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

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene expression profiling rendered for evaluation of the enrollees prostate cancer. Findings: Two physician reviewers found that several tissue-based molecular assays have been developed in an effort to improve decision making in newly diagnosed patients considering active surveillance and in treated patients considering adjuvant therapy or treatment for recurrence. Patients with clinically localized disease may consider the use of tumor-based molecular assays. Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network (NCCN) risk groups. Genome-wide expression profiles of high-risk patients with prostate cancer who developed rapid metastasis after prostatectomy were compared with those of a matched cohort of men with favorable outcomes following surgery. From this, the Decipher, a 22-marker genomic classifier, based on RNA expression, was developed. In addition to the prediction of metastasis after prostatectomy, the genomic classifier has also been shown to be associated with progressive disease following salvage radiation. Given the current peer-reviewed medical literature, the gene expression profiling rendered was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested continued applied behavioral analysis (ABA) therapy for treatment of the autism.  Findings: The request for continued ABA therapy at the frequency of 40 hours per week has been established as medically necessary for treatment of the patients autism. Mohammadzaheri and colleagues compared two intervention conditions, a naturalistic approach, Pivotal Response Treatment (PRT) with an adult-directed ABA approach on disruptive behavior during language intervention in the public schools. The study found that ABA was effective to decrease disruptive behaviors in school age children. In addition, ABA is one of the best therapies to address aggression and self-injury. In this case, the patient has maladaptive behaviors that have considerable safety implications due to elopement, self-injury and tantrum. There is a lack of records showing that the patients maladaptive behaviors are at a safe level. As such, a decrease in ABA hours is not indicated at this time. Therefore, based on the records submitted for review, 40 hours per week of ABA services is medically necessary for treatment of the patients autism.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Repatha SureClick 140 mg/mL for treatment of the enrollees pure hypercholesterolemia, essential hypertension, and disorder of thyroid.  Findings: The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved Repatha for treatment of hypercholesterolemia in patients with heterozygous familial hypercholesterolemia (HeFH) who have not reached goal despite maximally tolerated statin dose, or patients with atherosclerotic vascular disease who have not reached goal despite maximally tolerated statin. This patient does not have LDL levels that are elevated enough to diagnose HeFH without evidence of tendon xanthomas or corneal arcus (Sniderman, et al). In addition, the FDA label points out those long-term studies have not been reported regarding cardiovascular morbidity and mortality. So long-term benefit of the medication has not yet been shown. For these reasons, the requested Repatha SureClick 140 mg/mL is not medically necessary for this patient.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 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 Otezla 30 mg for treatment of the enrollees psoriasis. Findings: The physician reviewer found that Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. About 20% of patients have severe psoriasis, necessitating systemic drugs such as acitretin, methotrexate, cyclosporin A or the newer biologic agents. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. It has been well-documented that therapies of psoriasis with injectable biologics increase the risk for malignancy and infection, mandating prior testing for tuberculosis. Apremilast (Otezla) an oral PDE4 inhibitor, provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Its effects on cyclic adenosine monophosphate-regulated intracellular signaling, gene expression, and subsequent protein levels allow apremilast to modulate the immune responses that cause the inflammation associated with psoriasis. Otezla has been shown to result in significant improvement in well selected patients. Otezla has been studied in more than 4,000 patients, and the safety profile is consistent across indications. This patient has chronic plaque psoriasis that requires systemic treatment. Immunosuppressive and anti-TNF drugs can increase the risk for infection and malignancy. Otezla is approved by the U.S. Food and Drug Administration (FDA) for treatment of such patients. For these reasons, the requested Otezla 30 mg is supported as medically necessary for treatment of this patients 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment.  Per the guidelines, treatment-naive, genotype 1 patients should be treated with Harvoni.  Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials.  For these reasons, the requested treatment with Harvoni for eight weeks is medically indicated for the treatment of this patient.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for bilateral knee braces for treatment of the enrollees knee injury. Findings: The physician reviewer found that the evidence-based medical guidelines state that there are limited high quality studies that support or refute the benefits of knee braces for patellar instability, ACL tear, or medial collateral ligament instability. However, studies have found that in some patients a knee brace can increase confidence, which may indirectly help with the healing process. Pre-fabricated knee braces may be appropriate for patients with knee instability or ligament insufficiency/deficiency. Custom braces are supported when there is abnormal limb contour, such as disproportionate thigh and calf, precluding the use of a pre-fabricated brace. In all cases, braces need to be used in conjunction with a rehabilitation program and are medically appropriate if the patient is going to be stressing the knee under load. Bedi and colleagues concluded that there was a lack of high-quality evidence regarding immobilization, weight-bearing, bracing, or rehabilitation protocols for patients with posterior cruciate ligament injuries treated either non-surgically or surgically. Additional long-term clinical studies with homogeneous patient populations are needed to identify the ideal management of these injuries. In another study by Jansson and colleagues, they found that little evidence exists from the eight relevant articles to support the biomechanical efficacy of non-operative and postoperative PCL bracing protocols. This patient presented possible imaging evidence of a posterior cruciate ligament longitudinal tear with no disruption and no complaints of instability. The orthopedic appeal letter stated that the patient sustained a PCL injury to his left knee rendering the knee unstable in flexion. There is a current report of instability in flexion, with some medial and patellofemoral pain. However, there was a lack of evidence to show abnormal limb contour to support the medical necessity for the braces at issue. This patient had a diagnosis of left knee injury with no documentation of an ACL or PCL ligament tear or knee instability to support the medical necessity of wearing a brace. For the reasons stated above, the two knee braces were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the devices 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 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:  An enrollee has requested laser hair removal for their arms, axilla, chest, face, neck, low back. The patient was born with genetics to grow the terminal hair in her arms, axilla, chest, face, neck and low back. It would be abnormal for a female to have terminal hair on the face, chest, neck and low back.  This hair growth in a woman is known as hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in female body parts that are normally found in males. As such, the removal of terminal hair to the face, chest, neck and low back is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. These treatments will create a more feminine appearance for this patient and provide more than a minimal improvement in appearance. Moreover, removal of terminal hair to the face, chest, neck and low back will also improve this patients emotional function. However, females would be expected to have terminal hair in the axilla and on their arms. Therefore, removal of terminal hair to the axilla or arms is not medically necessary for treatment of this patient. Nor would removal of hair on the axilla and arms be considered reconstructive surgery, as the presence of hair in these areas is not considered an abnormal structure.Final Result: The reviewer determined that a portion of the requested services is medically necessary, and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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 modulated radiation therapy (IMRT) for treatment of the enrollees prostate cancer.  Findings: Three physician reviewers found that the patient has a history of pathologic stage T3bN0M0 and Gleason 8-9 prostate cancer. The patient was offered adjuvant or salvage radiation therapy for a post prostatectomy prostate specific antigen (PSA) of 0.59. The Health Plan denied the services at issue as investigational for treatment of this patient. This denial is the subject of this appeal and determination. In this clinical setting, the services at issue were likely to be more effective than any available standard therapies for treatment of this patient. IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure.  IMRT generally implies inverse planning algorithms, where the provider determines radiation treatment parameters to maximize dose to the target while minimizing dose to normal tissues. In this case, the treating provider recommended IMRT in this patient who was receiving post prostatectomy radiation. Radiation after prostatectomy is recommended for patients with high risk features and/or rising PSA in the absence of metastatic disease. There is limited prospective clinical studies which directly compare IMRT to conventional three dimensional (3D) radiation therapies. Conventional 3D radiation therapy is also considered a standard and safe approach.  However, IMRT is considered more effective to reduce dose to surrounding critical structures like the bowel and bladder. In general, the radiation field for the pelvis after prostatectomy is a concave treatment volume around normal structures, for which IMRT is much better suited to conform to, as opposed to conventional conformal radiation. Therefore, IMRT was the safest and most effective way to treat this patient. Thus, IMRT was likely to be superior to any available standard modality for the treatment of this patient.  Final Result: Three physician reviewers determined that the services at issue 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: All three 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Three physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In addition, the area of architectural distortion, felt to be likely post-surgical, can also be best evaluated with tomosynthesis. Therefore, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent an enrollee has requested authorization and coverage for 20 hours per week of direct applied behavioral analysis (ABA) therapy and 12 hours per month of supervision for treatment of the enrollees autism. Findings:  The physician reviewer found that the peer-reviewed literature has not definitively established how much ABA is necessary for children with autism. The study by Sallows and Graupner found that intensive behavioral treatment for children with autism was effective. In this case, the patient is in his sixth year of ABA treatment. However, he continues to have maladaptive behaviors. The research suggests that the patient can tolerate a reduction in his ABA hours. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested resumption of skilled nursing facility (SNF) services including rehabilitation with daily physical therapy for treatment of the enrollees hemiplegia and hemiparesis. Findings: The physician reviewer found that the functional impairments due to acquired brain insults such as intracerebral hemorrhage can improve with time including natural recovery processes, but are also amenable to rehabilitation interventions (Kreisel, et al; Manno). The role of inpatient rehabilitative care for patients with significant functional deficits in this setting is well-established in the medical literature (Dewey, et al; Langhorne, et al). Despite treatment, deficits can remain severe. Functional dependency following intracerebral hemorrhage is high (Kuramatsu, et al; van Asch, et al). In the present case, the patient sustained a right basal ganglia hemorrhage. His cerebral pathology has been accompanied by significant functional impairments. He underwent extensive inpatient rehabilitation. The records document that the patient plateaued at a level where he was non-ambulatory and dependent for care. He has been at a custodial level of care. There are no indications that there have been recent significant changes in his condition, such that participation and progress with therapies in an inpatient setting would be required. Further rehabilitative services may be considered going forward, but these services can be provided in a community setting, with custodial level services for his basic self-care. Caregivers should have had sufficient time to undergo the training to provide custodial level care in the home setting. If the current caregivers are unable to provide care, care in a custodial level facility would be an appropriate alternative. Overall, there are no documented ongoing skilled nursing needs such as complex wound care, initiation of self-care related to enteral feeding, or ostomy care requiring ongoing inpatient care. Thus, the requested resumption of SNF services including rehabilitation with daily physical therapy 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 physical medicine and rehabilitation 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.