Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the procedure to freeze tissue (cryosurgical ablation) of a tumor on the chest wall for treatment of the enrollee who has a history of primary mediastinal high grade spindle cell sarcoma.  Findings:  Two physician reviewers found that there is some support for the procedure at issue in this clinical setting. The submitted documentation indicates that this patient has already undergone numerous rounds of chemotherapy and radiation therapy for the treatment of his condition. In 2016, microwave ablation was successfully performed to treat an LUL nodule. There is sufficient peer reviewed literature to support that cryosurgical ablation of the T11 paravertebral mass would lead to a better outcome than any available standard therapy. For these reasons, the procedure to freeze tissue (cryosurgical ablation) of a tumor on the chest wall was likely to have been a better option than standard medical therapy for the treatment of this patients medical condition. Final Result: The reviewers determined that the procedure at issue was 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: Reviewer number one is board certified in interventional radiology and diagnostic radiology and is actively practicing. Reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. Reviewer number three is board certified in general surgery with expertise in interventional radiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 gene testing for evaluation of the enrollees lung cancer. Findings:  Two physician reviewers found that the Guardant360 gene testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines indicate that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. The NCCN guidelines strongly endorse 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 lung cancer. 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. This 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 and thus to facilitate prompt treatment or protocol inclusion. For the treatment of patients with lung cancer broad molecular profiling, such as with Guardant360 testing, is considered a standard of care. For the reasons provided, the Guardant360 gene testing provided was 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 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for occipital nerve blocks for treatment of the enrollee, who has been diagnosed with occipital neuralgia. Findings:  Two physician reviewers found that this patient currently has chronic neck pain and headache pain. Per the documentation, she has attempted treatment with multiple medications as well as trigger point injections. She has benefitted from occipital nerve blocks. Researchers noted that a local anesthetic agent injection with steroid may be used for therapeutic purposes and usually has a transient effect, but in some cases the pain subsidence may be maintained for several months. In the antoher article, the objective of this study was to determine whether adding triamcinolone to local anesthetic increased the efficacy of greater occipital nerve blocks and trigger point injections for chronic migraine. In both groups, the procedure resulted in significant and rapid relief of headache, neck pain, photophobia and phonophobia. There is sufficient support for the services at issue in this clinical setting. In sum, the services at issue were and are likely to be superior over other treatment options.  Final Result: The reviewers determined that the services at issue were and 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: Reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for more than one hour per day of skilled nursing care at home (up to 24 hours per day) for treatment of the enrollees chronic respiratory failure, severe sepsis with acute organ dysfunction, and tracheostomy. Findings:  The physician reviewer found that for most patients, the demands of invasive ventilation are too difficult to manage at home, and nursing home placement results. For patients who choose to stop invasive ventilation, symptoms of dyspnea, anxiety, and distress should be anticipated and treated. According to the available documentation, this patient should currently be receiving at least one hour of in-home skilled nursing services which should be adequate to handle ventilation, suctioning, and tracheostomy care, which are considered skilled nursing services. However, administration of medications, feeding, grooming, bathing, toileting and turning the patient, are considered custodial in nature and do not require in-home skilled nursing services. In addition, the records document that the patients current needs are met and the requested additional in-home skilled nursing services could substitute for her current care needs as a matter of convenience and to relieve the primary caregiver, but are not medically necessary. Moreover, the patient was stable at her most recent evaluation with her provider. For these reasons, more than one hour per day of skilled nursing care at home (up to 24 hours per day) is not supported as medically necessary for treatment of this 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 internal medicine with sub-specialty certification in hospice and palliative 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 reimbursement for one day inpatient hospital stay for treatment of the enrollees concussion. Findings:  The physician reviewer found that the inpatient admission was not medically necessary for treatment of this patients medical condition. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. Outpatient observation admission is appropriate when the provider is unsure about the patients need for inpatient admission and requires time for short-term treatment, assessment, and reassessment in order to make that decision or the provider anticipates that the patients condition can be evaluated/treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care.  At the time of admission, the patient did not report any loss of consciousness or alterations in baseline mental status. There were no bleeding and no urgent procedures that would have warranted an acute inpatient setting. Final Result: The reviewer determined that the services at issue were 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 internal 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for botulinum toxin for treatment of the enrollees migraines. Findings:  The physician reviewer found that The physician reviewer found there is sufficient support for the requested services in this clinical setting. This patient has been treated with an adequate number of preventive medications, without success.  Botox has established efficacy, not only in episodic migraine, but also in chronic daily headache as well as mixed headache disorders. The medical evidence supports botulinum toxin in this patients case. All told, the requested botulinum toxin is likely to be of greater benefit than other available treatment options. Three 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The enrollee has requested authorization and coverage for Nutropin AQ Nuspin 20 mg/2 mL pen for treatment of the enrollee who has been evaluated for short stature. Findings:  The physician reviewer found that the documentation provided does not support the requested medication in this patients case. The height data available for this patient is between 8 and 12 years of age, which indicated that he grew at a normal velocity and with an absolute height slightly below the 10th percentile. The fall off in height velocity appears to have occurred somewhere after age 12. His ongoing height velocity of around 4 cm per year is consistent with what is commonly observed in patients with short stature on the basis of constitution delay. The available laboratory data does not support a diagnosis of growth deficiency with a testosterone level of 22. This level is consistent with the very earliest indication of entry into puberty. Additionally, the bone age determinations obtained to date indicate a normal, within the lower half of normal, adult predicted height relative to the genetic target. In sum, this patients growth pattern is not supportive of growth deficiency. Growth hormone therapy would not be recommended, at this time. Based on the medical literature, the benefits from exogenous GH is either nonexistent or unlikely to be discernible above and beyond what growth this patient will do on his own. Importantly, given the last bone age data, the prediction is that the height velocity will increase spontaneously as expected in the next few months.  In this context, it is very unlikely that exogenous growth hormone would lead to any discernible benefits. Final Result: The reviewer 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 reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 authorization and coverage for carotid Doppler for evaluation of the enrollees left-sided carotid artery disease. Findings:  Two physician reviewers found that based on the records provided the patient presents with no documented neurologic symptoms, no documented focal neurologic deficits on physical examination, no documented carotid bruits, and no documented hemodynamically significant of greater than 50% stenosis on prior ultrasound. In this circumstance repeat yearly screening is not recommended and is not considered the standard of care in the medical community unless stenosis exceeds 50% or there is a clinical change such as new bruit or focal neurologic symptom. Even in this setting, the estimated risk of stroke attributable to an identified stenosis in patients with asymptomatic carotid atherosclerosis is very low at less than one percent annually. Final Result: The reviewers determined that the requested service 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Myriad genetic blood test for evaluation of the enrollee, who has a family history of breast cancer. Findings:  Thwo physician reviewers found that BRCA genetic testing is a well-accepted form of testing for breast and ovarian cancer susceptibility, and there are a series of possible clinical decisions that can be made on the basis of BRCA testing. The medical evidence supports BRCA genetic testing for a woman, without a personal history of breast cancer, if she has a first-degree or second-degree relative diagnosed with breast cancer below the age of 45. In this patients case, her aunt was diagnosed with breast cancer below the age of 45. However, this patient was evaluated with a 25-gene panel which includes many genes of unknown clinical implications. Therefore, the panel is of questionable clinical benefit. Although many of the genes in the panel are of ongoing interest, these genes as yet cannot be used for clinical decision making.  Therefore, the BRCA genetic testing portion of the services at issue was likely to have been more efficacious than other methods of evaluating this patient. The medical records fail to demonstrate the superior effectiveness of the remainder of the services at issue. Final Result: The reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Reviewers 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Remicade infusion 5 mg/kg, three times per week for eight weeks for treatment of the enrollees Crohns disease. Findings:  The physician reviewer found that current medical literature supports the requested medication in this clinical case. The diagnosis of Crohns disease has been established in this case by colonoscopy and biopsy results showing ileal disease. The patient also reported consistent clinical symptoms given rectal bleeding for two years and severe bloody diarrhea.  Based on this patients records, this patient has moderate to severe Crohns disease due to severity of symptoms. The American Gastroenterological Association guidelines for induction of remission in moderate to severe disease recommend anti-tumor necrosis factor (TNF) antibodies including Remicade. For maintenance of remission, TNF inhibitors are recommended by these guidelines. These recommendations are corroborated by the American Gastroenterological Association Guidelines for Initial Medical Treatment in Crohns Disease. Uncontrolled disease flares can rapidly result in complications, such as abscess and bowel obstruction, and over time can result in complications such as fistula, stricture, and the need for hospitalization and surgery. The medical literature supports immediate treatment to establish remission and avert complications of Crohns disease, such as stricture, fistula, and dysplasia leading to colorectal cancer.  Additionally, Remicade and the requested dosage is the recommended dosing by the U.S. Food and Drug Administration.  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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara 90 mg every six weeks. Findings:  The physician reviewer found that 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 to severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed . Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year . A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of immunosuppressants and anti-TNF medications, both of which the patient has failed .  A study showed dosing at 90 mg every four 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 four weeks .  For these reasons, Stelara 90 mg every six weeks is medically necessary for the treatment of this patients Crohns disease. Final Result: The reviewer determined that the requested medication dosage 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.