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

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the FoundationOne blood test. Chordomas are bone tumors that are locally invasive, frequently recur, and are relatively radioresistant. Systemic therapy for the treatment of relapse after maximal surgery and/or radiation therapy has focused on molecularly targeted therapies. This patient has exhausted standard molecularly targeted therapies known to effective for chordoma. Several signal transduction pathways including platelet-derived growth factor receptor, epidermal growth factor receptor, and mammalian target of rapamycin have been implicated in the pathogenesis of chordomas, leading to the development of targeted therapies. The National Comprehensive Cancer Network (NCCN) indicates that the best management of any patient with cancer is in a clinical trial. Moreover, molecular profiling can identify mutations which may enable a patient to enroll on a clinical trial. All told, the FoundationOne blood test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the FoundationOne blood test 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 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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 reimbursement for the DecisionDx-Melanoma Gene Assay testing for evaluation of the enrollees cutaneous melanoma.  Findings:  The physician reviewer found that DecisionDx-Melanoma Gene Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Gene Assay has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is a lack of published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the DecisionDx-Melanoma Gene Assay was 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 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:  One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in dermatology and is 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tramadol 50 mg. Per the Centers for Disease Control and Prevention (CDC) opioid prescribing guidelines, providers should continue opioid therapy when there is adequate documentation that there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. Further, the CDC recommends that if benefits do not outweigh harms of continued opioid therapy, providers should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. This patients records do not include evidence of significant objective and measurable functional improvement on prior Tramadol. The records lack documentation that the patient has failed non-opioid pharmacologic approaches used for pain include analgesics such as acetaminophen, NSAIDs, and cyclooxygenase 2 (COX-2) inhibitors, selected anticonvulsants, and selected antidepressants. Moreover, there is no documentation that the patient has failed cognitive behavioral therapy (CBT), exercise therapy, interventional treatments, and multimodal pain treatment) and non-opioid pharmacologic treatments for chronic pain. All told, Tramadol 50 mg is not medically necessary for 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services. The Child and Adolescent Level of Care Utilization System is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 2.  The patient has no prior history of suicide attempts. At admission, the patient did not have any suicidal ideation or homicidal ideation. The patient does have a history of being violent when intoxicated. He did not have any psychosis, mania, or hallucinations. With regards to functional status, the records support a score of 3. The patient had moderate functional impairment. The records document severe deficits in his interpersonal relationships and his ability to engage in socially constructive activities. He has been able to attend to his activities of daily living. In terms of comorbidity, the records support a score of 3. The patient has comorbidities of attention deficit/hyperactivity disorder, persistent depressive disorder with intermittent major depressive episodes, cannabis use disorder, and unspecified anxiety. He did not have medical problems which required 24-hour monitoring. With regards to environmental stress, the records support a score of 2. The patient has a mildly stressful environment. He has a supportive family. The patient has interpersonal conflicts with his parents over his substance use. In terms of environmental support, the records support a score of 2. The patient has supportive parents who are willing to participate in treatment. With regards to resiliency, the records support a score of 3. The patient has had an equivocal response to prior treatment and continues to struggle with substance use. In terms of acceptance and engagement, the records support a score of 3. The patient is passively cooperative with treatment. He has ambivalent relationships with his providers. Thus, the patient has a composite score of 18. Based on these criteria, the patient would meet criteria for an intensive outpatient program and could be treated in a less restrictive environment. Therefore, residential treatment center services were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 expertise 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 for Repatha Sureclick Injector 140 mg/mL for treatment of the enrollee who has a history hyperlipidemia.  Findings:  The physician reviewer found that submitted documentation fails to demonstrate the medical necessity of the requested medication. Based on the records provided, the patient has a history of hyperlipidemia and he is noted as intolerant of statins and Zetia. However, there is no other documented coronary risk and he has a recent low coronary calcium score of only 9.  Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in patients with heterozygous familial hypercholesterolemia and in patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL-cholesterol. According to the submitted records, this patient does not fit either of these categories. The diagnosis of heterozygous familial hyperlipidemia requires not only elevated LDL-cholesterol levels that significantly exceed 180 mg/dL but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomatas), a strong family history of coronary disease (younger than 50 years in second degree relative or younger than 55-60 years in first degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria. The records do not support this patient has either heterozygous familial hyperlipidemia or clinical cardiovascular disease. There is a lack of literature supporting the use of PCSK9 inhibitors in patient populations such as this patient. For these reasons, Repatha Sureclick Injector 140 mg/mL is not medically necessary for treatment of the patients medical condition.  In addition, current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for adult partial hospitalization level of care for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that addiction specialty services and psychotherapy are indicated, the clinical documentation does not demonstrate the medical necessity for partial hospitalization at this time.  This patient is sorting through identity and phase of life issues, but there is no evidence that the current level of care is either unsafe or inadequate. Per the records, the records noted improved sleep. He had no sadness, irritability or rumination. Although still a challenge, he was leaving the home at least once a day.  He was developing more interest in activities. He was actively engaged in the therapeutic process and was incorporating elements of behavioral activation. His sobriety was intact.  He had no acute psychiatric issues or safety concerns, while validated clinical rating scales evidenced a significantly less burdensome symptom complex. The provider indicated that the patient was benefitting from the placement. There was no evidence of cognitive impairment, substance use or an acute psychiatric syndrome. The patient was not taking any psychotropic medication aside from the buprenorphine. The providers plan was to continue intensive outpatient programming, while there was no mention that a higher level of care was indicated. As such, adult partial hospitalization level of care is not medically necessary for the treatment of this patient. 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 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 tummy tuck or mid body lift. The American Society of Plastic Surgeons (ASPS) states that when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. This patient presents with evidence of a severe overlapping symptomatic lower abdominal pannus and a severely abnormal protuberance of the upper abdomen. Documentation reveals that the patients upper abdomen is severely abnormal. Therefore, a panniculectomy and abdominoplasty are medically necessary for treatment of the patients medical condition. Moreover, panniculectomy and abdominoplasty are supported as reconstructive in nature for treatment of this patients abdominal excess skin. There is sufficient documentation from the medical records to support that the patient has a significant functional impairment associated with her lower abdominal pannus. There is insufficient documentation that a functional impairment exists for the upper abdomen, but there is severe prominence of the upper abdomen that is significantly abnormal and not related to a hernia formation. The upper and lower abdomen are considered abnormal structures. However, the lateral flanks and back are not an abnormal structure of the body. In addition, the patients condition is related to treatment of obesity, which is considered a disease. Moreover, a lower abdominal panniculectomy would treat the patients functional impairment while the upper abdominal treatment should be performed in an attempt to obtain normalcy. Both upper and lower abdominoplasty would provide more than a minimal improvement. For these reasons, a tummy tuck is medically necessary and reconstructive in nature, while a mid body lift is not medically necessary or reconstructive in nature, for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested surgery is medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for applied behavioral analysis (ABA). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder. The request for ABA is medically necessary for treatment of the enrollees autism spectrum disorder. Applied behavioral analysis (ABA) is a therapeutic intervention that must be customized to the needs of the individual patient and thus, there are no clear guidelines indicating a definitive number of hours per week of behavioral interventions such as ABA. It is also noteworthy to remember that cognitive plasticity exists through child development and adult life and ABA can continue to be of benefit to individuals with ASD as they move into adulthood. The patients provider documents the patient has steadily improved in his level of independence, communication and social skills while receiving ABA therapy per week. While the patient has been making gains, the provider notes he still continues to experience episodes of self-harm and occasional injurious actions toward others. In this case, the records demonstrate that continuation of ABA therapy at an intensive level is clinically indicated to prevent regression and maintain patient safety. 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 neurology with special qualification in child 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: A 53-year-old female enrollee has requested reimbursement and prospective authorization and coverage for the botulinum toxin A (Botox) injections. Botox, 155 units, is U.S. Food and Drug Administration (FDA) approved for treatment of chronic migraine headaches. The medical records indicate chronic headache of migraine type that are occurring 15 or more days per month. The headaches have not responded to first-line treatment options including failure of at least two medications for prophylaxis of migraine. Thus, the botulinum toxin A (Botox) injections were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the botulinum toxin A (Botox) injections were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in neurology and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology and is 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for New Ride Custom Cushion The submitted documentation fails to demonstrate the medical necessity of the requested equipment. There is an increased risk of low back pain for individuals who spend prolonged periods of time in wheelchairs. Weight shift behaviors in individuals who spend prolonged periods of time in wheelchairs are generally reduced and irregular.  This can result in poor posture, such as sacral sitting, with posterior pelvic tilt and lumbar kyphosis. In this case, the back of the patients wheelchair has been adjusted to provide better lumbar support. Some posterior pelvic tilt remains. This can be addressed by better posture  or adjusting frame angles.  The latter would be a more stable correction than a custom-fit cushion that may help initially, but will deform over time. The records do not document that these alternative interventions have been attempted and/or ruled out. Therefore, the requested New Ride Custom Cushion  is not medically necessary for the treatment of this patient. 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.