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 Foundation One gene testing performed.Findings:  The physician reviewer found that Molecular profiling of an individuals cancer cells, as is done with the Foundation One assay, is an assay of genomic or molecular abnormalities.  The goal is to identify a target at which a specific treatment could then be offered. At this time, there is a lack of convincing evidence that the assay adds to the decision making ability to improve patient outcome. There are a variety of non-randomized trials exploring the value of molecular profiling that have not been convincing. A randomized trial  did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. All told, the superior efficacy of Foundation One gene testing performed  has not been established.Final Result: The reviewers  2 of 3 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 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewer s 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 percutaneous tibial nerve stimulation (PTNS). Findings:  The physician reviewer found that there is currently a lack of peer-reviewed medical literature supporting the superior efficacy of treatment with PTNS for interstitial cystitis, pelvic pain and associated symptomatology stemming from this pathologic pathway. A study concluded that intermittent PTNS is not a satisfactory treatment for refractory interstitial cystitis/bladder pain syndrome. Similarly, another study found that intermittent PTNS in patients with refractory interstitial cystitis has no significant clinical effect over 10 weeks of treatment. While it is possible that PTNS could benefit some symptoms including overactive bladder and incontinence, overall there is a paucity of data that the requested PTNS 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 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 reviewers are board certified in urology 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 sacroiliac (SI) joint injections for treatment of her neck and SI pain. Findings:  Three physician reviewers found that the request for SI joint injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Researchers conducted a meta-analysis which demonstrated that [radiofrequency] RFA is an effective treatment for SI joint pain at 3 months and 6 months. This study is limited by the available literature and lack of randomized controlled trials. Further standardization of RFA lesion techniques needs to be established, coupled with prospective randomized controlled trials. Thus, this technique needs further investigation. In addition, clinical practice guidelines state that the evidence supporting radiofrequency lesioning is limited. Final Result: The reviewers determined that the requested service 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: Reviewers 1, 2, and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 molecular profiling gene test performed. Findings:  The physician reviewer found tha  : Adenocarcinomas of the lung should be evaluated for specific molecular abnormalities, such as EGFR mutation, ALK, and ROS1, which have clear therapeutic implications. Such testing can be done either through tissue sampling or by evaluating cell-free DNA in plasma, such as with the Guardant360 assay. The National Comprehensive Cancer Network (NCCN) recommends consideration of plasma testing if tissue testing is not feasible. There also seems to be a role for plasma testing in patients who were found to have an EGFR mutation, were treated with an EGFR related drug, and show progression. The Guardant360 assay can detect a further EGFR mutation for which there is accepted treatment. However, as best as could be determined from the records submitted in this case, this patient underwent a tissue biopsy which demonstrated that these possible mutations did not exist. Thus, additional testing with the Guardant360 assay would not have provided further diagnostic data beyond that obtained with standard testing. All told, the Guardant360 molecular profiling gene test performed  was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test using a panel of genes (molecular profiling) provided. Findings:  The physician reviewer found that the patient is with metastatic non-small cell adenocarcinoma of the lung. He was diagnosed over 2 years ago. He is currently being treated with Opdivo with possible progression. Multiplex genotyping with Guardant360 was for testing help guide further therapy decision making. The patient has requested reimbursement for gene test using a panel of genes (molecular profiling) provided. The Health Plan denied reimbursement for the services at issue noting that the gene testing was investigational for the evaluation of this patients medical condition. The medical evidence supports the superior efficacy of the services at issue in this clinical setting. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially one by one. The medical literature indicates that this type of testing is the most tissue efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time efficient process for screening patients facilitating prompt treatment or protocol inclusion. The National Comprehensive Cancer Network (NCCN) non-small cell lung cancer (NSCLC) guidelines panel strongly endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. For the treatment of patients with advanced NSCLC, broad molecular profiling, such as with Guardant360, is considered a standard of care. Therefore, in this case, gene testing provided assistance in identifying further treatment/management options of this patients condition. As such, gene test using a panel of genes (molecular profiling) provided was likely to have been more beneficial than the standard available therapy in the evaluation of this patients medical condition.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1,2 & 3 are board certified in internal medicine with sub-specialty certification in 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 spinal cord stimulator (CPT 62350) for treatment of her transverse myelitis. Findings:  Two physician reviewers found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with chronic back pain and lower extremity symptoms. She had an acute neurologic event years ago with residual symptoms. There is no documentation the patient has tried physical therapy, transcutaneous electrical nerve stimulation (TENS), injections, behavioral therapy, or a back brace in the last 24 months. In addition, there is no documentation of an electromyogram (EMG) to rule out peripheral neuropathy for her burning pain. For the reasons provided, the spinal cord stimulator trial is not medically appropriate for this patient. Final Result: The reviewers determined that the requested procedure 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: Reviewers 1, 2, and 3 are board certified in neurological surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ketamine hydrochloride 10 mg for treatment of his chronic low back pain. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested medication compound in this clinical setting. In the documentation available for review, there is no documented failure of other standard treatments for neuropathic pain. Furthermore, the records do not show that all non-opioid medications classes have been optimized or tried.  According to the patient, Lyrica was helpful but it is unclear from the documentation if this was titrated to the highest therapeutic dose. Moreover, the providers own treatment plan was for pain psychology and physical therapy. However, these treatment options are not noted to be tried or completed. While there is some support in the medical literature that ketamine helps with neuropathic pain, there is also evidence that it is not effective.  Final Result: The reviewer determined that the requested medication compound 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 anesthesiology with sub-certification in pain 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hysterectomy and related services. Findings:  The physician reviewer found that the hysterectomy and related services were not necessary for treatment of an emergency medical condition. Hysterectomy remains the most common surgical treatment for leiomyomas. The two most common symptoms of fibroids for which women seek intervention are abnormal uterine bleeding and pelvic pressure. The most frequent type of abnormal uterine bleeding is heavy or prolonged menstrual bleeding, which frequently results in iron deficiency anemia, as demonstrated in this case. The patient presented with similar symptoms that she had last year, which included pelvic pain and vaginal bleeding. The documentation submitted for review does not support the hysterectomy was emergent. For the reasons provided, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewers determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 pain management consultation. Findings:  The physician reviewer found that there is support in the medical literature for the requested consultation for pain management in this clinical setting. A consultation is a type of evaluation and management (E/M) service provided by a physician or other qualified health care professional whose opinion or advice regarding a specific clinical problem is requested by another physician or other appropriate source.  A consultation can be considered when there is a need to clarify a patients medical condition. A pain management evaluation would be expected to include a detailed musculoskeletal and neurological examination. Final Result: The reviewer determined that the requested services are medically necessary for the evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: the parent of an enrollee has requested authorization and coverage for 55 hours per week of direct applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that there is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30-40 hours of treatment per week. Final Result: The reviewers determined that a portion of requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for oxycodone. Findings:  The physician reviewer found that there are two medical recommendations for tapering off opioids and pursue non-opioid treatments. Final Result: The reviewers determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: the physician reviewer is board certified in anesthesiology with sub-specialty certification in pain 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 lumbar fusion. Findings:  The physician reviewer found that evidence based medical guideline criteria has not been met for lumbar fusion surgery at any level in this clinical setting. Guidelines typically do not recommend fusion for patients with degenerative disc disease (DDD), disc herniation, spinal stenosis without degenerative spondylolisthesis or instability, or nonspecific low back pain, due to lack of evidence or risk exceeding benefit. Fusion may be supported for segmental instability (objectively demonstrable) including excessive motion, as in isthmic or degenerative spondylolisthesis, surgically induced segmental instability and mechanical intervertebral collapse of the motion segment and advanced degenerative changes after surgical discectomy. Pre-operative clinical surgical indications require completion of all physical therapy and manual therapy interventions, x-rays demonstrating spinal instability and/or imaging demonstrating nerve root impingement correlated with symptoms and examination findings, spine fusion to be performed at 1 or 2 levels, psychosocial screening with confounding issues addressed, and smoking cessation for at least six weeks prior to surgery and during the period of fusion healing. Peer reviewed literature supports smoking cessation, as smoking has a significant impact on pseudoarthrosis rates. A study reported that the results of recent studies suggest that a patients pretreatment psychological state is a major independent variable that affects the ability to detect change in functional outcome. This patient presents with a history of worsening low back pain radiating into the bilateral lower extremities, left greater than right, with associated leg numbness, tingling and weakness. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no discussion supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Potential psychological issues are documented, with no evidence of a psychosocial screen. This patient is reported to be a current daily smoker, with no documentation of smoking cessation. As such, the recommended guidelines for lumbar fusion surgery, at any level, have not been met. All told, the requested procedure is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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 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.