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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing (MyRisk CPT 81479). Findings:  The physician reviewers found that this patients history is suggestive of a potential de novo mutation in her sister or predisposition to cancer with variable penetrance. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. These are the Amsterdam criteria and the Bethesda consensus guidelines. Notably, the Amsterdam criteria have low sensitivity in HNPCC detection so the Bethesda guidelines were developed. However, these guidelines are highly focused on patients with colorectal cancer who have microsatellite instability. The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral. In this case, the MyRisk panel was medically appropriate since the patients clinical situation may be caused by several potential cancer-causing genes. Therefore, the gene testing (MyRisk CPT 81479) performed  was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 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: 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 for Epclusa for 12 weeks. 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 to all patients, regardless of fibrosis stage.  Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI).Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI. The records demonstrate the patients back pain is localized to the right flank. He does not have radicular symptoms, tingling, or numbness. The patient does not have symptoms associated with a herniated disc, for which an MRI would be indicated. In addition, the patient has not been treated with conservative therapy with physical medicine or pain management. In sum, there is a lack of clinical documentation supporting MRI in this clinical setting. All told, the requested MRI is not medically necessary for evaluation of the patients medical condition.  Final Result: The reviewers determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for continuation of 40 hours per week of one-on-one applied behavioral analysis (ABA) therapy, 16 hours per month of supervision and eight hours per month of clinical team meetings provided. Findings:  The physician reviewer found that there is a strong correlation between treatment outcomes and treatment intensity for children with autism . The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30-40 hours of treatment per week. ABA has been effective for this patient, however she continues to demonstrate maladaptive behaviors that are occurring across multiple environments. Per the progress notes, she has 16 maladaptive behavior goals which she has not met. In addition, her maladaptive behaviors are described as dangerous to herself and others. Based on the documentation submitted for review, 40 hours per week of one-on-one ABA therapy, 16 hours per month of supervision and eight hours per month of clinical team meetings provided  since the beginning of the year and forward was and is medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer number one is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 right sacroiliac (SI) joint fusion. Findings:  The physician reviewer found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The standard of care when evaluating a patient for surgery is obtaining a detailed history and performing a detailed physical, neurologic, orthopedic, and vascular exam to rule out other reasonable causes of pain. In this case, a detailed history and physical examination was not provided for review. The x-rays and CT scans report a fracture of L4, loosening pedicle screws, spondylolisthesis at L4-5, and right hip osteoarthritis. These are potential sources of chronic low back pain that have not been ruled out. Thus, the patients pain generator has not been identified. A single SI joint injection with a positive response does not support the SI joint as the pain generator. Moreover, SI fusion is indicated for tumors, fracture, infection, and correction of spinal deformities. There are no indications for SI fusion for chronic back pain. For the reasons provided, the request for right SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested procedure 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: Physician reviewers are board certified in neurological 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 Harvoni 90-400 mg tablets for eight 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), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mepolizumab (Nucala) 100 mg once every four weeks for 26 weeks. Findings:  The physician reviewer found that Nucala is an add-on treatment for patients with severe persistent asthma with an elevated eosinophil count. However, this patients records do not support a diagnosis of severe persistent asthma. The patients chest was clear during three consecutive office visits. The patients estimated eosinophil count was 369. In addition, the patients oxygen saturation on room air was normal. Moreover, there is no documentation of intubation and placement on mechanical ventilation, treatment in an intensive care unit (ICU) for asthma, or a thorough work-up by a pulmonologist. All told, the requested Nucala 100 mg once every four weeks for 26 weeks is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine 30 mg four times per day. Findings:  The physician reviewer found that morphine is an opioid analgesic recommended after a trial of a first-line oral analgesic has failed. Guidelines provide specific requirements for the ongoing use of opiate pain medication to treat chronic pain. Recommendations state the lowest possible dose be used as well as ongoing review and documentation of pain relief, functional status, appropriate medication use and its side effects. Guidelines also recommend that providers of opiate medication document the patients response to pain medication including the duration of symptomatic relief, functional improvements, and the level of pain relief with the medications. It is not clear in this patients documentation, that the use of the prescribed opioid medication has decreased the level of pain the patient reported from one visit to the next. In addition, there was no noted functional improvement or improved pain noted during the duration of the prescription for morphine. There is also significant risk of comorbidity when combining a benzodiazepam with an opioid, particularly in a patient with a condition of respiratory compromise such as COPD.  For these reasons, the request for morphine 30 mg four times per day is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment. Findings:  The physician reviewer found that the progress notes indicate that the patient showed steady improvement in his anxiety symptoms throughout his residential stay. His anxiety attacks had decreased and he was able to manage these symptoms. The patient did not show any dangerous behaviors towards himself or to others. Progress notes indicate that the patients discharge plan included a PHP. It appears that the patient could have transitioned to a PHP. He was not displaying any significant or severe behavioral problems during the disputed period. The patient needs continued treatment to further improve his social functioning, anxiety, and paranoia. However, he no longer needed the restrictiveness of a residential psychiatric treatment facility as he had stabilized enough, over the three months of residential care at the facility, to transition to a less restrictive setting. Residential treatment is used for acute stabilization and is not evidenced based for long term type treatment as quoted in the following reference: Similarly, any gains made during a stay in residential treatment may not transfer well back to the youths natural environment, creating a cycle where children are often repeatedly readmitted.  Outpatient treatment and least restrictive options are considered first lines of care as referenced by The American Academy of Child and Adolescent Psychiatry who recommend that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. The medical evidence support residential treatment when used for acute stabilization. However, there is a lack of evidenced based reviews to support residential treatment for long term care as in this patients case. Children should be treated in the setting that is least restrictive and disruptive to their lives. There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting. Studies have shown that treatment outside of a residential setting are effective and appropriate and are as beneficial as RTC programs. The documentation provided supports treatment at a less restrictive setting. In sum, the RTC provided was 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for removal of ovarian cyst. Findings:  The physician reviewer found that the cyst is decreasing in size, as is expected for a benign process. Ovarian cysts are common, and most resolve with time. This patient describes pain and other symptoms that are unlikely to be related to the ovarian cyst, particularly since the cyst has decreased in size. The providers noted that the cyst is not likely the cause of the patients symptoms and surgery is not indicated. In addition, she has risk factors for surgery, including obesity and two prior abdominal procedures. One provider indicated the patients symptoms are likely urologic in origin, though she also may have gastrointestinal issues that could be contributing to her pain. She has not had an evaluation for non-gynecologic causes of her pain and symptoms. There can be many other causes of abdominal and pelvic pain, most of which do not require surgical intervention, and these have not been assessed. There is no indication from the patients work-up that her symptoms would resolve with removal of the ovarian cyst. All told, the requested removal of ovarian cyst is not 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 obstetrics and gynecology 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 and prospective authorization and coverage for the Anser IFX Prometheus blood test provided on the date of service in question and future testing. Findings:  The physician reviewers found that in this case, Anser IFX was ordered to determine infliximab level and whether antibodies to infliximab were present. The use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease. The presence of antibodies does not necessarily result in loss of response to infliximab, nor have clear infliximab levels been established. Studies have found that anti-infliximab antibodies can be transient and disappear over time, with many patients with antibodies maintaining their response. A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies. One study, with some patients undergoing dose intensification following initial non-response, showed no difference in serum levels of infliximab between patients who responded to dose intensification versus those who did not. Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing. For these reasons, the Anser IFX Prometheus blood test provided on the date of service in question and future testing was not and is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the testing at issue was not and 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 internal medicine with sub-specialty certification in gastroenterology 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.