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 expression profiling (gene test). Findings:  Three physician reviewers found that the National Comprehensive Cancer Network (NCCN) 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. All told, the gene expression profiling (gene test) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 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: All three reviewers 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for mental health treatment partial hospital program level of care. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services. The Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 3. The documentation indicates a moderate risk of harm. The patient has a history of an aborted suicide attempt. With regards to functional status, the records support a score of 3. The patient has moderate functional impairment. He stopped attending school due to worsening anxiety and depression. In terms of comorbidity, the records support a score of 3. The patient has significant comorbidity. The records document major depressive disorder and unspecified anxiety disorder. The patient had a referral to be tested for autism and attention deficit/hyperactivity disorder. With regards to environmental stress, the records support a score of 2. The patient had a mildly stressful environment. The patient has supportive parents and lives in a supportive environment. There are some expectations for performance at school, which the patient has not been able to meet. In terms of environmental support, the records support a score of 2. The patients parents are supportive of the patient. With regards to resiliency, the records support a score of 3. The patient has had an equivocal resiliency and response to treatment. He has had prior outpatient treatment with a psychiatrist and outpatient therapy which did not resolve the patients symptoms of anxiety and depression. With regards to acceptance and engagement, the records support a score of 2. The patient is cooperative with treatment. He had made modest improvement in his anxiety and depression. Therefore, the records support a composite score of 18. Based on these criteria, the patient meets criteria for intensive outpatient program level of care. The patient continued to need treatment for his unspecified anxiety disorder and major depressive disorder, but this could be performed in a less restrictive environment. Therefore, the requested mental health treatment partial hospital program level of care is not medically necessary for the treatment of this patient. 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 psychiatry with expertise in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential substance abuse treatment he received. Findings:  The physician reviewer found that, to objectively determine if the patient met the criteria for residential substance abuse treatment, the Level of Care Utilization System (LOCUS) guidelines are applicable. This is an accepted, national standard for determining the appropriate level of care for adults. On the date of service in question, the patient demonstrated a low risk of harm (score 2) as there was no documentation of prior suicide attempts and the patient did not have any suicidal ideation on that date. The patient demonstrated moderate functional impairment (score 3) as he has conflicted relationships with others, he has never had employment, is unable to engage in socially constructive activities, and his hygiene falls below usual standards on a frequent basis. The patient has a co-morbidity of amphetamine use disorder and cannabis use disorder (score 3) and there is also a chart history of bipolar disorder and paranoid schizophrenia. The patient has a moderately stressful recovery environment (score 3) as he has significant discord with family members over substance use. The patient has limited support (score 3) as his parents are supportive, but it appears that the patients parents have caregiver fatigue. The patient has had prior history of intensive outpatient program (IOP) treatment as well as Alcoholics Anonymous (score 3) which demonstrates equivocal response to treatment and recovery. The patient has shown positive engagement and is willing to participate in treatment (score 2). These findings give the patient a composite score of 19 which is consistent with IOP level of care services. The patient requires treatment for his amphetamine use disorder and cannabis use disorder, but this could have been safely and adequately provided in a less restrictive treatment environment. Therefore, the residential substance abuse treatment provided was not medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lynparza (olaparib) for treatment of the enrollees ovarian cancer. Findings:  The physician reviewer found that the request for Lynparza (olaparib) is not medically necessary for treatment of the patients medical condition. Lynparza is U.S. Food and Drug Administration (FDA) approved for the treatment of adult patients with deleterious or suspected deleterious germline BRCA-mutated advanced ovarian cancer. There is no documentation demonstrating that the patient underwent genetic analysis or was negative. As such, the requested medication is not supported per FDA approved prescribing guidelines. For the reasons provided, treatment with Lynparza has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in nternal medicine with sub-specialty certification in medical oncology 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 proton beam radiation therapy. Findings:  The physician reviewer found that : A review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested service. While proton therapy has the capability of reducing normal tissue complication risks, and perhaps increasing tumor control probability, to demonstrate medical necessity on an individual basis, a clinically meaningful dosimetric benefit should be demonstrated as mandated by the American Society of Radiation Oncology (ASTRO) model policy). In this case, the intensity-modulated radiation therapy (IMRT) plan is adequate for normal tissue sparing of the salivary gland, larynx, pharynx, and spinal cord. In sum, proton therapy is not superior to non-proton based IMRT. The clinical documentation provided for review do not demonstrate that proton therapy would provide a clinically meaningful benefit over a well-designed IMRT plan. All told, the request for proton beam radiation therapy has not been established as medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in radiation oncology 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 bilateral breast magnetic resonance imaging (MRI). Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this clinical setting. This patient does not meet the criteria for being at high risk for developing breast cancer, which is defined as having a 20-25% likelihood of developing the disease. Per the records, she has not had BRCA testing, and the occurrence of breast malignancy in aunts and a cousin does not constitute a greater than 20-25% risk of breast cancer.  Further, her prior mammograms have not detected any abnormalities suggestive of tumor. MRI studies of the breast are highly sensitive but have a relatively low level of specificity. The literature consistently does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound. In some studies, the specificity of breast MRI has been reported to be as low as 37%. In other words, it is common for an MRI report to state that there are subtle abnormalities that are not indicative of definite tumor, but that a follow-up MRI is recommended. Additionally, there are cases where an MRI has not detected a breast cancer. This patient has had consistently stable mammograms, which is probably the best indication that she does not have tumor. The most valuable tool in interpreting a mammogram is a comparison with an older mammogram, especially when there are no palpable masses. There is a lack of evidence to support the use of MRI as a surveillance tool rather than conventional mammography.  In this particular patient, while it is conceivable that the implant rupture occurred at the time of the mammogram, this is generally a rare occurrence. It is often difficult to distinguish an acute rupture from a chronic pre-existing rupture, and there is no indication on the prior mammogram reports that there were any acute symptoms or comments regarding issues during the procedures. Considering the normal prior mammograms, and the lack of any signs or symptoms of malignancy, a routine mammogram is appropriate in this patients case. All told, the requested bilateral breast MRI is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret for eight weeks for treatment of the enrollees hepatitis C virus. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  This patient should be considered treatment naive as the prior regimen was interferon three times weekly and ribavirin rather than a full course of PEG-interferon and ribavirin.  The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage.  The ENDURANCE-1 trial showed that only eight weeks of treatment is needed. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mayvret is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Guardant360 biopsy free tumor sequencing test provided for evaluation of the enrollees lung cancer. Findings: The three physician reviewers found that molecular diagnostic studies in non-small cell lung cancer are currently considered the standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. For these reasons, the Guardant360 biopsy free tumor sequencing test provided was likely to be more beneficial than any available standard therapy. Final Result: The reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter aortic valve replacement (TAVR) for treatment of the enrollee, who is status post aortic valve replacement. Findings:  2/3 of the physician reviewers found that the physician reviewer found this patient has had rather rapid deterioration of his porcine aortic prosthesis with severe aortic regurgitation and increasingly severe symptoms of heart failure and atrial arrhythmias. He has a clear indication for repeat valve replacement of his failing prosthesis due to symptomatic severe aortic insufficiency. He also has significant underlying lung disease, which places him at higher risk for a repeat open valve surgery operation. Catheter based TAVR for a failing aortic prosthesis is a medically appropriate option for this patient based on recent trial data and guidelines. Therefore, the requested TAVR is likely to be more effective than other treatment options. Final Result: 2/3 of the reviewers determined that the requested services are 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a mandibular advancement device for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that The physician reviewer found the submitted documentation supports the medical necessity of the requested device in this clinical setting. In February 2017, the patient has had a sleep study showing an apnea-hypopnea index (AHI) of 5.4.  An AHI of 5 to 15 indicates mild obstructive sleep apnea. The patient describes excessive daytime sleepiness causing trouble focusing. Physical examination demonstrated a blood pressure of 147/91, indicating a hypertensive state. The Health Plan noted that in order for an oral device to be considered medically necessary, the patient should first try treatment with a machine that helps breathing when she is sleeping, such as continuous positive airway pressure (CPAP) device. In this patients case, there is documentation of intolerance to CPAP manifested by claustrophobia and latex allergy. The current medical evidence supports the requested device for the treatment of this patient. All told, the requested mandibular advancement device is medically necessary in this patients case. Final Result: The reviewer determined that the requested device 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 dentistry 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 DecisionDx-Melanoma gene test. Findings:  Three physician reviewers found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases  to  regional  lymph  nodes  may  be  amenable  to  excision,  but  this  suggests  a  high  risk  for  the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx-Melanoma gene test has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma gene test provided was not likely to have been more effective than other methods of evaluating this patient. Final Result: 3 of 3 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.