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 gene panel testing for evaluation of the enrollee, who reported dizziness and palpitations. Findings:  Two physician reviewers found that per the records, this patient had some coronary risk, but no documented coronary disease. In this circumstance, guidelines for assessing the likelihood of obstructive coronary disease, managing cardiac risk and evaluating potential cardiac symptoms are published, periodically updated by expert national committees, and endorsed by several national organizations. These guidelines currently do not recommend the routine use of gene expression testing to help assess the presence of coronary disease or the risk for developing coronary disease.  Although the testing performed has promise with respect to assessing risk of obstructive coronary disease, there is a lack of data to indicate that a change in treatment based on these test results favorably affects cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling including basic lipid analysis. At this time, there is insufficient clinical outcomes evidence from well-conducted trials supporting the services at issue. 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are 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: An enrollee has requested authorization and coverage for Epclusa 400-100 mg for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic genotype 1a patients who have failed interferon regimens should be treated with Epclusa for 12 weeks, based on a 98% cure rate in the ASTRAL-1 trial. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) scan for evaluation of history of metastatic melanoma. Findings:  Three physician reviewers found that there has been a considerable amount of debate on imaging follow-up and surveillance in patients with history malignant melanoma. The National Comprehensive Cancer Network guidelines do not recommend routine imaging to screen for asymptomatic recurrence or metastatic disease. The guidelines noted the following, Routine imaging to screen for asymptomatic recurrence or metastatic disease is not recommended after 3-5 years. The records show that this patient did not have any signs or symptoms to suggest disease recurrence and was beyond three to five year interval. As such, PET scan performed was not likely to have been more effective than the standard methods available for the evaluation of 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: Reviewers 1, 2 and 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test to gauge risk for thyroid cancer. Findings:  The physician reviewer found that the cytopathology of the patients 1.8 cm thyroid nodule was consistent with FLUS. The risk of malignancy is 5-15% in FLUS . The American Thyroid Associations guidelines state that for nodules with FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. If the genetic test is suspicious, the risk of malignancy increases to 40% . The risk of malignancy decreases to less than 6% with benign findings. In this case, the patient has a solid thyroid nodule measuring 1.8 cm with worrisome features and the cytopathology was consistent with FLUS. The result of the Afirma from the same specimen was benign. This information was important to determine the decision whether to perform a thyroidectomy and may prevent the need for a repeat biopsy or diagnostic hemi-thyroidectomy. There are multiple peer reviewed scientific articles supporting the benefits of genetic testing of thyroid nodules. Moreover, the Afirma test is also included in the algorithm for diagnosis of thyroid nodules by the National Comprehensive Cancer Network (NCCN) guidelines. For the reasons provided, the gene test to gauge risk for thyroid cancer was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of three 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: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for thoracic radiofrequency ablation for treatment of the enrollees thoracic spine pain. Findings:  The physician reviewer found that medial branch radiofrequency ablation is a well-documented procedure which helps with chronic low back pain due to lumbar facet pain. The procedure is successful in treating lumbar spine pain in repeated fashion. Given the support in the peer-reviewed literature, the request for thoracic radiofrequency ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in anesthesiology with sub-specialty certification in pain medicine and 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 an additional 10 hours per week of applied behavioral analysis (ABA) services (for a total of 40 hours) for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the request for an additional 10 hours per week of ABA services (for a total of 40 hours per week) is medically necessary for treatment of the patients medical condition. ABA is a medically necessary intervention for the treatment of autistic children and remains one of the most evidence based interventions available. In this case, a total of 40 hours per week of ABA therapy has been recommended to address non-compliance, and restrictive and repetitive behaviors. A treatment plan has been developed that is consistent with the patients health needs and consistent with the diagnosis of an autism spectrum disorder. There is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. In addition, the Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Given the medical necessity of ABA therapy for children with autism and correlation between treatment outcomes and intensity, the request for 40 hours of ABA therapy per week is medically necessary for treatment of the 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 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 reimbursement for lab testing (DecisionDx-Melanoma)for evaluation of the enrollees cutaneous melanoma. Findings:  Three physician reviewers found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene assay should not be used outside of a clinical trial setting. The use of DecisionDx-Melanoma testing is not considered to be standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the treatment or outcome of the patients melanoma. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in dermatology 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 Taltz 80 mg/mL auto-injector pen. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. Taltz is a U.S. Food and Drug Administration (FDA) approved injectable biologic for the treatment of plaque psoriasis. Taltz works by a distinct mechanism of action by blocking IL-17 signaling.  Both Humira and Enbrel are FDA approved therapies for the treatment of plaque psoriasis which work by the same mechanism, namely blocking tumor necrosis factor (TNF) signaling. Head to head studies have shown that Taltz is superior to Enbrel in clearing plaque psoriasis. Given that the patient has already lost control of plaque psoriasis using a TNF inhibitor, it is not expected that the patient will achieve superior results with another TNF inhibitor. Therefore, the request for Taltz 80 mg/mL auto-injector pen is medically necessary for treatment of the patients chronic plaque psoriasis.  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 dermatology 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 authorization and coverage for Spinraza (nusinersen) for treatment of the enrollees spinal muscular atrophy. Findings:  Three physician reviewers found that spinal muscular atrophy is a rare autosomal recessive disorder characterized by muscle atrophy and weakness resulting from motor neuron degeneration in the spinal cord and brainstem. Spinraza has been approved by the U.S. Food and Drug Administration for intrathecal use in pediatric and adult patients with spinal muscular atrophy. Studies show improvement in motor function across spinal muscular atrophy of all types. This medication has been found to be safe and well-tolerated across all age groups studied. There is a lack of other treatments available. Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in neurology 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: The patient has requested reimbursement for the Njx Platelet Plasma provided. Findings:  The physician reviewer found that there is a lack of evidence to support the efficacy of platelet rich plasma for pain attributed to rotator cuff tendinopathy and as a consequence, platelet rich plasma injection is not included in any evidence based treatment algorithms. Moreover, there is a paucity of prospective controlled trials demonstrating the efficacy of platelet rich plasma in patients with partial thickness rotator cuff tears. Meta-analysis of trials of platelet rich plasma injection as an adjunct to healing following repair of more severe full thickness rotator cuff tears has failed to demonstrate efficacy. Thus, the Njx Platelet Plasma provided not likely to be more beneficial for the patients left shoulder pain than available standard treatment.Final Result: The reviewers determined that the service at issue was 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 1,2 & 3 are board certified in orthopedic 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the genotype testing performed. Findings:  The physician reviewer found that The documentation provided does not demonstrate that the genotype testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patients records do not specify medications, doses, and length of medication trials or combinations of medications tried and failed. The records do not indicate that the patient has failed medication trials of adequate dose and duration or that the patient has tried or failed evidence based psychotherapy trials. In addition, it is not clear that the patient has had cognitive behavioral therapy (CBT) for her anxiety disorder diagnosis. As noted in the peer-reviewed medical literature, CBT is considered the first-line treatment for this patients condition and has years of evidence to support its use. Medication and psychotherapy have strong evidence based support for their use in the patients condition and it is not clear that these treatments have been exhausted. The current evidence base does not support the routine use of pharmacogenomic testing in this clinical setting. For these reasons, the genotype testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition Credentials/Qualifications: All three physician reviewers 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for multi-functional foam support system for treatment of the enrollees back pain. Findings:  The physician reviewer found that the request for multi-functional foam support system is not medically necessary for treatment of the patients medical condition. In general, durable medical equipment (DME) is recommended due to a medical need and if the device or system meets the Medicare definition of DME. In this case, the requested foam wedge zero-gravity comfort and support system does not serve a medical purpose and is primarily used for convenience in the home. It does not meet the definition of DME. In addition, the patient does not have evidence of a current pressure ulcer or failure of treatment for a pressure ulcer which would support mattress overlay. The patient is able to ambulate with an assistive device and is not immobilized. For the reasons provided, the requested equipment has not been established as medically necessary for the treatment of the 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for magnetic resonance-guided high intensity focused ultrasound (MRgFUS). Findings:  The physician reviewer found that  Osteoid osteoma is a small, painful benign bone lesion that accounts for 10% of all bone tumors.  Osteoid osteomas may resolve spontaneously but the process can take several years. For many patients, the pain can be severe, with significant impact on health related quality of life, including effects on physical, emotional, social, and role functioning. Early pain management interventions can reduce pain duration and pain-related disability. Minimally invasive, percutaneous thermal ablation techniques, such as computed tomography (CT)-guided radiofrequency (RF) ablation, laser ablation, and cryoablation are the current standard of care treatment for peripheral bone lesions. MRgFUS is a thermal treatment modality that uses high power ultrasonic energy to thermally coagulate tissues in the body.  While there is current literature to support its efficacy in treating osteoid osteoma refractory to medical therapy, there is still a lack of data to show that this modality is more effective than the standard of care treatment. Therefore, MRgFUS is not likely to more efficacious than the available options for treatment of this patients medical condition. Final Result: Two of the three he 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 1, 2 & 3 are board certified in interventional radiology and diagnostic radiology 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.