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

Findings:  Currently, there is not enough published data to support DecisionDX-Melanoma test for its routine use in this clinical setting. More studies are required to determine the utility of the results from these tests. The DecisionDX-Melanoma assay examines the tissue genetics of the melanoma and can stratify whether a melanoma is high risk for metastasis or not. The patients provider sent a sample tissue to DecisionDX where the genes are examined for certain markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some accuracy determining the risk of metastasis in thin thickness melanomas like this patients; however, decision-making based on the results of the test is indeterminate at this time. There are no formal standard procedures or precautions that would be changed in light of the data. The treatment of this patient would not change based on the results from this test. Moreover, this test is not considered routine standard of care and is not currently recommended by the National Comprehensive Cancer Network (NCCN) guidelines. As such, the DecisionDX-Melanoma test was not likely to have provided a greater benefit over the established tests on outcomes for the evaluation this patients medical condition.   Final Result: All three reviewers have determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in dermatology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene assay. Findings:  Three physician reviewers found the prognosis for cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may also add to these statistics. DecisionDx-Melanoma gene assay is a study of 31 genes in an individuals melanoma cells. It then classifies that melanoma based on the likelihood of metastasis within five years. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification in patients undergoing sentinel node biopsy. However, it is not clear how the five-year DecisionDx-Melanoma gene assay data compares to the ten-year Balch data. More importantly, it is not clear if it can be used to make clinical decisions. Therefore, DecisionDx-Melanoma gene assay was not likely to have been superior over other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 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 food allergy testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee has been diagnosed with irritable bowel syndrome.Findings:  The use of food specific IgG level testing is unproven, does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance. The medical literature shows that food specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods. In addition, IgG4 is increased in patients who successfully underwent oral immunotherapy for milk or peanut allergy. The standard evaluation of food allergy consists of blood immunoglobulin E (IgE) level for foods and skin testing. IgE immunoassays are in vitro assays used to identify food specific IgE in the serum. These tests are widely available. Immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens. Values have been established for egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95%. Skin testing for food specific IgE is used in the diagnosis of IgE mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. A negative skin test result indicates the absence of an IgE mediated allergy upon subsequent challenge with a 90-95% predictive accuracy. Thus, food specific IgG should not be used as a tool to diagnose food allergy and the positive food should not be eliminated from the diet based upon results from these tests. In sum, food allergy testing (IgG) provided on 10/26/17 was not likely to have been superior over the available standard testing for the evaluation of this patients medical condition.  Final Result: All three reviewers have determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in allergy and immunology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a referral to a tertiary level facility, a referral to a neurosurgeon and a second magnetic resonance imaging (MRI) of the brain. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who has a history of pineal gland cyst.  Findings: Based on the documentation provided, the requested services are not medically necessary for the evaluation and treatment of this patients medical condition. This patient has a 9 mm cyst of the pineal on an MRI scan. He has not had any significant neurologic symptoms nor has he had any objective neurologic findings on examination. There were no other abnormalities on his MRI scan: no mass effect, no hydrocephalus and no evidence of increased intracranial pressure. Two CT scans of the head were normal and did not identify a pineal cyst, which is a common finding since the cyst fluid is isodense with cerebrospinal fluid. An incidental pineal cyst was found on a brain MRI scan, which was not seen on two CT scan. The medical literature indicates that in patients who are asymptomatic, there is no need for a repeat MRI scan. In this patients case, the cysts have been followed and deemed to be benign and not noted to grow. A study does not recommend a follow up imaging nor do they recommend a follow up neurosurgery surveillance.  The medical literature notes that pineal cysts are common MRI findings and are especially noted in asymptomatic individuals. They have been deemed incidental since they have not been not found to have clinical significance nor increase in size. They have been seen on scans performed for other reasons.  The medical necessity for tertiary care referral has not been demonstrated since the record indicates there are qualified credentialed providers available. As such, the patient does not need to present to a higher level of care because the necessary level of care is available in his medical community.  With regards to the neurosurgeon referral, the literature also states that incidental pineal cysts, as noted in this patient, do not require further imaging or neurosurgical surveillance. In sum, a referral to a tertiary level facility, a referral to a neurosurgeon and MRI of the brain are not medically necessary for the evaluation and treatment of this patients medical condition.Final Result: The reviewer has determined that the requested services are not medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  The reviewer is board certified in neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for immunotherapy with nivolumab (Opdivo). The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees grade IV glioblastoma. Although multiple trials are testing various forms of immunotherapy in patients with glioblastoma, published data remain limited. In a phase I trial investigating the safety of monotherapy or combination therapy with two checkpoint inhibitors, 40 patients received either Opdivo with or without ipilimumab. Overall, monotherapy with Opdivo was better tolerated than combination therapy. However, the authors concluded that further studies are needed to help select patients most likely to respond to checkpoint inhibitor immunotherapy. Available standard therapies include retreatment with temozolomide and low-intensity alternating electric fields, which have more data to support them than Opdivo in this clinical setting. Accordingly, the requested Opdivo is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that Opdivo is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a new ultralight manual wheelchair. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollee who has a history of paraplegia and stage 4 pressure ulcer on the coccyx.The records forwarded for review do not support the medical necessity for the requested equipment in this patients case. A custom ultralight weight manual wheelchair is appropriate and necessary for optimizing this patients community level mobility, independence and health.  The lightest weight wheelchair with a rigid frame would increase independence in the community, especially on uneven surfaces such as ramps and, in the long-term, reduce injury to the shoulders due to wear and tear damage. However, the patient in this case already has an ultralight weight manual wheelchair and it is less than two years old.  It was assessed in the community by a physical therapist and noted to be repairable. Therefore, there is no indication of replacing the wheelchair with a new wheelchair. In general, a wheelchair that requires complete replacement after such a short interval would be due to a faulty or improper manufacture design of the wheelchair. The submitted records do not show that this is the case in this clinical setting. As such, a new ultralight manual wheelchair has not been demonstrated as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 ADA diagnostic test. Findings:  Two of three physician reviewers found there is insufficient medical evidence to support the effectiveness of Anser ADA compared with conventional courses of action in the management of ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. A study showed that patients with loss of response may actually have high, rather than low, serum levels. Controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management. For these reasons, ADA diagnostic test was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined 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: Physician reviewers 1, 2 and 3 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for six transcranial magnetic stimulation (TMS) treatments. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients major depressive disorder (MDD). The submitted documentation does not support the medical necessity of the services at issue. Transcranial magnetic stimulation (TMS) is a novel, non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population. A standard course of TMS consists of 30 TMS treatments over six weeks, followed by six additional taper treatments spaced over the final three weeks of treatment. Additionally, from the clinical perspective, at session number 35, the patient had no drop off in mood. The patient was more positive in thought and felt better. The two validated rating scales that had been severe and very severe initially were both consistent with mild depression. At this time, there is a lack of adequately powered controlled studies showing the benefit of longer courses of TMS therapy. Thus, the medical literature does not support a reasonable expectation that additional TMS therapy at the time would have improved the patients condition or prevented a more serious episode of illness, particularly since the validated rating scales were consistent with minimal impairment by week nine. In sum, the six transcranial magnetic stimulation (TMS) treatments 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret 100 mg-40 mg tablets for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Mavyret for eight weeks. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100 mg-40 mg tablets for eight weeks is medically necessary for 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for growth hormone, Nutropin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients short stature. The submitted documentation does not support the medical necessity of the requested medication. This patient experienced a drop in weight prior to a fall-off in height. This is a pattern that is not consistent with growth hormone deficiency and is more likely to be related to decreased caloric intake, constitutional delay, and/or malabsorption. The patients height is not more than two standard deviations below the mean for the patients age and gender, and there is no information provided regarding bone age or pubertal status. The results of other tests ruling out additional causes of growth fall-off are not provided. Low growth hormone levels in response to stimulation testing cannot be taken as sole evidence of growth hormone deficiency. Therefore, Nutropin is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 patient has requested authorization and coverage for Vyvanse 70 mg three times daily (quantity of 90 per month). Vyvanse is a central nervous system stimulant that was first approved in 2007 for the treatment of ADHD. This patient has been diagnosed with ADHD. The patient has an established clinical relationship with his provider and meets with him at appropriate intervals. The current dose of Vyvanse was achieved after a systematic titration and has been in place for nearly two years. There is no evidence of side effect or misuse. The provider has posited a reasonable explanation for the supra-therapeutic dosing in this case. Indeed, individual variances in the cytochrome p450 system accounts for the rather unpredictable array of drug metabolism that is encountered in clinical practice, and patients that are rapid metabolizers require higher doses of medication to achieve the desired clinical effect. The current medication dose appears to be both efficacious and well-tolerated, with no evidence that it is unsafe. Moreover, the current regimen is optimizing the patients functionality and minimizing his illness burden. It is the recommendation of the treating provider to continue the medication at the current dose. Considering these factors, the relevant peer-reviewed literature, and current standards of medical practice, the requested Vyvanse 70 mg three times daily (quantity of 90 per month) is supported as medically necessary for treatment of this patients ADHD. Final Result: The reviewer determined that the requested medication dosage 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 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.