulin pumps which have been able to demonstrate improved mean blood glucose concentration, glucose variability, HbA1c (glycated hemoglobin) and to reduce insulin requirements by 14% over multiple daily injections of insulin in patients capable and motivated to use the insulin pump. It remains the best available option for type 1 diabetes. Continuous glucose monitoring systems (CGMS) including real time systems have been approved by the U.S. Food and Drug Administration. This patient may see a benefit in personal CGMS device. However, the Medtronic 670G insulin pump is a hybrid closed loop pump. This device is partially automated, a hybrid system (not fully automated), in that only the basal insulin doses are automatically adjusted depending on CGM results. Patients need to manually request prandial insulin doses. Although the preliminary results are promising from a smaller study, additional large scale long term trials are needed to be performed in the future for the Medtronic 670G hybrid. Therefore, the requested device is considered investigational as long term studies on this new system are not yet available. As such, Medtronic 670G insulin pump is not likely to be superior to the available standard options for the treatment of this patients medical condition.  Final Result: All three reviewers determined that the requested device is 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 number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for the DecisionDx-Melanoma testing for evaluation of the enrollees melanoma. Findings:  The physician reviewer found that The DecisionDx-Melanoma assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma test has shown some impressive accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. The test is currently not standard of care, has not been demonstrated to provide a beneficial effect on health outcomes. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three 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 number one is board certified in dermatology 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.Physician reviewer number two is board certified in dermatology 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.Physician reviewer number three is board certified in dermatology 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 periodontal scaling and root planning, billed as CPT code D4342, to LR tooth or quad, and periodontal scaling and root planning, billed as CPT code D4341, to UR tooth or quad for treatment of the enrollees periodontitis. Findings:  The physician reviewer found that the records including the patients perio-charting and x-rays do not support an indication for periodontal scaling and root planning. The provider noted the patients pocket depths range from 3-5 mm. There is no documentation of bleeding on probing, clinical attachment loss, or the presence of sub-and or supra-gingival build-up to support periodontal scaling and root planning. All told, the periodontal scaling and root planning, billed as CPT code D4342, to LR tooth or quad, and periodontal scaling and root planning, billed as CPT code D4341, to UR tooth or quad were not dentally necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not dentally necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Jakafi for treatment of the enrollees graft versus host disease (GVHD).Findings:  Two physician reviewers found that GVHD commonly affects organs including the skin, gastrointestinal tract, and liver. First-line treatment of GVHD is steroids. Second-line options include MMF, etanercept, photopheresis, mesenchymal stromal cells, sirolimus, and pentostatin. Other drugs that can be considered include monoclonal antibodies directed against CD25, TNF-alpha, T-cell receptor, and the IL2 receptor. Jakafi has been studied and results demonstrate efficacy in GVHD. A multicenter retrospective study demonstrated an associated 81.5% response, including 25 complete responses.  Final Result: Two 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: All three physician reviewers are is 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 InTone MV incontinence treatment system (non-implant pelvic floor electrical stimulator) for treatment of the enrollees urinary symptoms.  Findings:  The physician reviewer found that Electrical stimulation is a potential treatment option for patients with urinary incontinence. The electrodes could be implantable or not, and stimulation can be long or short duration. The exact mechanism of action of the electrical stimulation is not completely understood. Reorganization of spinal reflex and regulation of cortical activity are suggested as possible mechanisms. The type of stimulation could include suprapubic, transvaginal, sacral and tibial nerve stimulation. However, these are third-line options after prior therapy with behavior modification, bladder retraining, standard pelvic floor therapy and medications. The current medical documentation does not support appropriate use of first-line and second-line therapies. In addition, the current medical literature does not support the role of intravaginal pelvic floor electrical stimulation for the management of patients with overactive bladder or urinary incontinence.  All told, the requested InTone MV incontinence treatment system (non-implant pelvic floor electrical stimulator) is not likely to be more efficacious than other treatment options. Final Result: Two of three 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 16-year-old female enrollee has requested reimbursement and prospective authorization and coverage for the residential behavior health services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that To objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). The patient was at significant risk of harm (score 3) with a history of self-harm by cutting and history of suicide attempt. The patient has a history of self-harm by cutting. The patient will have intermittent, passive suicidal ideation which will typically come during episodes of distress. The patient demonstrated moderate functional impairment (score 3) as her school work has been less than satisfactory due to the patients behavioral health issues. She reports that she socially isolates with the exception of her boyfriend and her parents. The patient has a significant co-morbidities including cannabis use disorder, major depressive disorder, anxiety disorder with panic attacks, and binge eating disorder (score 3), but does not have any medical problems which require 24-hour monitoring. The patients recovery environment is mildly stressful (score 2) and her environmental support is overall supportive (score 2). The patients response to treatment has been equivocal (score 3) given her prior outpatient treatment with a limited response. The patient has been constructive in treatment (score 2) given her level of cooperation and friendliness with staff. These findings give this patient a composite score of 18, which meets the criteria for an intensive outpatient program (IOP). The patient continued to need treatment for her depression, anxiety, and substance use, but this could have been done in a less restrictive environment. Accordingly, the residential behavior health services provided were not and are not medically necessary for treatment of this patients medical condition. 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.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: A male enrollee has requested authorization and coverage for 20 hours per week of intensive behavior health treatment, four hours per week of supervision and four hours per week of parent training for treatment of the autism.Findings:  The physician reviewer found that The behavior therapy at issue is Developmental, Individual Difference, Relationship-Based Model of Intervention (DIR) appears to have some emerging data to support its use. Although, there may be some benefit from DIR based therapy, there is a lack of evidence in the medical literature to support is use in this clinical setting. The medical literature supports an ABA approach as effective for treatment of this patients condition. Moreover, there is sufficient medical literature supporting ABA therapy as an effective treatment for individuals with autism. Given the lack of sufficient support in the peer-reviewed literature, the request for 20 hours per week of intensive behavior health treatment, four hours per week of supervision and four hours per week of parent training 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for allergen specific immunoglobulin G (IgG) testing for evaluation of the enrollee, who reported a history of weight gain and an episode of gastroenteritis. Findings:  Three physician reviewers found that 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. IgG antibodies to food are commonly detectable in healthy adult patients and children, whether food-related symptoms are present or not. There is a lack of credible evidence that measuring IgG antibodies is useful for diagnosing food allergy or intolerance, or that IgG antibodies cause symptoms. The exception is that gliadin IgG antibodies can be used to monitor the success of avoiding gluten in people with proven celiac disease. Final Result: Three 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: All three physician reviewers are board certified in internal medicine and allergy and immunology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400/100 mg daily for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa 400/100 mg daily for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.  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 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.