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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene test for treatment of the enrollees colon cancer.Findings: Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic agent would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician, nor yields a result that is reliably clinically beneficial, (Von Hoff, et al). There are various nonrandomized studies exploring the value of molecular profiling but these studies are not convincing as to its efficacy.  A randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. Additionally, recent studies have expressed reservations about this approach in general. In sum, FoundationOne gene test was not likely to have been of greater clinical benefit over the standard options available for the evaluation of this patients medical condition.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: 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 Vemlidy 25 mg for treatment of the enrollees chronic hepatitis B virus. Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. On Viread, this patient with vitamin D deficiency may develop osteopenia in the future. For this reason, the request for Vemlidy 25 mg is medically necessary for the treatment of this patients chronic hepatitis B. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for evaluation of cancer risk using panels of genes (MyRisk) for evaluation of the enrollee, who has a history of breast cancer. Findings: The physician reviewer found that this patient meets National Comprehensive Cancer Network guidelines for genetic testing as she was diagnosed with breast cancer before age 50. Additionally, the records document triple negative breast cancer before age 60, and her close relative (maternal aunt) was diagnosed with breast cancer before age 50. The largest studies reporting on the outcomes of multigene testing indicate that among women tested in clinical settings, about 5 to 10 percent have a BRCA1 or BRCA2 mutation, and about 4 to 7 percent have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer, or a mutation in a newer gene that may also be associated with increased risks for these cancers. Panel testing, such as with MyRisk, is now considered a standard of care. Thus, evaluation of cancer risk using panels of genes (MyRisk) provided was likely to have been of greater benefit than other modalities for evaluating this patient.Final Result: 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: 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 Zepatier for 12 weeks for treatment of the enrollees hepatitis C.  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. This applies regardless of fibrosis stage. 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, treatment with Zepatier for 12 weeks to treat hepatitis C 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 in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for pollen and allergy injections performed weekly for treatment of the enrollees allergic rhinitis and asthma. Findings:  The physician reviewer found that based on the available documentation, the service of immunotherapy dosed at once weekly intervals meets the current criteria for medical necessity and is within the standard of care for providing immunotherapy injections to a patient who is symptomatic with asthma and allergic rhinitis. Review of the record shows sufficient documentation to support the increased dosing. There was allergy skin testing done with positive findings for several allergens. Clinic notes from provider indicate that the patient was actively taking multiple medications for rhinitis and asthma. The provider also stated that Allergan immunotherapy has been effective for improvement of the patients rhinitis and asthma. Clinic notes from provider report the severity of her condition indicating that the patients symptoms flared when injections were given monthly rather than weekly, and her parent stated that when the patient does not receive weekly injections then she gets sick. The provider stated that immunotherapy was indicated for weekly intervals due to increased symptoms of asthma and rhinitis indicating and that the patient had effective results on immunotherapy when dosed more frequently than every month. As per the allergy practice parameters on dosing, immunotherapy level of efficacy can be determined by measuring objective and subjective parameters. Objective measures, such as an increase in allergen-specific IgG levels and decreased skin test reactivity, as measured by means of skin test titration, are changes generally associated with effective immunotherapy but, at present, are not practical for routine clinical use. Most providers rely on subjective assessments demonstrated by a reduction in medication use as well as improvement in symptoms. An increase in serum allergen-specific IgA and IgG levels, particularly of the IgG4 isotype, has also been associated with immunotherapy. Given this support and this patients response to previous weekly injections, the requested pollen and allergy injections performed weekly is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in allergy and immunology 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 authorization and coverage for vision care therapy for treatment of the enrollees vision problems.  Findings:  The physician reviewer found that Evidence based research demonstrates that vision therapy has a high success rate in the treatment and management of vergence dysfunction. Office-based vision therapy has been shown to have the greatest impact on improving the fusional ranges of patients with convergence insufficiency. In-office therapy has also been shown to be more effective than either prescribed computerized home therapy or pencil push-ups alone. For these reasons, vision care therapy has been the method of choice for the treatment and management of convergence insufficiency and some accommodative anomalies. In addition, elimination of vergence dysfunction has been shown to improve reading scores. In this case, the patient has difficulty with completing reading tasks in addition to complaints of persistent headaches. For the reasons provided, the request for vision care therapy for the treatment of vergence dysfunction has been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 optometry 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 alprazolam (Xanax) 2 mg tablets. Findings:  The physician reviewer found that in the early 1960s, the newly synthesized benzodiazepine class of medication effectively supplanted barbiturates as the mainstay of psychopharmacologic treatment of anxiety.  Although safer than their predecessor, the benzodiazepines possess an array of potential side effects.  Disinhibition, cognitive dulling, perceptual disturbances and exacerbation of depression are common, while a connection with Alzheimers disease later in life has been suggested in the peer-reviewed literature. In this patients case, the risks of benzodiazepine therapy outweigh the potential benefits. The patient has a history of addiction. Benzodiazepines should be avoided in patients with history of addictive illness. In terms of medication alternatives, the patient has not failed an adequate trial of pro-serotonergic medicines, which represent first-line interventions for depression and anxiety. The record illustrates that the patient has been presented with reasonable somatic alternatives, but he declined those treatments. Further, it does not appear that the patient has pursued trusted non-pharmacologic interventions, such as chemical dependency counseling or cognitive behavioral therapy for anxiety and/or depression. In this patients case, the plan for alprazolam tapering was consistent with contemporary practice standards. The current medical evidence does not support the requested medication in this clinical setting. All told, alprazolam (Xanax) 2 mg tablets are not medically necessary for the treatment of this patient. Final Review: 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 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 Synvisc-One (hyaluronic acid) injection. Findings:  The physician reviewer found that while there is medical literature to support hyaluronic acid as a pharmacologic intervention for knee osteoarthritis, there is insufficient evidence for its use for the treatment of other conditions, including osteochondritis dissecans. This patient presents with persistent and worsening left knee pain, following a left knee arthroscopy and partial medial meniscectomy. Clinical examination findings are consistent with imaging evidence of osteochondritis dissecans over the medial femoral condyle and x-ray evidence of mild left medial compartment osteoarthritis. Current peer reviewed literature supports the use of hyaluronic acid as a better option than corticosteroid injections for the treatment plan knee osteoarthritis. However, current evidence based medical guidelines recommend the use of hyaluronic acid injections for severe osteoarthritis and not for osteochondritis dissecans. There is no compelling rationale presented to support the medical necessity of this request for treatment of her left knee pain, which is primarily associated with osteochondritis dissecans and in the setting of mild osteoarthritis. Therefore, the request for Synvisc-One (hyaluronic acid) injection is not medically necessary for the 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for a wearable cardiac defibrillator for treatment of the enrollee, who has a history of congestive heart failure.Findings:  The physician reviewer found that The physician reviewer found in this circumstance, there is potential for recovery of left ventricular function over time with medical therapy. There was no documented indication for immediate placement of a defibrillator, such as sustained or inducible ventricular tachycardia, unexplained 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 is documented to persist despite appropriate treatment. A prophylactic defibrillator, either wearable or implantable, before this time has not been demonstrated to improve outcome. For example, studies assessing efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction less than or equal to 35% before ventricular function has had a chance to recover have not demonstrated improved 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. Moreover, more recent retrospective trials in patients with newly diagnosed nonischemic cardiomyopathy have not demonstrated benefit with prophylactic wearable defibrillators.  At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explanation. All told, the wearable cardiac defibrillator from 2/14/17 forward was not and is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the device at issue was not and 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 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: 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 risk for heart disease. 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), myeloperoxidase, Apo-B, sub-classifications of low density lipoprotein, high density lipoprotein, subclasses, lipoprotein(a), C-reactive protein, insulin, 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.  For example, randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits. Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results are lacking. As such, the advanced lipoprotein testing was not likely to have been more effective than the standard methods for the evaluation this patients medical condition.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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewer 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: The parent of an enrollee has requested authorization and coverage for PediaSure Enteral Formula. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested formula. The patients parent reported that the patient has food aversions. However, there is a lack of documentation from a medical provider indicating that the patient does not eat well. The medical documentation does not support that the patient needs PediaSure Enteral Formula. The records do not document failure to thrive, and there is no documentation of other treatments tried and failed. Thus, PediaSure Enteral Formula is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested formula 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 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.