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 gene test (CPT 81420). Findings:  Three physician reviewers found that fetal aneuploidy screening is supported for pregnant patients by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. Cell free DNA testing has been validated as having a high detection rate for fetal chromosomal abnormalities including sex chromosomes. Currently, the non-invasive screening test of choice for aneuploidy is cell free DNA testing. Part of the commercial testing includes an analysis of fetal sex chromosomes. Fetal sex chromosomal abnormalities are common. The rate in the general population is 1:448. Sex chromosome abnormalities such as Turners syndrome include significant associated medical morbidities. Using the cell free DNA test to detect sex chromosome abnormalities is not an investigational procedure. This technique has been highly validated and shown to have a high detection rate. Early detection of fetal aneuploidy allows patients to make informed decisions about the pregnancy and select appropriate medical care. For these reasons, the gene test (CPT 81420) provided was likely to have been more efficacious for the evaluation of this patients medical condition than any available standard modalities. Final Result: 2 of 3 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: All three reviewers are board certified in obstetrics and gynecology and are actively practicing. All three 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 reimbursement for gene test (molecular profiling). The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung cancer.Findings:  Molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that affect therapy selection. The National Comprehensive Cancer Network guidelines for non-small cell lung cancer 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 for the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. All told, the gene test (molecular profiling) was likely to have been of greater benefit than the other standard treatment modalities available for the evaluation of this patients medical condition.Final Result: Two of the three reviewers determined that 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three 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: An enrollee has requested reimbursement for the DecisionDx-Melanoma test. Findings:  Three physician reviewers found DecisionDx-Melanoma assay tests the tissue genetics of melanoma and can stratify whether a melanoma is high risk for metastasis or not. At this time, 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 guidelines. The current standard of care is wide local excision and sentinel lymph node biopsy. At this time, there is a need for clinical trials to determine the utility of the results of the test. In sum, DecisionDx-Melanoma test provided was not likely to have been more effective than other methods of evaluating this patient.  Final Result: The 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: Physician reviewers 1, 2 and 3 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin and clinical examinations. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and oftentimes are referred to medical oncology for adjuvant medical therapy. However, there is a lack of peer-reviewed published studies confirming the role of DecisionDx-Melanoma Gene Assay in this clinical setting. All told, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 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 Plegridy syringe. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Although Plegridy has been shown to reduce disease activity in relapsing-remitting multiple sclerosis, the current medical evidence has not demonstrated that this medication is more efficacious than other approved therapies. In this patients case, the Health Plan has offered Copaxone, Extavia and Gilenya as alternatives. These alternatives are medically appropriate. The records document previous treatment with Betaseron. However, there is no documentation of failure of the formulary alternatives. All told, the medical necessity of Plegridy syringe has not been established.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: A 51-year-old female enrollee has requested authorization and coverage for continued intensive outpatient program (IOP) level of care services (five days per week) for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that The records provided for review document that this patient has not been a danger to herself or others and she has not demonstrated self-harm urges or behaviors. She continued to have urges to weigh herself and over exercise, while episodes of bingeing had decreased significantly. She has been medically stable and not orthostatic, as well as psychiatrically stable to the extent that she does not require IOP services five days per week. She has developed insight into her behavior, and has been described as an active and engaged participate in her treatment plan. There has been no acute worsening or development of new symptoms. All told, continued IOP level of care services (five days per week) are not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollees parent has requested authorization and coverage for magnetic resonance spectroscopy. Findings:  Three physician reviewers found the requested MRS is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Mitochondrial diseases are disorders of mitochondrial respiration resulting in defective energy production which typically manifest in systems with high energy demands, such as the central nervous system. Diagnosis is challenging because symptoms may affect any system and are typically non-specific. Structural magnetic resonance imaging (MRI) and functional brain imaging methods including MRS, diffusion-weighted imaging, and perfusion MRI, have been instrumental in acquisition of knowledge about mitochondrial disorders in a non-invasive fashion. A study reported that clinical diagnosis in children with mitochondriopaties is not easy because of variable clinical symptoms. MRS examination is a noninvasive complementary tool for helping to corroborate the diagnosis. With the current level of knowledge and expertise in this field, the use of MRS in this patient is consistent with the current standard of care, and more likely to be beneficial than other available standard interventions. Final Result: The reviewers determined that the requested MRS is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: All three physician reviewers are board certified in pediatrics 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 Lyrica. Findings:  The physician reviewer found that in the documentation available for review, not all treatment options have been exhausted. Specifically, behavior therapy has not been discussed or completed despite much research to support its use. In addition, the non-controlled medication gabapentin has not been optimized and the dose of gabapentin that failed to provide adequate pain relief was not documented. Moreover, the Lyrica is noted to cause headaches for this patient and no objective functional improvement is documented. For these reasons, the requested Lyrica 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 anesthesiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 15-year-old male enrollee has requested reimbursement for the residential treatment services. Findings:  The physician reviewer found that The medical records do not document active or passive suicidal ideation or psychosis during the disputed period. The documentation indicates that the patient was functioning well at the residential treatment center (RTC) and he was described as cooperative with treatment. The patient was not displaying any signs of self-harm behavior or aggression towards others. In addition, he was not noted to have any serious or significant psychiatric symptoms. He had no active serious medical problems and no symptoms of substance withdrawal. Applying the American Society of Addition Medicine (ASAM) criteria for patient placement, the patient was not acutely intoxicated or at risk for withdrawal (score 0), the patient had no serious medical condition (score 0), and the patient had stable emotional and behavioral issues (score 1). Further, the patient demonstrated motivation to change (score 1), had a risk rating suggestive of a potential for relapse given his minimal period of sobriety (score 2), and his recovery environment included a supportive and sober living environment (score 1). Overall, the patients presentation suggests risk rating scores in the range of 0 to 2. This overall risk rating places the patient at a level 2.1, which is consistent with intensive outpatient services (IOP), nine or more hours of service per week. Given these findings, the patient could have been safely and effectively treated in a less restrictive treatment setting. Thus, the residential treatment 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 child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The submitted documentation does not support the medical necessity of the requested sclerotherapy for treatment of this patients lower extremity varicose veins. There is a lack of documentation ruling out other etiologies that may be the source of the patients leg pain. The patient is noted to have abnormal pedal pulses in the setting of hypertension and hyperlipidemia. The patient presented without complaints status post left greater saphenous vein ablation. In the absence of documentation that the patient has undergone thorough evaluation to rule-out other causes of her symptoms, the requested sclerotherapy is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in surgery with sub-specialty certification in vascular 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 authorization and coverage for right knee joint replacement surgery. Current guidelines recommend total knee replacement as a reliable and suitable surgical procedure to return highly symptomatic patients to better function. The most common indicated diagnosis is advanced osteoarthritis. Indications for surgery include failure of conservative treatment, including exercise therapy and medications, subjective findings of stiffness, nighttime joint pain, minimal pain relief with conservative care, current significant functional limitations, age over 50 years, body mass index less than 40, and x-ray findings of significant osteoarthritis. In this patients case, she presents with persistent significant right knee pain with associated swelling, clicking, catching and giving out. Functional limitations have been noted. This patients symptoms and clinical examination are consistent with radiographic evidence of tricompartmental osteoarthritis, end-stage in the lateral compartment with valgus deformity. There is documentation of long-term comprehensive nonoperative treatment, including bracing, ambulatory assistive devices, NSAIDs, physical therapy, activity modification, and corticosteroid injections, without sustained improvement. There is sufficient support for the requested services in this clinical setting. Thus, the requested right knee joint replacement surgery is medically necessary for the treatment of this patient. 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 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 reimbursement for magnetic resonance imaging (CPT 73721). Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. In this patients case, x-rays of the hip were not conclusively diagnostic. She did not have gross arthritic disease, avascular necrosis or an occult fracture.  In this setting, MRI is the most appropriate next step. In an extensive review of the various causes of hip pain in an active individual, studies concluded that MRI can assist in treatment decision making, as well as detecting different causes of the patients symptoms. It may be appropriate to delay MRI in a patient who has sudden onset of hip pain, as patients will often heal without any significant intervention other than rest and anti-inflammatory medications. However, in this patients case, she has had symptoms for at least six months and could not relate the symptoms to any traumatic event. It was medically appropriate to obtain an MRI in this setting. Therefore, MRI (CPT 73721) provided was medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested enrollee has requested authorization and coverage for implantation of the hypoglossal nerve stimulator. Findings:  The physician reviewer found that the documentation provided does not support the superior efficacy of the requested services in this patients case. Specifically, the records do not indicate that this patient has exhausted other methods of management. Other surgical procedures have not been attempted such as improvement of the nasal airway with turbinate reduction and possible nasal septal reconstruction. These methods have not been shown to improve sleep apnea but can improve tolerance to nasal CPAP therapy, which is the gold standard modality for treating OSA. Additionally, the patient may be a candidate for other traditional oropharyngeal surgery such as uvulo-palatopharyngoplasty with tonsillectomy, which has been effective in improving symptoms. As such, while the requested implantation with a hypoglossal nerve stimulator have shown some efficacy in treatment of OSA, the research has not shown that it is superior to the available standard options. Accordingly, in this patients case, implantation with a hypoglossal nerve stimulator is not likely to be of greater benefit than the available standard procedures for the treatment of this patients medical condition. Final Result: All three reviewers determined that services at issue were 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: All three reviewers are board certified in otolaryngology and are actively practicing. All three 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.