Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the psychiatric residential treatment services rendered. Findings:  The physician reviewer found that Modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community intervention settings optimize treatment gains. However, episodic placement in more restrictive settings is often clinically appropriate for patients with significant mental illness. The American Psychiatric Association (APA) states that the psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the patients safety, but also to promote improvement in the patients condition. In this patients case, the patient reported co-occurring depression and anxiety. This is of particular relevance since it has been well-established in both clinical practice and the medical literature, such as the definitive Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, that anxiety-ridden mood disorders are difficult to treat and generally have poorer outcomes. Additionally, the early age of onset, and subsequent chronicity of symptoms, were additional factors suggestive of a formidable illness burden and the need for a conservative course of treatment. Further, during the episode of illness, the patient had previously failed treatment in a less restrictive setting. Thus, the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Additionally, the services provided were reasonably expected to improve the patient's  condition and prevent a more serious episode of illness. Considering the clinical presentation and current peer-reviewed literature, the psychiatric residential treatment services rendered were medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The parent of the enrollee has requested authorization and coverage for genetic testing (Fragile X DNA analysis and ID Next) for evaluation of the enrollees autism spectrum disorder.Findings: Two physician reviewers found that the American Academy of Pediatrics has issued guidelines specifying that any child with global developmental delay or isolated speech/language delay of unknown cause be tested for Fragile X syndrome as a first tier evaluation. The American College of Medical Genetics has also published practice guidelines that call for the testing of Fragile X syndrome in individuals with autism. Therefore, Fragile X DNA testing is the standard of care and is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. However, there is a lack of published data in the peer-reviewed literature supporting the clinical utility of ID Next or other intellectual disability gene panels.Final Result: The reviewers determined that a portion of the requested testing is 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: All three physician reviewers are board certified in pediatrics and clinical genetics 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 genetic testing performed on 9/30/16.Findings:  The physician reviewers found that the patient was diagnosed with invasive ductal carcinoma of her breast in September 2016. Her family history includes a sister who was diagnosed with breast cancer at age 51 and a sister who was diagnosed with pancreatic cancer at age 47. Three paternal aunts were also diagnosed with breast cancer and one paternal aunt was diagnosed with ovarian cancer (all are deceased). On the basis of her personal history of breast cancer and significant family history of cancer, the patients treating provider recommended a genetic panel test. The patient is requesting reimbursement for the genetic tests performed on 9/30/16. The Health Plan denied the services at issue as investigational for the evaluation of this patient. The medical evidence supports the efficacy of a portion of the services at issue.  This patient has a personal history of breast cancer as well as a significant family history of cancer. She meets the criteria outlined and recommended by National Comprehensive Cancer Network Guidelines (NCCN) guidelines and the US Preventative Services Task Force for BRCA genetic testing. However, the testing performed on 9/30/16 was a 25 gene panel that included BRCA within it but also a variety of other suspected risk genes. Although many of these other gene mutations are of real interest and are being studied, they have not been found to be significant enough to be the basis for clinical decisions for the carriers or their family members. Such broad testing is not included within guidelines from major organizations. Final Result: Two reviewers determined that a portion of the services 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: 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa 400mg-100mg, once daily for 12 weeks and ribavirin 200 mg three times daily for three weeks. Findings:  The physician reviewer found that, according to 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. All patients should be treated, regardless of fibrosis stage.  Per the guidelines, cirrhotic patients are high priority for treatment, and Epclusa for 12 weeks is recommended as first-line therapy for treatment naive, genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate in compensated cirrhotic patients with this regimen.  However, the addition of ribavirin is not recommended by the evidence-based AASLD/IDSA guidelines noting that ribavirin is associated with significant adverse effects based on a study of ribavirin monotherapy. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Epclusa monotherapy 400mg-100mg, once daily for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection, but ribavirin is not. Final Result: The reviewer determined that a portion of the requested medication regimen is 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zoll Life Vest for three (3) months. Findings:  Three physician reviewers found that the superior efficacy of the device at issue has not been demonstrated in this clinical setting. Based on the records provided, this patient has been diagnosed with a newly recognized nonischemic cardiomyopathy. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy. Based on the records, there was no indication for an immediate placement of a defibrillator. The documentation did not indicate sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time (greater than 90 days) where continued left ventricular dysfunction (ejection fraction less than or equal to 35 percent) is documented to persist in spite of appropriate treatment. A prophylactic defibrillator, wearable or implantable, before this time has not been demonstrated to improve outcome. Also, studies evaluating wearable defibrillators during periods of increased risk, where criteria for implantable defibrillators have not yet been met, are largely comprised of registry data without adequate control groups. Therefore, in this circumstance, a Zoll Life Vest for three (3) months is not likely to be more effective than standard medical therapy available for treatment of this patient. Final Result: 3 of 3 reviewers determined that the requested device is 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: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a wearable cardioverter defibrillator for treatment of his coronary artery disease. Findings:  Three physician reviewers found that the patients attending provider indicated that the patient required a wearable cardioverter defibrillator to protect him during a three to six month period after which an assessment would be made as to whether the patient would require an implantable cardioverter defibrillator. The patient requested reimbursement for a wearable cardioverter defibrillator. The Health Plan denied reimbursement for the wearable cardioverter defibrillator. Per the Health Plan, the device at issue was investigational for the treatment of the patients medical condition. There is a lack of support in the relevant medical literature for a demonstrated definitive improvement of health outcomes or improved survival benefit when a wearable cardiovascular defibrillator is deployed in the treatment of a newly diagnosed cardiomyopathy. The current literature does not show that wearable cardioverter defibrillator reduces mortality in patients with newly diagnosed cardiomyopathies during the 90 day period of medical therapy.  Final Result: The reviewers determined that the device at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.
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 for evaluation of the enrollees mixed hyperlipidemia. Findings:  Three physician reviewers found that in this circumstance guidelines for the management of cardiac risk have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, insulin resistance, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. In addition, randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for corneal collagen cross linking (procedure code 0402T). Findings:  The physician reviewer found that the patient is a 54-year-old male who presented to his provider with blurred vision and a history of laser assisted in situ keratomileusis. The patients provider noted a worsening astigmatism. The provider also noted that the patient requires rigid contact lens in the right eye.  Visual acuity measured 20/30 in the right eye and 20/15 in the left eye.  Per the provider, corneal topography showed inferior steepening of both corneas. The patients diagnosis was bilateral corneal ectasia. The provider recommended corneal collagen cross linking (procedure code 0402T). The Health Plan denied the requested procedure as investigational/experimental for the treatment of this patient. There is sufficient support in the medical literature for the superior efficacy of the requested procedure. The provider noted that this patients vision has continued to worsen. The vision loss is caused by the thinning corneas. The provider recommended corneal collagen cross linking procedure to prevent further degeneration.  Based on the patients vision loss and stage of ectasia, the crosslinking is the most appropriate and most effective treatment available. The body of evidence shows corneal collagen crosslinking is a safe and effective procedure for stabilizing corneal ectasia. Moreover, this procedure has the potential in preventing the need for full-thickness corneal transplant. There are very limited treatment options for this eye condition. In sum, the requested corneal collagen cross linking (procedure code 0402T) is likely to be superior to any available treatment options for this patient. Final Result: The reviewers determined that the requested procedure is 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: Physician reviewers are  board certified in ophthalmology 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 digital breast tomosynthesis performed for evaluation of her breast cancer examination. Findings:  Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has extremely dense breast tissue. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. The 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: 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.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services and ultrasound for treatment of an emergency medical condition. Findings:  The physician reviewer found that the urgent care services and ultrasound were not necessary for treatment of an emergency medical condition. The patient presented to urgent care with reports of a right breast lump. In this case, there was no emergent intervention indicated based upon the clinical presentation. A work-up for a breast lump was indicated and could have been scheduled at a facility in-network. An emergent breast ultrasound was not indicated in this clinical setting. All told, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier 50mg-100mg for 12 weeks for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions, 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 percent cure rate when NS5A resistance is absent. However, Zepatier is significantly less effective when NS5A resistance is present, and a different regimen is recommended (Zepatier and ribavirin for 16 weeks). In this patients case, NS5A resistance testing results were not provided. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 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.