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

Nature of Statutory Criteria/Case Summary: The parent of a deceased enrollee has requested reimbursement for the Foundation One Heme Testing for evaluation of the enrollees malignant rhaboid tumor of the liver. Findings:  The 3 physician reviewers found that Hepatoblastomas arise from primitive cells that can differentiate into a variety of histologies which as a result can give rise to complex tumors. They typically present as well circumscribed lesions that can be as large as 20 cm. They are very rare and prognosis is usually poor. SMARCB1 gene germline mutations cause a rhabdoid tumor predisposition syndrome (RTPS). Individuals with this condition have an increased risk of developing aggressive cancerous growths, in particular rhabdoid tumors. An additional mutation that deletes the normal copy of the gene is needed for tumors to develop. Somatic mutations in both copies of the SMARCB1 gene result in absence of the SMARCB1 protein and result in noninherited (sporadic) rhabdoid tumors in children. Due to the rarity of this tumor there are a lack of established guidelines for treatment in this clinical setting. In this case, somatic tumor testing was performed. The presence or absence of a germline and somatic or bi-allelic somatic would be consistent with RTLS. This is significant in characterizing the syndrome and determining if other family members should be tested for the germline mutation. For the reasons provided, the Foundation One Heme Testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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: Physician reviewer number one 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.Physician reviewer number two is board certified in pediatrics with sub-specialty certification in pediatric oncology and hematology 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.Physician reviewer number three is board certified in pediatrics and clinical genetics 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 gene testing that was performed for evaluation of the enrollees indeterminate thyroid nodules. Findings: Two physician reviewers found that the cytopathology of the 1.5 cm thyroid nodule was consistent with a follicular neoplasm. The risk of malignancy is 15 to 30% in follicular neoplasm nodules. The Bethesda System recommends a diagnostic thyroid lobectomy for this type of nodule. The newest 2015 American Thyroid Associations guidelines state that for follicular neoplasm nodules, molecular testing may be used to supplement malignancy risk assessment data in lieu of proceeding directly with surgery. The risk of malignancy is 15 to 30% in follicular neoplasm nodules. The finding of positive medullary thyroid carcinoma gene allows the surgeon to determine the best course of action. Final Result: Two of three physician reviewers determined that the services at issue were 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 overturned. 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 reimbursement for gene testing provided for evaluation of the enrollees elevated prostate specific antigen (PSA). Findings:  The 3 physician reviewers found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The testing at issue does not eliminate the need for serial PSAs and rectal examinations to detect changes in the patients medical condition. In addition, the provider noted that the patients increase in PSA is not likely related to prostate cancer. For the reasons provided, the gene testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: Physician reviewer number one is board certified in urology 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.Physician reviewer number two is board certified in urology 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.Physician reviewer number three is board certified in urology 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 twice weekly therapy visits for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the medical literature does not define the frequency or duration for the amount of psychotherapy required for each patient. However, it is generally accepted that patients in crisis require more frequent sessions than patients who are stable. The medical literature also supports that in unrestricted therapies, each additional psychotherapy session has a diminished effect. An article by colleagues, they report, Our findings suggest that, at least in unrestricted therapies, the average rate of change during psychotherapy can be expected to diminish with each additional session irrespective of the length of treatment. These results are consistent with previous studies. Given this information, the patient has been stable, and her symptoms of social isolation and social anxiety have improved. She has been sober from alcohol for several years. It appears from the documentation that the patient is mentally stable and not in an acute crisis. In this patients case, her chronic problems can be addressed during a weekly psychotherapy basis. It is also important to note that biweekly psychotherapy sessions in general are not common practice unless one is undergoing intense evidenced based treatment protocols such as prolonged exposure therapy or dialectical behavioral therapy. Even with these protocols, biweekly treatments are time limited. Given this information, the patients records do not support biweekly psychotherapy sessions. Therefore, twice weekly therapy visits are not medically necessary for treatment of this patients medical condition. 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: A 62-year-old female enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks for treatment of the enrollees hepatitis C. 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), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier 50-100 mg for 12 weeks is medically necessary 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 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 the EpiFix placental allograft skin substitute for treatment of the enrollees chronic right heel wound. Findings:  2/3 of the physician reviewers found that EpiFix is an amniotic membrane biologic product that has strong evidence for healing diabetic foot ulcers versus standard care. EpiFix is also superior to other biologics. Standard wound care includes debridement, glycemic control, offloading and infection control. Although the patient underwent debridement, the patient remained on Santyl for two years with little variation. Recent notes do not mention appropriate offloading such as a total contact cast. In this case, dressings including iodine based products, collagen, foam, were not exhausted. There was no mention of local tissue oxygenation. All told, the EpiFix placental allograft skin substitute was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: 2/3 of 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in infectious 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.Physician reviewer number two is board certified in family practice 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 15-year-old female enrollee has requested authorization and coverage for implantation of a patient-activated cardiac event recorder for evaluation of the enrollees palpitations. Findings:  The physician reviewer found that There is sufficient support for the requested services in this clinical setting. In the study by Giada and colleagues involving patients with symptoms of palpitations and without severe structural heart disease, a diagnosis was significantly more likely with the use of an implantable loop monitor than with a conventional strategy. This patient has had recurrent palpitations for several years which has eluded a definitive diagnosis. This is despite empirical therapy with a beta blocker. Based on the available data and given the inability to arrive at a diagnosis after both conventional ambulatory monitoring and electrophysiological study, the requested implantation of a patient-activated cardiac event recorder is likely to be superior over other methods of evaluating this patient. Final Result: Two of three reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: A female enrollee has requested authorization and coverage for sclerotherapy for treatment of the enrollees peripheral venous insufficiency.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The current medical evidence suggests that the current place of sclerotherapy in modern clinical practice is limited to the treatment of accessory recurrent varicose veins following surgery and thread veins. Intervention for CEAP 1-2 disease without evidence of axial reflux, complications of chronic venous insufficiency and failure of conservative measures is not standard of care. The medical evidence does not support the requested services in this clinical setting. Therefore, the requested sclerotherapy 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 vascular 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 strabismus surgery (CPT codes 67311 and 67312); and bilateral upper eyelid blepharoplasty (CPT code 15823) and right upper eyelid retraction repair (CPT 67911) for treatment of the enrollees dermatochalasis and right upper eye lid retraction. Findings:  The physician reviewer found that Thyroid eye disease, also known as Graves ophthalmopathy, can affect multiple aspects including the orbit, the eyelids and the muscles which can require surgical repair. In this case, the patient underwent orbital decompression as well as lower eyelid repair. Based on the clinical documentation provided for review, the patient has upper eyelid retraction as well as diplopia both of which are medically necessary to repair by performing eyelid retraction repair and strabismus surgery. However, based on the clinical documentation and photographs provided, the dermatochalasis and fat prolapse of the upper lids does not interfere with the patients vision and no evidence such as visual fields were provided to support the medically necessity of upper eyelid blepharoplasty. Therefore, strabismus surgery (CPT codes 67311 and 67312) and right upper eyelid retraction repair (CPT 67911) have been established as medically necessary. However, bilateral upper eyelid blepharoplasty (CPT code 15823) is not medically necessary. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of your medical condition.  Credentials/Qualifications: The reviewer is board certified in ophthalmology 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 Foundation One gene test for evaluation of the enrollees recurrent glioblastoma. Findings:  The physician reviewers found that Foundation One 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 Foundation One assay adds to decision making ability, or yields a result that is reliably 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. All told, the Foundation One test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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 a female enrollee has requested reimbursement and prospective authorization and coverage for ultrasound, sclerotherapy and anesthesia performed for treatment of the enrollee who has a history of varicose veins and Klippel-Trenaunay syndrome. Findings:  The physician reviewer found that there is sufficient support in the documentation provided for the services at issue in this clinical setting. This patient has been diagnosed with KTS and it is considered standard to treat lesions that are painful and localized for adequate venous drainage. KTS is a relatively rare condition, and there are limited universal treatment guidelines. However, there is sufficient medical literature to support the use of sclerotherapy for treatment of lesions associated with KTS. These studies have shown that sclerotherapy in patients diagnosed with KTS have been effective. As such, the ultrasound, sclerotherapy and anesthesia performed were and are medically necessary for treatment of this patients medical condition. Final Result: The reviewer 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 vascular 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.