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 Guardant360 gene testing for evaluation of the enrollees non-small cell lung cancer (NSCLC). Findings:  Two of the physician reviewer found that 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 and thus to facilitate prompt treatment or protocol inclusion. The National Comprehensive Cancer Network (NCCN) guidelines indicate that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. The NCCN non-small cell lung cancer (NSCLC) guidelines panel 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 NSCLC. For the treatment of patients with advanced NSCLC broad molecular profiling, such as with Guardant360 testing, is considered a standard of care. As such, the Guardant360 gene testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for acupuncture services for treatment of the enrollees neck pain.  Findings:  The physician reviewer found that the request for acupuncture services are medically necessary for treatment of the patients medical condition. Acupuncture is clinically indicated as an adjunct to physical rehabilitation for this patient. In this case, the patient has neck pain after a cervical spine injury and is being transitioned from a hard spinal orthosis to a soft cervical collar. The patient impairment of strength is expected to limit use of self-applied modalities. Treatment with acupuncture services is medically reasonable to facilitate improvement in the patients residual musculoskeletal impairments. In addition, his comorbid conditions that include depression, anxiety, and insomnia may also improve with acupuncture. For these reasons, the requested services are considered medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The representative of the patient has requested reimbursement for air ambulance and ground ambulance transportation services for treatment of the enrollees stage III cervical cancer. Findings:  The physician reviewer found that Air ambulance is considered medically necessary under certain circumstances. Emergency circumstances include when the point of pickup is inaccessible by land or there is a great distance or obstacle involved in land transport, when the time needed to transport the patient by land poses a threat to a patients survival, or when the proper equipment needed for the patient is not available on a land ambulance. Air ambulance may be appropriate to transport a patient from one facility to another if the patient requires a higher level of care than the sending facility can provide. In such cases, air ambulance is needed to transport the patient to the closest facility capable of providing the necessary care for that patient. Air ambulance transport is not indicated for purposes of patient request or convenience. In this case, the patient was not transferred emergently. The transport was arranged in advance. The patient was not transferred from one facility to another to receive a higher level of care. She was discharged and being transported home per her request. There are multiple hospice facilities in Los Angeles capable of providing hospice and palliative care. She was using patient controlled anesthesia for pain control and did not receive any intravenous medications during transport. She was using low dose supplemental oxygen and did not require titration during transport. This patient could have been transferred by stretcher car or gurney van to a hospice facility in closer proximity to UCLA. Criteria for air ambulance transport are not met in this case. Thus, the ground ambulance services provided were medically necessary while the air ambulance services provided were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were 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 emergency 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Harvoni 90-400 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. 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 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  For these reasons, the requested treatment with Harvoni 90-400 mg for 12 weeks 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. Fulfills Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the clinical chemistry test (Anser IFX) for evaluation of the enrollees Crohns disease. Findings:  The physician reviewer found that The Prometheus Anser IFX test is a quantitative measurement of serum infliximab and anti- infliximab antibodies. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. However, in a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. Moreover, the reasons for therapeutic failures remain unclear. While there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. Accordingly, the Prometheus Anser IFX testing performed on 11/7/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 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 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.Physician reviewer number two 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.Physician reviewer number three 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: The patient has requested reimbursement for the residential treatment center level of care services  for treatment of the enrollees alcohol abuse. Findings:  The physician reviewer found that the patients withdrawal symptoms were mild-to-moderate in nature, and cravings were moderate. She was not a danger to herself or others. There were no emotional, behavioral, cognitive, or impulsive symptoms to warrant residential level of care. Her activities of daily living were intact. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with her care. She was medically and psychiatrically stable to the point that she could have been managed at an ambulatory level of care. She appeared to be engaged and working the program and had completed step I in Alcoholics Anonymous. She was cooperative and medication compliant. Given that the patient has had multiple prior substance abuse treatments at residential of care, she would have been educated regarding issues of relapse prevention and impulse control, thus already having a foundation from which to work. No new problems had arisen. The issues she was dealing with in therapy could have been addressed in an outpatient setting. Although she required further treatment to help her develop and solidify coping skills, this could have been accomplished in an ambulatory setting. She no longer required 24-hour residential monitoring and could have been stepped down to an ambulatory level of care. Thus, the residential treatment center level of care services provided from 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Copaxone for treatment of the enrollees multiple sclerosis.Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication in this clinical setting. Multiple sclerosis (MS) is a neurological disease mediated by the immune system within the central nervous system. Based upon the documents submitted, the patients clinical history is suspicious for MS and the patient is at a high risk for disease progression.  In this clinical setting, evidence supports disease-modifying therapy. Interferons have shown benefit in patients with both multiple sclerosis as well as in patients that have a high risk of developing multiple sclerosis.  In studies comparing glatiramer acetate with interferon, therapy effects were similar with possible less lesion burden with interferon therapy. The therapies available on the Health Plans formulary include Avonex, Gilenya, Rebif, and Plegridy. These medications have been shown to be effective and equal to if not better than glatiramer acetate (Copaxone). Considering the available evidence, the formulary plan options are medically appropriate for this clinical scenario. Therefore, the requested medication Copaxone is not medically not medically necessary for treatment of 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 neurology 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 ankle replacement surgeryfor treatment of the enrollees ankle painFindings: The physician reviewer determined that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient presents with continued right ankle pain and associated functional limitations in weight-bearing activities. He is status post right ankle fracture at age 18, right retrocalcaneal exostectomy with Achilles tendon debridement in January 2016, and Achilles tendon lengthening on 7/12/16. Detailed evidence of long-term reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. He has been diagnosed with post-traumatic right ankle arthritis with x-rays on 5/01/17 showing early ankle arthritis per the orthopedic surgeon. He also has severe right Achilles tendinosis/tendinitis. There is no compelling rationale presented to support the medical necessity of ankle replacement for 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5 mg, twice a day for the treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current medical evidence supports a trial and failure of full dose disease modifying anti-rheumatic drug (DMARD) therapy and then anti-tumor necrosis factor therapy prior to the use of Xeljanz. In this patients case, the records do not document that she has failed an adequate trial of methotrexate at full dose alone or in combination with Plaquenil, sulfasalazine or other DMARDs. Additionally, despite the potential hepatic toxicity with methotrexate, the records do not document that the patient has risk factors outside of the norm for methotrexate-related hepatotoxicity. The patient also does not have specific documented risk factors for coccidioidomycosis limiting her ability to take an anti-tumor necrosis factor agent if she fails or does not tolerate methotrexate. Per American College of Rheumatology guidelines, after the failure of DMARD therapy alone or in combination, the recommendation is to add or use an anti-tumor necrosis factor agent or biologic agent, such as Enbrel or Humira, prior to Xeljanz. There is a lack of support for the requested medication in this clinical setting. All told, Xeljanz 5 mg, twice a day is not medically necessary for the treatment of 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 rheumatology 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 anesthesia services for evaluation of the enrollees colonoscopy. Findings:  The physician reviewer found that there is a lack of sufficient support in the medical literature for the services at issue in this clinical setting. The medical literature supports the use of conscious sedation for endoscopic procedures. The patient reports to having anxiety, however is not on an anxiolytic. In this case, there is a lack of documentation supporting anesthesia services for this patient. For the reasons provided, the anesthesia services provided were not medically necessary for evaluation of the patients medical condition. Final Result: The 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 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 authorization and coverage for Hetlioz for treatment of the enrollee's non-24 sleep wake disorder.  Findings:  The physician reviewer found that the request for Hetlioz is not medically necessary for treatment of the patients medical condition. According to the American Academy of Sleep Medicine criteria for non-24 sleep wake disorder, The sleep disturbance is not better explained by another current sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder. (Sateia). The progress notes do not indicate the patient has been screened for substance use disorders or has had a neurological evaluation. In addition, the guidelines for insomnia recommend cognitive behavioral therapy (CBT) as the initial therapy rather than medication (Smith and Neubauer). According to Trauer and colleagues CBT is an effective treatment for adults with chronic insomnia with clinically meaningful effect. In this case, the records submitted for review indicate that the patient has tried various sleep hygiene methods but there is no evidence the patient has had a trial of CBT for insomnia. For the reasons provided, the requested medication is not 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 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.