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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Caris Molecular Intelligence tumor testing for evaluation of the enrollees mesothelioma.  Findings:  The physician reviewer found that standard treatment for mesothelioma is chemotherapy, with multiple first-line options.  Pembrolizumab can be considered as a subsequent treatment and is U.S. Food and Drug Administration (FDA) approved for patients with unresectable or metastatic solid tumors that progress on treatment or have no satisfactory alternative treatments and have microsatellite instability high (MSI-H) cancers. Therefore, there is support for microsatellite instability testing in this clinical setting. The patient did not require a full panel of molecular testing.  In this patients case, the panel performed was not standard therapy. In sum, the microsatellite instability testing portion of the services at issue was likely to have been superior over other available treatment methods. However, the submitted records fail to demonstrate the superior efficacy of the remainder of the services at issue. Final Result: Two of three reviewers determined that a portion of the services 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 partially overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal 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.Physician reviewer number two is board certified in internal 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.Physician reviewer number three is board certified in internal 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Findings:  Three physician reviewers found that the DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Gene Assay has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Since this test has not been demonstrated to provide superior benefit compared to established tests, the DecisionDx-Melanoma Gene Assay provided 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 Physician 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: An enrollee has requested authorization and coverage for a podiatry consultation for evaluation of the enrollees hallux valgus of the right foot. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for a podiatry consultation. According to the documentation provided for review, there is a lack of evidence supporting a hallux abducto valgus deformity.  There is no documentation of a crooked toe, degenerative changes at the metatarsophalangeal joint (MPJ), or pain with shoe gear. In addition, there is a lack of documentation to support the patient has failed on any conservative treatment consisting of but not limited to change in activity level, use of over-the-counter shoe inserts, or alternate shoe gear with padding. The documentation provided also does not demonstrate cross-over deformity of the second toe due to the hallux valgus, diabetes or other peripheral neuropathy, foot pain localized to the first MPJ, or inability to wear retail shoes. As such, the requested service is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested service is 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 podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services provided for treatment of the enrollees polysubstance dependence. Findings:  The physician reviewer found that the patient did not show significant post-acute withdrawal symptoms. He was not a danger to self or others. He did not show violent behavior. There were no emotional, behavioral, or cognitive factors that would require ongoing residential treatment. His activities of daily living were intact. He was medically and psychiatrically stable, with conditions that could have been treated in an outpatient setting. He was not agitated, manic, or psychotic. The patient was not reportedly treated for his anxiety. His opiate use disorder could have been addressed in an outpatient setting with medically assisted treatment such as suboxone. He showed good motivation as evidenced by his participation in groups, individual, and 12 step meetings. His mother was supportive and his home environment was safe. No new problems had arisen and there was no reason that returning him to the community would lead to decompensation. He did not require 24-hour monitoring and could have continued relapse prevention planning and coping skills development at an ambulatory level of care, with concomitant community supports in the 12 step groups and counseling. All told, the RTC services provided were not medically necessary for treatment of the patients medical 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 sub-specialty certification in addiction 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:An enrollee has requested reimbursement for a wearable cardioverter defibrillator (Zoll LifeVest) or treatment of the enrollee who has a history of hypertrophic cardiomyopathy. Findings:  The physician reviewer found that The benefits of the wearable cardiac defibrillator (WCD) have been the subject of intensive study. Moreover, WCD has not been a proven benefit for newly diagnosed patients with cardiomyopathy. Guidelines of the Heart Rhythm Society (HRS) and the American College of Cardiology (ACC) do not support use of the WCD. Instead, the guidelines recommend permanent ICD after a waiting period of 45 to 90 days if potentially reversible causes are present but the WCD has not been proven beneficial in this situation. There is a lack of randomized trial, which have shown the benefits of WCD over and above that of optimized medical therapy. The medical literature recommends further study of the use of this equipment. Based on this data, the wearable cardioverter defibrillator from 11/2/17 through 1/2/18 was not likely to have been more effective than the available standard methods for the treatment of this patients medical condition. Final Result: Three reviewers determined that the equipment 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX prostate assay. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the services at issue in this clinical setting. This patient underwent genomic and protein biomarker testing (Oncotype Dx) to help in clinical decision making. The provider had recommended the testing in order to further evaluate risk of disease progression and prognosis. There are some studies that show that molecular and genomic testing appears to be helping those patients with low risk disease to make decisions regarding observation versus treatment. However, the drawbacks include heterogeneity of prostate cancer and uncertainty of potential clinical benefit. This particular testing may be helpful in both low and high risk patients but the clinical benefit remains to be elucidated. The Oncotype DX prostate assay provided was not medically necessary for the evaluation of this patients medical condition. Final Result: The physician reviewer determined that the services at issue were 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 urology 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 genetic testing for evaluation the enrollees major depressive disorder and post-traumatic stress disorder (PTSD). Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The medical literature lacks well-designed and adequately powered studies illustrating consistent and reproducible results that provide clinically useful information pertaining to genomic testing and its relationship to specific pharmacologic interventions.  In this case, the patient tried many medications and had frequent medicine changes. However, there is a lack of documentation demonstrating the specific type and duration of psychotherapies provided, which are standard therapies that often outperform psychotropic medication. For example, evidence-based trauma-focused therapies for PTSD, interventions for depression such as cognitive behavioral therapy, interpersonal therapy or psychodynamic therapy, and, considering the chronic suicidality and family stress, dialectical behavior therapy and family counseling, respectively, may have been more appropriate at the time.  In sum, the records do not support that the patient had exhausted standard treatments available to treat her condition. In conclusion, considering the relevant peer-reviewed literature and current practice standards, the genetic testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. All three 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Latuda prescription for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that Lurasidone is an atypical, or second generation, antipsychotic medication initially approved for the treatment of schizophrenia. In mid-2013, lurasidone gained two additional indications, both for the treatment of bipolar illness, and is one of only three U.S. Food and Drug Administration (FDA) approved medications for bipolar depression.  The other two, quetiapine and olanzapine-fluoxetine combinations, are frequently associated with weight gain, glucose intolerance and dyslipidemia.  The medical evidence appears to indicate that lurasidone is associated with fewer metabolic side effects and less weight gain. The Health Plan suggested aripiprazole as an alternative.  However, the data supporting aripiprazole as a monotherapy or in conjunction with lamotrigine in the treatment of bipolar depression are weak when compared to lurasidone. Lurasidone is approved by FDA for this patients condition and is reasonably expected to improve the patients condition and to prevent a more serious episode of illness.  Therefore, Latuda is medically necessary for the treatment of this patients medical condition. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Cologuard testing. Findings:  Three physician reviewers found that evidence of impact on healthcare outcomes of Cologuard testing versus standard medical care is lacking, and Cologuard testing is not standard of care at this time. Cologuard testing is U.S. Food and Drug Administration (FDA) approved to test for colon cancer, proved 92% sensitive for detection of colon cancer, and can detect most (but not all) adenomas if they have high-grade dysplasia. Studies reported that 154 persons would have to be screened to find one cancer using colonoscopy, versus 166 persons using Cologuard testing, raising concern that Cologuard testing may have missed cancer. The evidence of the impact of Cologuard testing on patient care or health outcomes is lacking. Although Cologuard testing is able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop. The long-term health outcomes of foregoing regular polyp removal and instead using Cologuard testing have not been determined. A family history of reaction to anesthesia applies to general anesthetics, which are not typically used for colonoscopy, and only certain adverse reactions to anesthesia are hereditary. In this patients case, the type of adverse reaction to anesthesia was not noted. Additionally, health outcomes using Cologuard have not been compared over the long-term with other screening methods for colon cancer, even if colonoscopy was not an option. For these reasons, Cologuard testing provided was not likely to have been more effective than other modalities for 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 3 Physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 Mavyret 100-40 mg for eight weeks. Findings:  The physician reviewer found that, according to the most 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. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg for eight weeks is medically necessary 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks. Findings:  The physician reviewer found that according to the most 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. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1b patients should be treated with Epclusa for 12 weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Epclusa for 12 weeks is medically necessary 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 ternal 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.