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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The current guidelines do not support use of the advanced lipid testing.  The medical evidence supports the use of standard risk factors and standard lipid profile to make decisions about lipid management.  In addition, the guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy.  Thus, advanced lipoprotein testing performed was not likely to have been more effective than other methods of evaluating this patient. 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: All three physician reviewers 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacroiliac surgery. Findings:  The physician reviewer found that there is sufficient support for the requested services in this patients case.  She presents with persistent left-sided buttocks pain radiating into the left posterior thigh and calf, with numbness and tingling down the leg.  Functional difficulty was documented in sitting tolerance and sleep.  She is eight years status post L4-5 lumbar fusion. There was evidence of long-term conservative treatment with activity modification, medications, sacroiliac injections, and sacroiliac radiofrequency ablation.  Clinical examination findings have documented tenderness at the left sacroiliac joint with three positive sacroiliac provocative tests.  There is radiographic evidence of sacroiliac joint spurring. She has been diagnosed with sacroiliitis.  There is evidence of an L5-S1 disc protrusion with annular fissure, but no physical examination or imaging evidence of nerve root compression.  Multiple left sacroiliac joint injections have produced at least 75% pain relief.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested sacroiliac surgery 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 physician 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: An enrollee has requested reimbursement for residential treatment services. Findings:  The physician reviewer found that there is a lack of support in the documentation for the medical necessity for the requested services. He was medically and psychiatrically stable.  There was no evidence of danger to self or harm to others. The patient showed mild post-acute withdrawals. There were no emotional, behavioral, cognitive, or impulsive symptoms to have required additional residential treatment. He was not agitated or manic, and he showed no signs of psychosis.  He verbalized motivation and appeared to be working the program.  He had a plan to attend IOP and continue in AA.  He indicated that he had a sober support system in his friends. He no longer required the structure of a 24/7 setting and could have continued treatment in IOP.  Residential services were no longer medically necessary. As such, he did not require 24 hour nursing and medical supervision at a residential level of care. Therefore, the residential treatment center services during the dates of service in question were not medically necessary for 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 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 Gel-One injections to the right knee, every six months. Findings:  The physician reviewer found that viscosupplementation with hyaluronic acid for knee osteoarthrosis has been performed in the United States since 1997 and is now an established part of treatment algorithms for the management of osteoarthritic knee pain and is a second-line treatment after simple pain medications such as nonsteroidal anti-inflammatory medications. Multiple studies have documented both safety and efficacy, but individual results vary. There is currently a lack of scientific evidence that one brand name is more effective than another. The diagnosis of osteoarthrosis is generally confirmed by imaging studies such as x-ray and magnetic resonance imaging (MRI) which have likely been performed in this case, but have not been documented for this review. In this case, limited records from the treating provider note that right knee viscosupplementation was performed with limited short-term improvement and a request for bilateral viscosupplementation was made approximately four months later. Given the lack of data supporting ongoing injections every six months, the requested Gel-One injections to the right knee, every six months, is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer  determined that the requested service 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 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: an enrollee has requested authorization and coverage for 30 treatments of light therapy for nerve rejuvenation. Findings:  The physician reviewer found that there are few peer-reviewed studies reporting any use of light therapy in neuropathy. Lavery and colleagues reported that there were no significant differences in measures for quality of life, Michigan Neuropathy screening instrument (MNSI), vibration perception threshold (VPT), Semmes-Weinstein monofilaments (SWM), or nerve conduction velocities in active or sham treatment groups. In addition, Khamseh and colleagues noted that low intensity laser therapy had positive effect on nerve conduction velocity in neuropathy, but additional studies were recommended to show benefit in regard to pain. 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 neurology with sub-specialty certification in pain 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene test. Findings:  Three physician reviewers found that FoundationOne gene testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hope of identifying markers that can help guide therapy decision making. Per the National Comprehensive Cancer Network guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis in this clinical setting. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy (NCI-MATCH: Targeted Therapy Directed by Genetic Testing in Treating Patients With Advanced Refractory Solid Tumors or Lymphomas). However, genetic testing in this setting is still the subject of an ongoing phase II trial. As such, the genetic testing performed would be considered investigational/experimental for this patient. Therefore, FoundationOne gene test performed was not likely to be more beneficial than other standard options available for the evaluation of this patients medical condition. Final Result: 2 of 3 reviewers determined that the services at issue were not likely to have been 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 physician reviewers 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left hip core decompression with concentrated bone marrow (stem cell) autograft surgery. Findings:  The physician reviewers found that there is a lack of support in the medical literature for the superior efficacy of the requested procedure in this clinical setting. In addition, platelet rich plasma and stem cell use for treatment of hip avascular necrosis (AVN) are not approved by the U.S. Food and Drug Administration. Instead, standard core decompression or hip replacement surgery have been associated with consistent superior results for patients who have undergone these standard procedures. There is a lack of high level studies in peer reviewed orthopedic literature supporting stem cell concentrated bone marrow autografting of core decompression in AVN of femoral head. As such, the requested left hip core decompression with concentrated bone marrow (stem cell) autograft surgery is not likely to be more effective than the available standard therapy such as standard core decompression or hip replacement surgery for treatment of this patient. Final Result: 2 of 3 reviewers determined that the requested procedure 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: All three physician reviewers are board certified in orthopedic surgery 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 Otezla. Findings:  The physician reviewer found that the records provided for review document that this patient presents with a longstanding history of plaque psoriasis. The patient has been treated with Otezla for the past year and has found good efficacy and has tolerated it well. Otezla is a U.S. Food and Drug Administration (FDA) approved oral medication for the treatment of psoriasis and psoriatic arthritis. Otezla is not considered to be immunosuppressive, as no laboratory monitoring is required for patients using the medication. Alternative treatment with either Enbrel or Humira carry risks of reactivation of latent infections and malignancy. As the patient has been stably treated with Otezla, its continued use is supported as medically necessary. Final Result: The reviewer determined that the requested medication 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 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: An enrollee has requested authorization and coverage for Viekira Pak and Sovaldi for 24 weeks. Findings:  The physician reviewer found that, according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), Deferral of treatment is recommended, pending availability of data for patients with HCV genotype 1, regardless of subtype, in whom previous treatment with any HCV nonstructural protein 5A (NS5A) inhibitors has failed, who do not have cirrhosis, and do not have reasons for urgent retreatment. In this case, the patient does not have cirrhosis, and no other reason for urgent re-treatment compatible with the high-urgency group in the guidelines is provided. All told, the requested Viekira Pak and Sovaldi for 24 weeks is not supported as medically necessary for the re-treatment of this patients HCV. Final Result: The reviewer determined that the requested medications 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 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 authorization and coverage for Euflexxa injections.  Findings:  The physician reviewer found that evidence-based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  This has been found to be safe and effective and allow for delay of total knee replacement.  In this case, the patient been diagnosed with left knee tricompartmental osteoarthritis, bone-on-bone in the medial compartment.  She had failed to adequately respond to other conservative treatment, including anti-inflammatory medications, steroid injections, and bracing.  Prior viscosupplementation injections resulted in significant benefit, allowing resumption of normal activities.  The patient has requested Euflexxa injections to reduce pain, improve function, and delay total knee replacement.  There is sufficient support for the requested services in this clinical setting.  All told, the requested Euflexxa injections are medically indicated 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 physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a 12-week course of Epclusa 400/100 mg. Findings:  The physician reviewer found that, according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  This applies regardless of fibrosis stage. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients.  A delay in treatment may result in decreased survival.  All told, the requested 12-week course of Epclusa 400/100 mg is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fetal sex and sex chromosome aneuploidy panel options for Harmony Prenatal Test. Findings:  Three physician reviewers found that fetal aneuploidy screening is supported for pregnant patients by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine.  Cell-free DNA testing has been validated as having a high detection rate for fetal chromosomal abnormalities, including sex chromosomes.  This patients age places her at increased risk for all fetal chromosomal abnormalities.  Currently, the screening test of choice is cell-free DNA testing.  Sex chromosome abnormalities, such as Turners syndrome, include significant associated medical morbidities.  In sum, fetal sex and sex chromosome aneuploidy panel options for Harmony Prenatal Test provided were likely to have been of greater benefit than other methods of evaluating this patient. Final Result: 2 of 3 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: All three 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  Three physician reviewers found that the American College of Cardiology (ACC) guidelines do not support use of advanced lipid testing in this clinical setting. Rather, the ACC guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. In addition, the guidelines emphasize use of the pooled risk score analysis for decisions regarding statin therapy. The ACC guidelines are formulated based on thorough review of current literature. Given these findings, the advanced lipoprotein testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Results: 2 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 three physician reviewers 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the dopamine transporter single photon emission computed tomography (DaT SPECT) scan for evaluation of his tremor in bilateral hands and legs. Findings:  Three physician reviewers found that researchers concluded that DaT scan imaging has an impact on clinical decision making. Further, the authors noted that DaT scan has the potential to provide support in diagnosis, especially for those patients who have an unclear presentation of Parkinsonian syndrome (PS). Similarly, other researchers reported that an accurate diagnosis is important for timely and adequate treatment in patients with clinically uncertain parkinsonian syndrome (CUPS)DaTscan imaging significantly affected the clinical management and diagnosis of patients with CUPS. Thus, the literature does support the use of DaT SPECT imaging to assist in the diagnosis in patients with suspected parkinsonian syndromes and help guide treatment decisions. Final Result: The reviewers determined that the diagnostic procedure 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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