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 Guardant360 testing. Therapy for certain adenocarcinomas is affected by the finding of EGFR mutations. All patients with EGFR mutant lung cancers eventually develop acquired resistance to EGFR tyrosine kinase inhibitors (TKI). Studies identified the EGFR T790M mutation as the most common mechanism of acquired resistance, conferring resistance to erlotinib in 60% of patients with progressive disease on erlotinib. While a TKI, osimertinib, is available to target this mutation, the mutation must first be identified. In this case, the Guardant360 test, a liquid biopsy, was used to determine whether the patient had developed an EGFR T790M mutation while results of a bronchoscopy were pending. Based on the available data and the clinical circumstances of this patient, the Guardant360 test was appropriate and consistent with the NCCN guidelines. Therefore, the Guardant360 testing at issue was likely to have been more beneficial for the evaluation of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the Guardant360 testing at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for hypoglossal nerve stimulator implantation. Several studies have evaluated hypoglossal nerve stimulation as a way to improve upper airway stimulation and treat patients with OSA. Researchers found across a multi-institutional study that upper airway stimulation (UAS) therapy showed significant improvement in OSA outcomes. Researchers concluded that improvements in objective respiratory and subjective quality of life outcome measures were maintained at three-year follow-up. Medical literature demonstrated that UAS maintained a sustained benefit on patient reported outcomes on the Epworth sleepiness scale, functional outcomes of sleep questionnaire, and snoring level. Medical literature found that AHI, oxygen desaturation, sleepiness, and functional outcomes were improved with hypoglossal nerve stimulation in patients who failed treatment with CPAP. In this case, the patient has already failed CPAP therapy and is not an optimal candidate for oral appliance therapy due to the severity of his OSA. Therefore, the requested hypoglossal nerve stimulator implantation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 1 additional acupuncture session.Peer reviewed literature recommends an initial trial of five to six acupuncture appointments in combination with a conditioning program of aerobic and strengthening exercises to stimulate self-reliance. Future acupuncture appointments should be tied to improvements in objective measures to justify an additional 6 sessions, for a total of 12 sessions. Additional treatments should only occur based on progressively greater, incremental objective gains. In addition, passive care (acupuncture) should be combined with active care (conditioning-aerobic-stretching exercise program) to stimulate self-care and avoid medical dependency. Significant objective benefits include a decrease of pain (Visual Analog Scale), increased endurance, increased body mechanics and ability to perform ADLs (activities of daily living), increased ability to perform job-related duties, improved sleep or reduced pain behaviors, amongst others. Indications for care discontinuation would include resolution, intolerance, lack of measurable improvements, or non-compliance including non-compliance with aerobic and strengthening exercises.In this case, while the patient reported prior acupuncture as beneficial, no pre-acupuncture and post-acupuncture baselines were documented for comparison purposes. The patients medical records do not reflect the total number of sessions completed or the frequency of the visits. In addition, measurable, progressive, significant, objective benefits (quantifiable response to treatment) obtained with previous acupuncture, to support the reasonableness and necessity of the additional acupuncture requested, was not noted in the available records. There is also no indication in the patients records of whether the patient is undergoing an independent exercise program (conditioning-aerobic-stretching exercise program based on patient's tolerance), which is recommended by peer review literature. Under these circumstances, the requested 1 additional acupuncture session is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed acupuncturist, board certified in oriental 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: Overturned Decision of Health Plan

The patients parent has requested authorization and coverage for HP Acthar Gel injections, initiated at 80 units weekly and titrated up to 80 units three times a week as tolerated. Crane and colleagues found that adrenocorticotropic hormone (ACTH)  can be effective at decreasing or eliminating ocular inflammation, and that adverse effects of ACTH are rare and most likely to be reported with relatively high doses of ACTH therapy. Sharon and Chu noted that subcutaneous ACTH gel has shown to be a safe and effective therapy in the management of non-infectious uveitis, specifically in those who do not respond to or are unable to tolerate other immunomodulatory therapies. In this case, the patient has tried and failed alternatives and has an underlying liver condition which makes him unable to tolerate other therapies. Therefore, HP Acthar Gel injections, initiated at 80 units weekly and titrated up to 80 units three times a week as tolerated is medically necessary to prevent disease, disability, and other health conditions or their progression. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with type 2 diabetes, peripheral neuropathy, hyperglycemia, and mixed hyperlipidemia. The patient reported that he does not monitor his blood glucose due to the pain of needle stick and his peripheral neuropathy. Laboratory results revealed the patients hemoglobin A1c level was 8.1. The patient has requested authorization and coverage for a continuous glucose monitor. The Health Plan denied the request and reported the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a continuous glucose monitor is medically necessary for the treatment of the patients medical condition. Continuous glucose monitoring is an emerging technology for diabetes care which records blood sugar levels at repeated intervals throughout the day and night. Researchers reported, This systematic review with meta-analysis concludes that the use of continuous glucose monitoring (CGM) in type 2 diabetes mellitus is beneficial, as it significantly reduces hemoglobin A1c compared to the usual method of self-monitoring blood glucose (SMBG). Researchers reported, Initial data indicate that even for patients with type 1 diabetes treated with multiple daily injections, real-time CGM alone has been found to reduce both severe hypoglycemia and hypoglycemia unawareness. In this case, the patient has been diagnosed with type 2 diabetes and peripheral neuropathy. The patient reported pain due to needle sticks, which prevented him from frequently monitoring his blood glucose levels. The medical evidence supports the requested equipment in this clinical setting. Therefore, a continuous glucose monitor is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 endocrinology, diabetes, and metabolism 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 patient has requested reimbursement for MRI of the lumbar spine. Findings:  The physician reviewer found that While routine imaging for low back pain may not be beneficial, Chou and colleagues found that diagnostic imaging is indicated if a patient with low back pain has severe progressive neurologic impairments, signs or symptoms suggesting a serious or specific underlying condition are present, or is a candidate for invasive interventions. Immediate imaging is recommended for patients with severe or progressive neurologic deficits, while imaging after a trial of treatment is recommended for patients who have minor risk factors for inflammatory back disease, vertebral compression fracture, radiculopathy, or symptomatic spinal stenosis. Subsequent imaging should be based on new symptoms or changes in current symptoms. The American College of Radiology (ACR) appropriateness criteria for lumbar imaging recommends imaging for patients presenting with red flags raising suspicion for a serious underlying condition. In the absence of red flags, imaging is indicated if persistent or progressive symptoms continue following six weeks of conservative management, if the patient is an interventional candidate, or diagnostic uncertainty remains. In this case, the patient complained of new onset low back and right hip pain with numbness radiating into the right groin and medial thigh, affecting his functional ability in daily activities of living. He was status post L3/4 decompressive surgery, and clinical examination demonstrated motor and sensory deficits. Based on current medical literature, given the onset of signs and symptoms of a significant underlying condition, and that the patient was a candidate for surgical treatment, the MRI was medically indicated. Therefore, MRI of the lumbar spine was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was 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 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Synvisc-One injection in the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of chronic right knee pain due to osteoarthritis. The records show the patient had a prior excellent response to a Synvisc-One injection to the right knee, providing pain relief and functional improvement. The patient has tried and failed other conservative measures, including corticosteroid injections, which are no longer effective, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, Synvisc-One injection in the right knee is medically necessary for the treatment of this patient.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for orthotic shoe inserts for right and left feet. Findings:  The physician reviewer found that Fong and colleagues note that it is a routine practice to prescribe a combination of rocker shoes and custom-made foot orthoses for patients with plantar fasciitis. In this case, the patient reports painful plantar fasciitis and having flat feet since birth, a condition which may cause and/or exacerbate plantar fasciitis pain. Given that custom orthotics are routinely used to treat plantar fasciitis, and that this patient has reported relief using them in the past, custom orthotics are medically indicated for this patient. Therefore, orthotic shoe inserts for right and left feet are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 podiatry 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

The parent of a patient has requested authorization and coverage for Omnipod DASH insulin pump and supplies. Findings: General practices for healthy pump sites are similar across different systems, including changing the site of cannula every two to three days to avoid infections, avoiding areas of broken skin, and rotating and varying injection sites. In this case, the provider reported that the patient has experienced fluctuations in blood sugar levels with a different pump due to how often the patient has to disconnect from it. The Omnipod DASH insulin pump does not require tubing and is not removed for exercise and activity. The medical evidence supports the requested equipment in this clinical setting. Therefore, Omnipod DASH insulin pump and supplies are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 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: Upheld Decision of Health Plan

The patient is requesting authorization and coverage for Otezla 30 mg tablets.Findings: Anti-tumor necrosis factor (TNF) agents have been proven very effective for psoriatic arthritis and are disease modifying agents. They prevent progression of disease, erosions and disability and are thus the preferred agent for psoriatic arthritis. Medical literature supports the use of conventional and biologic agents (anti-TNF agents) over the use of a targeted synthetic biologic such as Otezla (apremilast) for the treatment of psoriatic arthritis. A study states that at this time, apremilast should be reserved for patients unable to take disease-modifying antirheumatic drugs. In this case, the submitted documentation does not reflect that the patient has either failed or has a contraindication to conventional synthetic (csDMARD) and biological (bDMARD) disease-modifying antirheumatic drugs. Under these circumstances, the requested medication, Otezla 30 mg tablets, is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, and allergy and immunology, with subspecialty certification in rheumatology, 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

The patients parent has requested authorization and coverage for six (6) months of RTC services to treat the patients major depressive disorder with psychotic features, substance abuse, and autism spectrum disorder. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had serious risk of harm, due to repeated suicidality, substance use, anger and threats at home, and aggression during his most recent RTC admission. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment, due to serious deterioration of interpersonal interactions with consistent conflict with his parents at home and in interactions with peers and staff at the RTC when he was asked to leave group because of his behaviors. With regard to comorbidity, the records support a score of 5. The patient had severe comorbidity, due to the presence of mood disorder, autism spectrum disorder, and significant substance abuse. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to multiple moves between home and various treatment settings, as well as significant difficulties in school. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents active participation in treatment and treatment planning. In terms of resiliency and treatment history, the records support a score of 5. The patient had negligible resiliency and/or response to treatment. He had persistent symptoms despite an extensive treatment history at various levels of care, including RTC services and multiple psychiatric hospitalizations. With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrated incomplete engagement, minimizing or rationalizing distressing behaviors and consequences, and glorifying drug use. Thus, the patient has a total score of 26. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the RTC level of care requested. Therefore, six (6) months of RTC services to treat the patients major depressive disorder with psychotic features, substance abuse, and autism spectrum disorder are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) services.  TMS is currently indicated for the acute phase of major depression. Perera and colleagues noted that daily left prefrontal TMS had substantial evidence of efficacy and safety for treating the acute phase of depression in patients who were treatment resistant or intolerant. In this case, the patient has severe depression and has failed trials of Cymbalta, Effexor, and Prozac. Given the severity of the patients symptoms and functional impairment, TMS was and is clinically indicated. Therefore, TMS services were and are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the transcranial magnetic stimulation (TMS) services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the transcranial magnetic stimulation (TMS) services were 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 1, 2, and 3 are board certified in psychiatry 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.