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

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for gene test.  Findings:  Three physician reviewers found that the evidence based, peer reviewed literature does not support the superior efficacy of pharmacogenomic testing in this clinical setting. The documentation provided does not indicate that the patient has failed medication trials of adequate dose and duration or that the patient has tried or failed evidence based psychotherapy trials.  The documentation does not indicate the exact symptoms that have reportedly worsened or have not been under control or the clinical reason guiding the requested testing.  The request for testing indicates that the results from the test would drive medications selection for the patient.   The current evidence base does not support that genetic testing will allow for medication selection in an individual with difficult psychiatric symptoms or failure of past medication or psychotherapy trials. It does not appear from the literature that the testing will be more beneficial than standard available treatment. Medication and psychotherapy have strong evidence based support for their use in the patients conditions and it is not clear that these treatments have been used in an evidence based manner. Lastly, there is still some controversy on whether adjustment of dosage driven by genetic information may improve therapeutic efficacy. In sum, the gene test (CPT 81226, CPT 81225, CPT 81401, CPT 81479 and CPT 81291) provided was not likely to have been more efficacious than the standard treatment options for the evaluation of this patients medical condition. Final Result: 3 of 3 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: 2 reviewers are board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and are actively practicing. The third reviewer is board certified in psychiatry with expertise in child and adolescent psychiatry and is actively practicing. All 3 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 genetic testing for evaluation of the enrollee who presented for prenatal care. Findings:  The physician reviewers found there is support in the medical literature for a portion of the services at issue in this clinical setting.  The NIPT testing was an indicated procedure for this patient because she would be over 35 years old at the time of delivery. Patients who are 35 years of age or older at the expected time of delivery are considered in a high risk setting. The American College of Obstetricians and Gynecologists Committee (ACOG) endorses the discussion and use of NIPT testing in this patient population. In this case, the patient elected to have NIPT testing performed and her results were normal. With regards to the additional screening, there is a lack of support in the documentation provided for this portion of the genetic testing. Fetal sex determination in a patient without evidence of sex linked specific risk factors are not indicated. Current guidelines from the ACOG recommend prenatal screening and genetic counseling for fragile X in women with a family or personal history of fragile X, unexplained mental retardation or developmental delay, or premature ovarian insufficiency. In addition, ACOG recommends that all women who request fragile X carrier screening be offered DNA testing after appropriate genetic counseling. Testing for these genetic disorders is usually directed at patients with a specific family history or particular ethnicity. The records submitted do not document any specific risk factors for this patient. Typically, the recommendation is based on being of Ashkenazi Jewish heritage or having a relative or previously affected infant, with one or more of the tested conditions. Additionally, if a fetus is demonstrating one or more major structural anomalies on ultrasound screening, this would be considered an indication for the additional tests. These conditions do not appear to be present in this patients case. As such, the NIPT testing done for trisomy screening was likely to have been of greater benefit than the other methods of screening this patient. However, the genetic screening for additional disorders and fetal sex determination were not likely to have been more beneficial than the standard options for the evaluation of this patient. Final Result: Two of three 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: Physician reviewer number one is board certified in obstetrics and gynecology 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 Prometheus Anser IFX diagnostic testing for evaluation of the enrollees ulcerative colitis. Findings:  The physician reviewer found that In this case, Prometheus Anser IFX diagnostic testing was ordered to determine Remicade level, and whether antibodies to Remicade were present. However, loss of response to Remicade can occur for many reasons. The presence of antibodies alone does not necessarily result in loss of response to infliximab or infusion reactions, nor have threshold levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. A study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies. In summary, the medical literature lacks high-quality controlled studies to define drug level or antibody level thresholds requiring action to definitively establish that use of Prometheus Anser IFX improves outcome. The medical literature is not sufficient to establish improvement in health outcomes, and studies are contradictory. For these reasons, the Prometheus Anser IFX diagnostic testing performed was not likely to be more beneficial for evaluation of the patients ulcerative colitis 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the AmnioFix material for treatment of the enrollees necrotizing fasciitis. Findings:  2/3 of the physician reviewers found that Amnion chorion products are well established treatments to promote wound healing. According to a study by colleagues, the results from both the in vitro and in vivo experiments established that dehydrated human amnion/chorion tissue allografts retain their biological activities related to wound healing, including the potential to positively affect four distinct and pivotal physiological processes involved in wound healing including cell proliferation, inflammation, metalloproteinase activity and recruitment of progenitor cells. According to Tenenhaus, amniotic membrane has long been recognized to possess unique properties favorable for healing. All told, the AmnioFix material was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the service 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: Physician reviewer number one is board certified in family practice 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 infectious 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 plastic 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 reimbursement for laceration repair of the fifth finger with the use of NeuraGen nerve guide for treatment of the enrollees laceration of right fifth finger. Findings:  The physician reviewer found that When a peripheral nerve is completely resected, no recovery of function occurs without surgical repair.  In this case, the digital nerve is a sensory nerve and the patient would not recover any sensibility in the ulnar tip of the small finger without repair. Tension on nerve repairs is detrimental and the 1 cm gap between the ends of the lacerated nerve in this case needs to be bridged surgically.  One option is to harvest a nerve autograft or vein for use as a conduit, which involves an additional surgical site and associated risks. Another option is to use a synthetic conduit such as performed in this patients case.  The medical literature notes that for digital nerve repair with a gap under 2 cm, the use of a synthetic conduit is the preferred repair technique. As such, the conduit used in this case was likely to have been effective for repair of the patients lacerated digital nerve with a 1 cm gap. Accordingly, the laceration repair of the fifth finger with the use of NeuraGen nerve guide was likely to have been more efficacious for the treatment of this patient than the available standard methods. Final Result: Two of three reviewers determined that the services at issue were 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 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.Physician reviewer number two 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.Physician reviewer number three 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for acute inpatient mental health treatment for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue. Modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community-based settings are preferred as they offer optimization of treatment gains. However, placement in more restrictive settings is often clinically appropriate. In this patients case, he had not yet consolidated the illness burden that prompted the admission. The inpatient setting remained recommended by the attending provider due to the patients inability to effectively provide self-care. He was isolative, depressed, guarded and irritable. He was becoming less communicative, taking long periods of time to respond, if at all. In addition to the thought blocking, there were growing concerns of preoccupying internal stimuli. The patient refused to eat, even though he was hungry. Despite prompting from staff, he was not engaging treatment on the unit. Since he was reportedly stealing, was unpredictable, and was refusing aftercare planning, discharge to family was not an option at the time. The records support a protracted acute psychiatric syndrome. Discharging a patient under such circumstances would have been inconsistent with current practice standards. However, as the admission progressed, the patient began to slowly embrace therapeutic offerings. He was started first on an antidepressant followed thereafter by a second-generation antipsychotic. He eventually began attending groups and participating in discharge planning, which ultimately facilitated transition to the outpatient setting. During the disputed timeframe, the acute inpatient setting remained safe, appropriate, and consistent with good medical practice. The services at issue were reasonably expected to both improve the patients condition and prevent a more serious episode of illness while assisting with diagnostic formulation. Further, the duration of services was consistent with community standards for a case of this severity. All told, acute inpatient mental health treatment was medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found the medical services provided were not necessary for treatment of an emergency medical condition. The patient presented with a headache that had been present for two weeks. The patient reported occasional numbness of the area and ear congestion. The patient was afebrile. The neurologic examination was normal. The patients pain worsened with neck range of motion. The radiologic studies were ordered on an outpatient basis. A thyroid ultrasound was not indicated for an acute complaint. Although imaging may have been indicated, there was no emergent indication for the neck x-rays, brain CT scan, or thyroid ultrasound. In addition, the patients symptoms were not sudden or acute. In sum, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer 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 emergency 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for speech therapy services and reimbursement and prospective authorization and coverage for speech therapy services at an intensity of seven hours per week (three to five hours a week for speech therapy and one to two hours per week for language therapy for treatment of the enrollees autism and verbal apraxia. Findings:  The physician reviewer found that children with apraxia of speech respond better to higher intensity of speech including getting speech therapy three to five times per week. Children with childhood apraxia of speech should receive speech therapy five times per week. In this case, the patient continues to make progress with speech therapy. The patient has met several goals and is producing some words. Children with childhood apraxia of speech do not have a ceiling level of speech acquisition as might be seen in children with cognitive problems. In general, children tend to lack focus after 30 minute sessions and thus need a higher number of sessions. Based on the clinical documentation submitted for review, speech therapy is clinically indicated at the intensity of five days per week at 15 to 30 minutes per session. As such, speech therapy services provided and at the intensity of five days per week at 15 to 30 minutes per session were and are medically necessary. Final Result: The reviewer determined that a portion of the services at issue were and are 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 and 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 Vascepa for treatment of the enrollee who has a history of coronary artery disease and dyslipidemia. Findings:  The physician reviewer found that there is a lack of support in the documentation provided for the requested medication in this clinical setting. In this circumstance, treatment of hypertriglyceridemia is being considered to help reduced overall cardiovascular risk. Randomized trials have not directly compared most agents for the reduction of cardiovascular risk in patients with hypertriglyceridemia.  Although statin therapy is generally less effective in reducing triglyceride levels compared to fibrates, fish oil preparations or niacin, the proven efficacy of statins to reduce cardiovascular risk is compelling and makes them the preferred agents when cardiovascular risk reduction is the main aim of treatment.  Accordingly, most expert consensus guidelines focus on statin use in this setting. It is uncertain whether specifically targeting treatment to lower triglyceride levels reduces overall cardiovascular risk.  In addition, there are no well controlled randomized trials comparing various non statin therapies.  Moreover, a study, which conducted a randomized trial assessing the addition of niacin to statin therapy, did not demonstrate benefit.  Overall, since the patients hypertriglyceridemia is not severe (not greater or equal to 500mg/dl) and since there is no documented treatment failure or intolerance to other preferred non statin medications, the documentation provided does not support an indication for the requested medication. Therefore, Vascepa is not medically necessary for the treatment of this patients medical condition. 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 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: The patient has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Findings:  The physician reviewer found that The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of melanoma. Moreover, the DecisionDx-Melanoma Gene Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Gene Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 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: All 3 Physician reviewers are board certified in dermatology 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.