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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for trametinib. There is a lack of support for the requested medication in this clinical setting. The treating provider provided several references regarding the activity of trametinib for children with low grade glioma (LGG). In one study, two patients with LGG responded, but both had BRAF mutations. In several other publications, children who respond to trametinib have had a BRAF mutation. In addition, there are other more proven options that have not yet been offered. Vinblastine and thioguanine, procarbazine, lomustine and vincristine (TPCV) are well-established regimens for the treatment of LGG in children. Although these regimens are more demanding (require a port and intravenous administration), were proven to work mostly in patients with focal progressive disease, and carry some risk of toxicity, they are well-established, standard regimens and should be considered prior to pursing a targeted therapy in a patient who does not have the target. Trametinib is of unproven efficacy in this setting. The patient is responding to the current regimen. It has not been established that the addition of another agent will provide better disease control, and it might add toxicity. Should additional therapy be required, there are more proven options available. Therefore, trametinib is not likely to be of greater benefit than other available treatment options. Findings:  Two of the three physician reviewers found the requested medication 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.Final Result: The reviewers determined that the requested medication 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 1, 2 and 3 are board certified in pediatrics with sub-specialty certification in pediatric hematology and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Otezla 30 mg at a quantity of 60 pills per month. Review of the submitted clinical documentation does not support the medical necessity of Otezla 30 mg at a quantity of 60 pills per month. Given the patients co-morbidities, the use of methotrexate or cyclosporine is best avoided due to her history of liver and kidney issues. However, based upon the documentation provided, the patient has not attempted treatment with Enbrel, Humira or Cosentyx. The efficacy of these alternative medications has been sufficiently established in this setting and it is anticipated they are likely to be more effective than the requested Otezla. Furthermore, the patients co-morbidities do not preclude the use of these preferred systemic agents. As there is no contraindication or documented history of adverse effects from treatment with the preferred agents which are U.S. Food and Drug Administration (FDA) approved for this patients medical condition, the requested Otezla 30 mg at a quantity of 60 pills per month is not medically necessary. Final Result: The reviewer determined that the requested medication regimen 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 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: The parent of an enrollee has requested authorization and coverage for 15 hours of applied behavioral analysis therapy per week. The patient has been receiving these services on-going and has reportedly made significant gains in this time. While there are still goals to be addressed, the provider has indicated that these goals can be met through a lesser amount of hours of ABA therapy per week and a significant amount of supervised hours over a six-month period. The Behavior Analyst Certification Board (BACB) indicates that service intensity should be dictated by the patients needs and results of the assessment. The assessment provided, recommends that the service intensity lessen to 10 hours of direct ABA services per week. Thus, the requested 15 hours per week of direct ABA therapy is not supported as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested amount of services is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is a board certified psychologist and is a board certified behavioral analyst 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 a power wheelchair, group 3 standard, captains chair. In this case, the medical documentation does not support that the requested equipment is medically necessary. The records do not establish that the enrollee has upper impairments that would preclude effective propulsion of an optimally configured manual wheelchair to accomplish her mobility-related activities of daily living. Poor subjective tolerance of propelling a manual wheelchair does not constitute an impairment or functional limitation with respect to this activity. The records do not establish that the enrollee has upper impairments that would preclude effective pressure relief maneuvers in conjunction with an appropriate pressure relieving seat cushion. Researchers have studied how movements such as sideward leans, for instance, can provide significant reduction in interface pressure at the ischial tuberosities. Poor subjective tolerance of or compliance with performing pressure relieving maneuvers does not constitute an impairment or functional limitation with respect to this activity. The records, notably, otherwise indicate that the enrollee is able to transfer independently, and a physical therapy evaluation indicated that the enrollee's pressure relief needs in a wheelchair can be met with an air villous cushion. These documented capabilities are largely not consistent with an inability to perform effective pressure relieving maneuvers independently without powered means. Researchers have noted that lack of compliance can result in pressure ulcer development with or without tools such as power tilt-in-space. A group 3 power wheelchair, therefore, is not medically necessary for the patient based on the available documentation. Accordingly, the requested equipment is not medically necessary to treat the enrollees medical condition at this time.Final Result: The reviewer determined that the requested equipment 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 molecular test. Per National Comprehensive Cancer Network (NCCN) guidelines, patients with metastatic gastric cancer only require Her2neu testing. To date, genomic testing and ctDNA as offered by the Guardant360 molecular test have not been shown to be of clinical value in this setting. To demonstrate the clinical utility of the Guardant360 molecular panel in gastric cancer, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with the standard of care. Currently, such studies are lacking. The available literature on clinical utility consists of a small number of uncontrolled studies and non-randomized controlled trials that use imperfect comparators. This evidence is not sufficient to draw any conclusions on clinical utility. As such, the use of expanded mutation panel testing such as Guardant360 for targeted treatment in cancer remains of unproven efficacy and was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and hematology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator.Findings: Two of the three physician reviewers found that this patient has obstructive sleep apnea. The records documented nasal obstruction with inferior turbinate hypertrophy and septal deviation. There has been no treatment of the nasal obstruction which contributes to sleep apnea. The patient has not been able to tolerate the CPAP device. The Inspire device is an FDA approved device for the treatment of OSA device. At this point, the patient is not a candidate for the Inspire device given the nasal obstruction has not been addressed medically or surgically. Therefore, the requested implantation of a hypoglossal nerve stimulator is not likely to be of greater benefit than other treatment options.Final Result: The reviewers determined that the requested services are 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 1, 2 and 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Plegridy injection. Multiple sclerosis is a progressive immune disease affecting the central nervous system, causing neurological dysfunction. Multifocal inflammation of the central nervous system characterizes the disease and causes impaired nerve conduction. The most common form of multiple sclerosis is the relapsing and remitting subtype, which clinically refers to episodes of new or worsening functioning with magnetic resonance imaging (MRI) correlation and periods of clinical stability. Multiple sclerosis is not a curable pathology. However, there are several therapies that can manage the disease. While Plegridy has been shown to be an effective medication in the management of multiple sclerosis, the medical evidence has not demonstrated that the requested medication is superior over the Health Plans alternatives. Therefore, Plegridy injection is not medically necessary for the treatment of this patient.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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing for breast cancer (CPT codes 81211, 81213, and 81321).  Findings:  Three physician reviewers found that this patient has a personal history of breast and endometrial cancer and meets criteria for panel genetic testing on several levels. She meets National Comprehensive Cancer Network (NCCN) criteria for BRCA testing based on a personal history of breast cancer and a family history of a close relative with pancreatic cancer. She meets NCCN criteria for testing for Li-Fraumeni with several relatives with brain cancer on the same side of the family. In addition, she meets NCCN criteria for testing for Lynch syndrome given a personal history of both breast and endometrial cancer and a close relative with pancreatic cancer and brain cancer. Panel testing is now considered standard of care. In sum, genetic testing for breast cancer (CPT codes 81211, 81213, and 81321) was likely to have been more efficacious than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in 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 a continuous positive airway pressure (CPAP) machine. As noted in the current medical literature, CPAP is recommended as the first-line treatment for patients with OSA. Further, the American College of Physicians (ACP) support CPAP as initial therapy for patients diagnosed with OSA and note that this recommendation is supported by moderate-quality evidence. In this case, the medical records provided for review document the patient was diagnosed with OSA, was subsequently titrated on CPAP, and recommended a CPAP for home use. Although the patient does not present with comorbid conditions, his clinical presentation and history as reported in the consult notes meet the diagnostic criteria for OSA. Considering that CPAP is considered the first-line treatment for patients with OSA, and this patient meets the diagnostic criteria for OSA, the provision of a CPAP unit and related accessories is within the generally accepted standards of clinical practice. Thus, the requested CPAP machine is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 neurology with sub-specialty certification in sleep 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 hypoglossal nerve stimulation (Inspire Upper Airway Stimulation system).Findings:  Three physician reviewers found that there is sufficient support for the requested services in this patients case. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea. This trial has demonstrated the hypoglossal nerve stimulator to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed CPAP, have nonconcentric airway collapse, an AHI between 20 and 50, and a body mass index less than 32. With a body mass index of 23, AHI of 44 and nonconcentric airway collapse, this patient meets the criteria. She has failed CPAP, which is the gold standard treatment for OSA. Therefore, hypoglossal nerve stimulation (Inspire Upper Airway Stimulation system) is likely to be more effective than other available treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services. Monitored anesthesia care is warranted in prolonged or painful procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography, or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, monitored anesthesia care may be necessary in patients with failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater than 70, pregnancy, increased aspiration risk, ASA class III or higher, or morbid obesity. The submitted records do not support the medical necessity of monitored anesthesia care over short-acting sedation in this case. Therefore, anesthesia services were not medically necessary for the treatment of this patient. 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 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 reimbursement for all or any of the residential treatment center services provided. Review of the submitted documentation supports the medical necessity of the services at issue. The patient had failed a step-down to lower level of care. Medical guidelines recommend  that residential treatment or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use[and who] lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The submitted documentation demonstrates the patient required a safe and stable living environment in order to develop his recovery skills. As such, he met criteria for American Society of Addiction Medicine (ASAM) Level III treatment, which includes residential treatment level of care. All told, the residential treatment center services were in accordance with generally accepted standards of medical practice and clinically appropriate for the patient's illness; therefore, the services at issue were medically necessary.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.