Persius/hicric huggingface dataset:
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 injection. Findings:  The physician reviewer found that this patient presents with increased coronary risk, including hyperlipidemia, but no documentation of clinical coronary disease or heterozygous familial hyperlipidemia.  Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied only in patients with heterozygous familial hypercholesterolemia or in patients with documented clinical atherosclerotic heart disease who require additional lowering of low-density lipoprotein cholesterol. This patient does not fit either of those categories. There is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. These diagnoses require not only elevated low-density lipoprotein levels that significantly exceed threshold amount, but also a combination of physical examination findings, a strong family history of coronary disease and documented genetic defects related to cholesterol metabolism according to published criteria. There is no documentation to support clinical coronary disease, such as angina, myocardial infarction or prior coronary revascularization. Studies that have evaluated Repatha do not include patients without familial hyperlipidemia or clinical cardiovascular disease.  PCSK9 inhibitors have not been studied in other patients for primary prevention and are not recommended in this patient group according to current guidelines. Thus, the requested Repatha 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 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: An enrollee has requested reimbursement for the DecisionDx-Melanoma gene assay. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.Findings: The National Comprehensive Cancer Network guidelines indicate while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The records of this testing is not likely to alter treatment and surveillance recommendations. As such, DecisionDx-Melanoma gene assay was not likely to have been of greater benefit than any available standard therapy of evaluating this patients medical condition.Final Result: All 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 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: The parent of an enrollee has requested reimbursement for the Prometheus Anxer IFX diagnostic test. Anser IFX has not definitively demonstrated efficacy for the management of Crohns disease. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. Another review reported that there is ongoing debate as to the relevance of antibodies to infliximab development in clinical care and that published studies on this topic lack uniform reporting of outcomeshigh risk of bias was present in all the included studies. In summary, current medical literature reports contradictory outcomes and lacks high-quality controlled studies to define drug level or antibody level thresholds requiring action, compare clinical strategies such as dose increase or change in medication based on those thresholds, and then definitively establish that use of Anser IFX improves outcome. All told, the Prometheus Anser IFX testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the Prometheus Anser IFX testing 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for lumbar fusion L5-S1, single level (CPT code 22612). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients lumbago. The submitted documentation supports the medical necessity of the requested services. There is moderate evidence supporting the requested services in the settling of lumbar generative disc disease without instability, in the presence of chronic low back pain with failed non-operative treatment, and the presence of S1 radiculopathy on electromyography. Based on the current medical evidence, the requested single level fusion procedure at L5-S1 is medically necessary for the patients medical condition of degenerative disc disease at L5-S1, which did not respond to nonoperative treatment. In sum, the medical evidence supports the requested services in this clinical setting. Therefore, the requested lumbar fusion L5-S1, single level (CPT code 22612) is medically necessary for the treatment of this patient.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genotype testing. In the peer-reviewed medical literature, it states that, to demonstrate the true clinical benefit of genotyping for predicting treatment response or adverse effects, it would be necessary to conduct prospective head-to-head comparisons of different specific treatments chosen by genotype, which have not yet been performed., it was noted that phenotyping of cytochrome P450 enzymes may be relevant. However, sufficient high-quality, replicated, and controlled studies demonstrating that pharmacogenetics and pharmacogenomics reliably improve health outcomes are not yet available. There are some circumstances that genetic testing is done for safety reasons such as with treatment with carbamazepine. This patients documentation does not report that this medication is a consideration. Thus, the genotype testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the genotype testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the genotype testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in psychiatry 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 Neocate Junior formula (chocolate flavor). The Health Plan has denied this request indicating that the requested formula is not medically necessary for treatment of the enrollee who has a history of allergies to certain food.The submitted documentation supports the medical necessity for the requested oral formula. Dietary elimination is recognized as an established treatment for eosinophilic esophagitis. A four-food elimination diet with avoidance of milk, wheat, egg, and soy, can induce remission in 64% of subjects as reported in a recent publication.  However, even more stringent restrictions are not effective in all patients.  Furthermore, dietary elimination alone has not been able to maintain appropriate growth in this patient. According to the North American Society of Gastroenterology, Hepatology, and Nutritions guidelines on management of eosinophilic esophagitis, the use of elemental formula should be considered as an effective therapy in all children diagnosed with this condition. Moreover, the guidelines state that when deciding on the use of a specific dietary therapy, the patients lifestyle and family resources should be considered. This patient has also been diagnosed with autism syndrome disorder and exhibits difficulty with multiple food textures; however, the documentation indicates that she has been able to grow with use of chocolate-flavored Neocate Junior. Therefore, Neocate Junior formula (chocolate flavor) has been demonstrated as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested oral formula 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 pediatric gastroenterology with expertise in pediatric nutrition 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 FoundationOne gene test. In keeping with the standard of care as summarized in National Comprehensive Cancer Network (NCCN) for colon cancer, only KRAS, NRAS, BRAF, and MSI genomic molecular markers have been demonstrated to provide improved health outcomes. To demonstrate clinical utility of panel testing for somatic genomic alterations such as FoundationOne assay, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with the standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions on clinical utility. In addition, there is potential for harm if ineffective therapy is given based on test results, because there may be adverse effects of therapy in absence of any benefit. As a result, the use of expanded mutation panel testing for targeted treatment in cancer is not supported for use in this clinical setting. Thus, the KRAS, NRAS, BRAF, and MSI portions of the testing were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the testing 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 a portion of 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 partially 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.There is sufficient support in the documentation provided for the medical necessity of the services at issue in this clinical setting. The patient remained symptomatic.   His mood was often described as irritable and anxious.  He was documented as being intrusive to peers, impulsive, and having lack of motivation. He was noted to minimize his relapses and probation and was detained at a juvenile detention facility.  The American Society of Addiction Medication (ASAM) Criteria, a set of objective guidelines used by clinicians to assist with treatment planning, advocates for service intensity provided in the least intensive but safe treatment setting.  ASAM also advises that the length of service should be determined by the patients progress with his treatment plan as determined by the patient and treatment providers. Based on current medical literature, ASAM criteria, and the patients documented clinical history, the patients admission to the IOP level of care from was and is medically necessary for treatment of this patient.  Findings:The reviewer has determined that the services at issue were and 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive care (ICU) services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition.There is support in the medical literature and the documentation provided for the services at issue in this patients case. The progress notes and the clinical course  met the medical necessity criteria for hospitalization in the ICU.  The patient continued to have frequent neuro checks hourly and concerns for seizure were noted. There was close monitoring of the fluid status and serum sodium, an especially important parameter for postoperative neurosurgical patients. On that date, the patient was getting hourly neuro checks by nursing, was receiving anticonvulsant medications as well as antibiotics. He had drains in place that required monitoring. For these reasons, ICU services were medically necessary for the treatment of this patients medical condition.Findings:The reviewer has 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 internal medicine with sub-specialty certification in medical oncology 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 and prospective authorization and coverage for residential treatment center services. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. During her stay, the patient was noted to be cooperative in treatment. She was engaged in family and individual therapy and was noted to have some issues with difficulty interacting with peers. Throughout the first portion of her stay, the patient described suicidal ideation. The progress notes do not indicate that the patient made any suicide attempts or self-harm attempts during her stay. During her stay, the patient gained more insight into her behaviors and it appears that she made significant progress. In this patients case, residential treatment was initially medically necessary because she was endorsing suicidal ideation on a frequent basis. However, this suicidal ideation resolved, and the patient was documented to have shown improved coping skills. After the resolution of her suicidal ideation, the patient could have transitioned to a less restrictive setting. Based on the records, residential treatment center services provided from certain dates were medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue was 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychiatric services for their medical condition of psychiatric emergency medical. Findings:  The physician reviewer found that This patient received a full biopsychosocial assessment prior to the disputed dates. The records did not document suicidal or homicidal ideation.  He was not experiencing acute episodes of psychosis or any other emergency psychiatric symptoms that would require emergent treatment and necessitate emergency stabilization or evaluation. Residential treatment is used for acute stabilization and is not evidenced-based for long-term type treatment.  There was no indication in this case that there were acute or emergent issues that needed stabilization. It appears that the patient had substance use as a primary concern. Outpatient treatment and least restrictive options are considered first lines of care. The services at issue were not necessary for treatment of a psychiatric emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive psychiatric 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 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.