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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). Findings:  The physician reviewer found that upon review of available data, IMRT is not likely more beneficial than standard three-dimensional (3D) conformal radiotherapy for this patients Hodgkins disease. The potential benefit of IMRT over 3D conformal radiotherapy is that with multiple modulated beams, a more conformal dose can be achieved covering the target volume, thus possibly sparing normal tissue from intermediate and high dose exposure. The disadvantage is that with more beams, more normal tissue is exposed to low dose radiation. This extra low dose exposure may increase the chance of secondary malignancy. The potential decrease in side effect with IMRT should be balanced with this increased risk of secondary malignancy . According to the National Comprehensive Cancer Network (NCCN) guidelines, the proposed consolidative dose of 30 Gy is above the dose tolerances of organs in the region including the small bowel, rectum, bladder, and bone marrow. Based on these findings, the requested IMRT is not likely more beneficial than 3D conformal radiotherapy for treatment of this patients medical condition. Final Result: Two of the three reviewers determined that the requested services are 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 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the balloon sinus ostial dilation provided. Findings:  The physician reviewer found that according to the American Academy of Otolaryngology, Head and Neck Surgery (AAOHNS) chronic rhinosinusitis is defined as a persistent inflammatory disorder of the paranasal sinuses with symptoms of persistent facial pain, discolored nasal discharge, and symptoms that are refractory to appropriate medical management including antibiotics, nasal anti-inflammatory medications and decongestant therapy. Additionally, computed tomography (CT) scan imaging usually demonstrates extensive mucous membrane changes within the ethmoid, maxillary and other paranasal sinuses with blockage of the ostiomeatal complex. At present, functional endoscopic sinus surgical techniques for the management of recurrent acute and chronic rhinosinusitis which are refractory to medical management are still considered the surgical treatment of choice. Orlandi and colleagues noted that conservative approaches can provide short-term clinical outcomes comparable to traditional endoscopic sinus surgery in patients with limited disease. For patients with moderate-to-severe chronic rhinosinusitis, traditional endoscopic sinus surgery has the potential for improved long-term sinus ventilation and delivery of topical medications. All told, the balloon sinus ostial dilation provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three of 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 otolaryngology 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 parent of an enrollee has requested authorization and coverage for the STAR program for treatment of the enrollees sensory processing disorder.  Findings:  Two physician reviewers found that the American Academy of Pediatrics (AAP) released a policy statement for sensory integration therapies for children with developmental and behavioral disorders. The AAP states that it is unclear whether children who present with sensory-based problems have an actual disorder of the sensory pathways or whether these deficits are associated with other developmental and behavioral disorders. The AAP notes that because there is no universally accepted framework for diagnosis, sensory processing disorder generally should not be diagnosed. According to the AAP, occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan. However, parents should be informed that the research regarding the effectiveness of sensory integration therapy is limited and inconclusive. In addition, Researchers conducted a systematic analysis on the outcomes of 17 single case design studies on sensory integration therapy (SIT) for people with, or at risk of, a developmental or learning disability, disorder or delay. The authors noted that SIT is a controversial intervention that is widely used for people with disabilities. An assessment of the quality of methodology of the studies found most used weak designs and poor methodology. The authors concluded that based on limited comparative evidence, functional analysis-based interventions for challenging behavior were more effective that SIT. The authors further stated that the studies did not provide convincing evidence for the efficacy of SIT. Given the lack of support in the peer-reviewed literature, the STAR program has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are 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: Reviewer 1 is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. Reviewers 2 and 3 are board certified in pediatrics and neurology with special qualification in child 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 enrollee has requested reimbursement for the Guardant360 biopsy free tumor sequencing test for evaluation of the enrollees non-small cell lung carcinoma (NSCLC).  Findings:  Two physician reviewers found that adenocarcinoma of the lung should be tested for specific molecular abnormalities, such as epidermal growth factor receptor (EGFR) mutation, ALK, and ROS1 as each of these have therapeutic implications. Such testing is usually done by tissue testing on the biopsy performed. Guardant360 assay is a plasma based assay of multiple molecular profiles. When an EGFR mutation is found and is treated with evidence of progression, Guardant360 assay can be used to detect a further EGFR mutation. Beyond such clinical situation, there is no expected benefit from Guardant360 testing. 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: 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensive outpatient program (IOP) services at a facility that specializes in dual diagnosis disorders (eating disorder and post-traumatic stress disorder (PTSD)/trauma for treatment of the enrollees bulimia nervosa and PTSD. Findings:  The physician reviewer found that although specialty care services are indicated in this case, the documentation does not support the medical necessity of the requested services. The records do not demonstrate that an eating disordered IOP program in conjunction with outpatient trauma-focused therapy, such as prolonged exposure or cognitive process therapy, would be unsafe or inadequate in this case. Despite twice weekly outpatient visits, that the patients eating disordered behavior worsened after she broke up with her boyfriend. Thus, a higher level of care would be a reasonable course of action, and it appears that the Health Plan offered an appropriate option with IOP level of care. Regarding the trauma-related services, there is no evidence that the patient has failed a course of evidence-based PTSD therapy in the outpatient setting, which is the considered the standard setting for treatment delivery, particularly initial episodes of care, and recovery. As such, a higher level of care is not medically necessary for the diagnosis of PTSD. In sum, the patient should be considered for eating disorder IOP services and a diagnostic evaluation focusing on the appropriateness for a time-limited course of outpatient evidence-based therapy for PTSD. However, the requested IOP services at a facility that specializes in dual diagnosis disorders (eating disorder and post-traumatic stress disorder (PTSD)/trauma) is not supported as medically necessary for 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 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: The enrollee has requested reimbursement for residential treatment services for treatment of the enrollees substance abuse. Findings:  The physician reviewer found that the patient was not in withdrawals as she had only used once and did not require detoxification. She was not a danger to herself or others and she was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the residential treatment center (RTC) level of care. She was not psychotic or manic and she was medically and psychiatrically stable. Her medication regimen could have been managed in an ambulatory setting. She was cooperative and participated in her treatment plan. She had multiple prior treatments and therefore had a base of knowledge from which to continue to build her relapse prevention plan. Her difficulties with abuse and relapse were chronic in nature and did not require 24-hour monitoring in the absence of unstable medical or psychiatric conditions. She could have safely been treated in an ambulatory level of care, with the assistance of medically assisted treatment such as suboxone for opiate use disorder if deemed appropriate by her provider. 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 sub-specialty certification in addiction psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ultraviolet light therapy system panel for treatment of the enrollees aquagenic pruritus. Findings:  The physician reviewer found that there is sufficient support for the requested device in this clinical setting. This patient has a history of aquagenic pruritus. She has been treated in-office with phototherapy, with good resolution of symptoms. She has also tried and failed treatment with topical steroids and gabapentin. There is evidence in the medical literature of the utility of ultraviolet B phototherapy in the successful treatment of aquagenic pruritus.  Given that the patient has already had an in-office trial and found success with this treatment, a home unit is medically appropriate. 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for an oral device to reduce upper airway collapsibility for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that based on the current medical literature and the presented clinical records, the request for an oral device to reduce upper airway collapsibility is medically necessary for treatment of the patients medical condition. In cases of mild and moderate OSA, oral appliance (OA) therapy is as an appropriate first-line therapy. In this case the patient is noted to have mild OSA. According to the American Academy of Sleep Medicine (AASM) guidelines Although not as efficacious as CPAP, OAs are indicated for use in patients with mild to moderate OSA who prefer OAs to CPAP, or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail CPAP or behavioral measures such as weight loss or sleep position change. In addition, the joint practice guidelines from the AASM and the American Academy of Dental Sleep Medicine (AADSM) state We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. As such, an oral appliance is supported by current practice guidelines for this patient who prefers alternate therapy with an OA. In addition, the patient has no dental issues that would prevent the use of an oral appliance. The use of an oral appliance in this case would be considered to be clinically appropriate and medically necessary based on current practice guidelines. For the reasons provided, the requested device is medically necessary for treatment of the patients medical condition. 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 neurology with sub-specialty certification in sleep 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a special blood test (Guardant 360 biopsy-free tumor sequencing test) for evaluation of the enrollees non-small cell lung cancer. Findings:  Two physician reviewers found that National Comprehensive Cancer Network guidelines endorse 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. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially one by one. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients, thus facilitating prompt treatment or protocol inclusion. For the treatment of patients with advanced non-small cell lung cancer, broad molecular profiling is considered standard of care. 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: 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa tablet 400-100 mg for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. In this case, there is imaging evidence of cirrhosis. Per the guidelines, Epclusa for 12 weeks is recommended as a first line regimen for treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic marker testing panel for evaluation of the enrollees non-small cell lung cancer. Findings:  Two physician reviewers found that  the National Comprehensive Cancer Network strongly endorses 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. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients, thus facilitating prompt treatment or protocol inclusion. In this clinical setting, advanced broad molecular profiling, such as with Guardant 360 testing, is considered standard of care. 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: 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Mekinist/trametinib. Findings:  The physician reviewer found that the physician reviewers found there is sufficient support for the requested medication in this clinical setting. Mekinist has been shown in multiple studies to have clinical response, specifically in patients with plexiform neuroma and also in low grade gliomas in patients with neurofibromatosis, type 1. Furthermore, research shows excellent two-year progression-free survival.  Because neurofibromatosis, type 1 is a cancer predisposition syndrome, treatment with radiation should be withheld unless there are no other options. Otherwise, the risk of secondary malignancies is greater.  In addition, chemotherapy versus targeted therapy has a higher side effect profile. In sum, Mekinist/trametinib is likely to be more efficacious than other treatment options. Final Result: Two of the three 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: Physician reviewers 1,2 & 3 are board certified in pediatrics with sub-specialty certification in pediatric hematology-oncology and are 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.