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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the FoundationOne test for evaluation of the enrollees left thigh pleomorphic sarcoma. Findings:  Two physician reviewers found that FoundationOne is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the FoundationOne assay adds to decision making ability, or yields a result that is clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment. A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. 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: 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: The parent of an enrollee has requested authorization and coverage for 35 hours per week of direct applied behavioral analysis (ABA), three hours per week of supervision, and one hour per week of caregiver training for treatment of the autism spectrum disorder.  Findings:  The physician reviewer found that the request for 35 hours per week of direct ABA, three hours per week of supervision and one hour per week of caregiver training is medically necessary for treatment of the patients medical condition. There is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. Based on the documentation submitted for review, the patient continues to demonstrate significant behavioral concerns. The patient continues to require a high level of support to due to maladaptive behaviors that include screaming, aggression and self-injury. Failure to master these skills places the patient at an increased risk for injury, and makes it difficult to be successful in more generalized environments. In addition, the Behavior Analyst Certification Board indicates that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Final Result: The reviewer determined that the requested services are 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The patient has requested reimbursement for the immune cell function assay blood test provided. Findings:  The physician reviewer found that in the peer-reviewed medical literature, a study noted that inherited thrombophilias do not appear to be related to unexplained infertility. The authors reported that a large retrospective study showed no significant association with common thrombophilias, including factor V Leiden and lupus anticoagulant, and diminished in vitro fertilization success. Thus, neither screening for thrombophilias nor treating them is advised in cases of repeated infertility treatment failure. Similarly, the authors discussed the immunologic testing of infertile women and stated that, an increased frequency of abnormal immune test results in women with early reproductive failure has been reported repeatedly; however, the most rigorous studies have not proven a cause and effect between these phenomena. Thus, the immune cell function assay blood test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three  reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers are  board certified in obstetrics and gynecology 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 SummaryThe patient has requested authorization and coverage for a Cologuard cancer screening test. Findings:  The physician reviewer found that evidence on healthcare outcomes of Cologuard versus standard medical care is lacking at this time. Cologuard is U.S. Food and Drug Administration (FDA) approved to test for colon cancer, proved 92% sensitive for detection of colon cancer, and can detect some adenomas if they have high-grade dysplasia . However, the limited evidence for Cologuard suggests that 154 patients would have to be screened to find one cancer using colonoscopy, versus 166 patients using Cologuard . In addition, there is a lack of consensus in clinical guidelines form the United States Preventive Services Task Force and the American Cancer Society to support that Cologuard has a positive impact on health outcomes as guidelines. Moreover, although Cologuard may be able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop. Furthermore, Cologuard may be indicated for patients with average risk for colon cancer, but not elevated risk as in this case with a positive fecal immunochemical test (FIT) test. For these reasons, Cologuard is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation 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: The parent of an enrollee has requested authorization and coverage for 38 hours per week of direct applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the request for 38 hours per week of direct ABA services medically necessary for treatment of the patients medical condition. There is sufficient peer-reviewed literature supporting ABA as a medically necessary for the treatment of children with autism. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, the records indicate the patient was previously making excellent progress at the frequency of 38 hours per week of ABA. Moreover, a decrease in the weekly ABA hours will make it difficult for the patient to make progress towards his 44 ABA goals. Final Result: The reviewer determined that that requested services are 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Synvisc injection for treatment of the enrollees osteoarthritis.  Findings:  The physician reviewer found that the current medical evidence supports the medical necessity of the requested services. Evidence-based peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and is more effective than corticosteroid injections. In this case, the patient has been diagnosed with osteoarthritis of the left knee. He presents with recurrent left knee pain and swelling. Clinical examination findings have been consistent with reported radiographic evidence of moderate osteoarthritis of the left knee. Conservative treatment has included activity modification and anti-inflammatory medication, with inadequate relief. Prior Synvisc injections have provided at least six months of pain relief and reduction in medication use. Final Result: The reviewer determined that the requested services are 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tofacitinib citrate (Xeljanz XR) 11 mg TB24 for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that the available medical records do not adequately document failure of treatment with methotrexate nor do they document any trial and failure of at least two biologic agents such as Humira, Enbrel, Remicade, or Simponi. The current medical literature supports first-line therapy with these biologic agents as effective for most patients with rheumatoid arthritis. On the basis of this lack of documentation, the request for treatment with tofacitinib citrate (Xeljanz XR) 11 mg TB24 is not supported as medically necessary for treatment of this patients rheumatoid arthritis. 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 rheumatology 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 balloon sinus ostial dilation for treatment of the enrollees chronic bilateral frontal sinusitis. Findings:  Two physician reviewers found that in this case, the patient reportedly had headaches. He underwent successful endoscopic sinus surgery seven years previously.  Although the provider reported that the patient had some moderate frontal sinus disease that was poorly responsive to antibiotics and nasal steroids, details regarding the medical management or outcomes of that therapy were not documented. Additionally, there is no clinical objective evidence of the degree of obstruction by radiographic imaging studies. Balloon sinus ostial dilation is a technique to improve a patients symptoms of recurrent acute rhinosinusitis to help widen and dilate the sinus pathways. Researchers noted that the use of balloon dilation for patients with chronic sinus disease was met with failure in 65% of the patients on whom the procedure was performed. There are some references which indicate that there may be some improvement with the use of balloon sinus ostial dilation technology. However, many references demonstrate the lack of randomization of patient symptomatology and the fact that some patients required hybrid techniques with the use of combined balloon sinus dilation and standard functional endoscopic surgical techniques to achieve adequate success. Final Result: The reviewers determined that the services at issue were 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 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 inpatient hospitalization for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the request for inpatient hospitalization is not medically necessary for treatment of the patients medical condition. The medical literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy (CBT) can be effective for treatment of eating disorders. According to researchers, after inpatient weight restoration, CBT significantly reduced relapse risk and increased the likelihood of good outcomes compared with nutritional counseling, based on nutritional education and food exchanges. Without a specific medical complications or need for refeeding, inpatient admission is typically not recommended for treatment of eating disorders. According to other researchers, clinical practice guidelines recommend treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. In this case, the records do not demonstrate that the patient has medical complications that requires inpatient care. According to the documentation submitted for review, the patient was initially admitted to the inpatient program due to suicidal ideation. The patient also reported symptoms of depression and anxiety as well as eating disorder symptoms. The patients vital signs as well as weight and body mass index were all within normal limits. Her body mass index also remained within the normal range. The records demonstrate that the patient has eating disorder symptoms as it was noted that she was not eating 100% of the meals. However, despite not eating all of the meals the patients vital signs remained within normal limits. In addition, the records do not indicate what type of prior treatment the patient has had for the eating disorder for other psychiatric conditions. The records also do not indicate that the patient was exhibiting aggressive or dangerous behaviors towards self or others. The patient was noted to be uncooperative in group treatment but had agreed to take psychiatric medication as recommended by the provider. In sum, the patients symptoms do not support the need for inpatient care. 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret for 12 weeks. Findings:  The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials. Additionally, the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage.  The ENDURANCE-1 trial showed that only eight weeks of treatment is needed, not 12 weeks.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Therefore, Mavyret for 12 weeks to treat hepatitis C infection 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 internal medicine with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right and left foot for evaluation of the enrollees bilateral neuroma. Findings:  The physician reviewer found that the requested diagnostic magnetic resonance imaging (MRI) is not supported as medically necessary for the evaluation of this patients medical condition. Review of the documentation provided indicates the patient has not failed alternate conservative treatment options including immobilization, off-weight bearing, series of steroid injections, shoe modifications/orthotics, oral anti-inflammatory medications, physical therapy, and has not had a diagnostic ultrasound examination. Therefore, the requested MRI of the right and left foot are not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedures are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in podiatry 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 authorization and coverage for dilated cardiomyopathy sequencing panel. Findings:  The physician reviewers found that currently, the value of the genetic testing for dilated cardiomyopathy has not been established in the prospective, randomized, controlled clinical trials for routine use in this clinical setting . Overall, there is a lack of data demonstrating improved health outcomes with use of dilated cardiomyopathy sequencing panel for patients with isolated cases of dilated cardiomyopathy. The American College of Cardiology (ACC) discussed genetic testing for dilated cardiomyopathy in patients with idiopathic hypertrophic subaortic stenosis (IHSS) or Long QT syndrome, but not for patients with isolated cases of dilated cardiomyopathy. Accordingly, the requested dilated cardiomyopathy sequencing panel is 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 requested testing is  not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 & 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.