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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. There currently are three major approaches to the management of localized prostate cancer. These include surgery, various forms of radiation therapy, or active surveillance with no specific anti-cancer treatment being given. Recommendations as to these options are based on risk stratification, which will estimate the risk for the future development of progressive cancer. Various features of an individual patients cancer are included in the assessment, particularly the Gleason grade and PSA, as well as physical findings. In this case, the patient is in the low risk category. Further refinement of such prognostics with gene panels such as Oncotype Dx will not likely alter the patients treatment course. While the National Comprehensive Cancer Network (NCCN) does recommend consideration of the assay for intermediate risk patients, this patient has low risk disease, and has already been placed on active surveillance. Additional information with the Oncotype Dx was not likely to yield information beyond that obtained with standard testing. Thus, the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service 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:  One reviewer is board certified in internal medicine, hematology, and oncology and is actively practicing. One Reviewer is board certified in internal medicine, medical oncology, and hematology and is actively practicing.  One Reviewer is board certified in internal medicine and medical oncology and is 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: A female enrollee has requested reimbursement for the transcranial magnetic stimulation (TMS) treatments. Depression is considered treatment resistant when multiple antidepressants and augmentation strategies have not successfully brought on remission. The guidelines for treatment of depression endorsed the value of TMS in the acute phase of treatment for patients with depression. Moreover, in the peer-reviewed medical literature, studies show that a moderate improvement in symptoms in patients with treatment resistant depression. Studies demonstrated that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Furthermore, studies provided evidence that TMS is a safe and effective treatment option for patients with major depressive disorder. This patients records document failure to significantly improve with medications and augmentation strategies. Given these findings, the TMS treatments provided were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer found that the TMS treatments provided were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in psychiatry and is actively practicing. One Reviewer is board certified in psychiatry and is actively practicing.  One Reviewer is board certified in psychiatry and is 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Omnipod insulin pump. Per colleagues, [i]nsulin pumps can provide a greater flexibility in insulin administration and meal planning, as compared with multiple insulin injections, and they may be particularly suitable for the pediatric age group. Per colleagues, [p]atients using insulin pump therapy had a better longterm glycemic control relative to the matched injection therapy cohort. Continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain, reduces the frequency of hypoglycemic events, and results in overall improved satisfaction in patients and their parents. Here, this patients caregivers have demonstrated that they possess the necessary tools to carry out an effective treatment and follow-up plan on insulin pump therapy. The patient and his family have adhered to frequent blood glucose monitoring, have kept appointments with the childs various health care providers, and have adhered to dietary recommendations. The patients current insulin pump is malfunctioning and is in need of replacement. A new insulin pump is medically necessary and appropriate for this patient.Final Result: The reviewer determined that the requested service 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 pediatrics with a subspecialty certificate in pediatric endocrinology, 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 placement of an esophageal stent. A study found that [t]he aim of palliation in patients with inoperable esophageal cancer is to relieve dysphagia with minimal morbidity and mortality, and thus improve quality of life (QOL). The use of [an esophageal stent] is a well-established modality for palliation of dysphagia in such patients. Stent placement is the standard of care for patients with severe dysphagia and a short life expectancy. In this case, the patient has stage IV esophageal cancer. He has been maintained for some time on trastuzumab based on HER2 amplification in the adenocarcinoma. Thus far, there has been no progression but he has had intermittent, severe dysphagia. This clinical situation is common with this disease and patients need frequent intervention from gastroenterologists to open the esophageal lumen. The patient previously had a stent placed on two occasions but each time the stent migrated. The new stenting proposed for this patient is the standard care and is medically necessary and appropriate.Final Result: The reviewer determined that the requested service 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 subspecialty certificates in medical oncology and hematology, 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 the gene testing (DecisionDx-Melanoma Gene Expression Assay). Based on current peer-reviewed medical literature, there is a lack of scientific evidence permitting conclusions concerning the effect of genetic testing such as the DecisionDx-Melanoma Assay for use in this clinical setting. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Moreover, there is a lack of published data to support its routine use to guide treatment decisions resulting in improved patient health outcomes. Therefore, the gene testing (DecisionDx-Melanoma Gene Expression Assay) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the gene testing (DecisionDx-Melanoma Gene Expression 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 gene testing (DecisionDx-Melanoma Gene Expression 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for functional neuromuscular electrical stimulating ergometer (RT300 FES Cycle Therapy System).Findings:  Two of the three physician reviewers found that this patient has had a spinal cord injury that resulted in reduced mobility and reduced ability to engage in exercise. FES cycling has been developed as a means to stimulate muscle activity in paralyzed limbs to reproduce physiological effects of exercise. The literature has explored the effects of FES cycling to determine if this artificial form of exercise has clinical benefit. The net weight of evidence has been positive, showing that FES cycling promotes improved health status in patients with spinal cord injury. Ashe and colleagues showed an increase in lower extremity bone density and muscle mass in patients with spinal cord injury who used FES cycling. Kahn and colleagues showed lower extremity cycle ergometry may reduce the risk of cardiovascular disease by improving markers of blood coagulability. The medical literature supports the requested equipment in this clinical setting. Therefore, functional neuromuscular electrical stimulating ergometer (RT300 FES Cycle Therapy System) is likely to be superior over other available treatment options. Final Result: The reviewers determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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 reimbursement for a breathing test. While the measurement of fractional exhaled nitric oxide (FENO) is not utilized by itself in the evaluation and management of asthma, it has been demonstrated to be of value in conjunction with clinical parameters. Its use is associated with significantly lower asthma exacerbation rates compared with asthma managed using clinical parameters alone. Further, a recently published review of the literature found that algorithms that include FENO measurements can help in monitoring response to anti-inflammatory, or long-term control medications, including dose titration, weaning, and treatment adherence. In this case, the patient has experienced side effects from various therapies. In order to monitor and treat the patients symptoms, the breathing test was likely to be more beneficial than any available standard testing.Final Result: Two of the three reviewers determined that the service 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:  One reviewer is board certified in internal medicine with sub-specialty certification in allergy and  immunology and is actively practicing. One reviewer is board certified in internal medicine with sub-specialty certifications in allergy and  immunology and rheumatology and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in allergy and  immunology and is 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 gene test (fetal sex and/or fetal chromosomal microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in maternal blood).Findings:  Two of the three physician reviewers found that the American College of Obstetricians and Gynecologists recommends cell-free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. Since this patient is 27 years old, the aneuploidy risk for this patient in this pregnancy does not warrant cell-free DNA testing for aneuploidy. Testing for sex chromosomes and microdeletion syndromes is also not indicated. Given the rarity of these conditions, the detection rate is significantly lower than for trisomy 21 and 18. In sum, the superior efficacy of gene test (fetal sex and/or fetal chromosomal microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in maternal blood) has not been established.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 reviewer 1 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 2 is board certified in clinical cytogenetics and genomics and is actively practicing. Physician reviewer 3 is board certified in clinical biochemical genomics and is 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 DecisionDx-Melanoma testing. Findings:  Three physician reviewers found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by researchers. Other researchers index may also add to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the risk of metastasis over five years. Studies reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification in patients undergoing sentinel node biopsy. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year research data. Most importantly, it is not clear if it can be used to make clinical decisions. Therefore, the superior efficacy of DecisionDx-Melanoma testing has not been established.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 internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for three Orthovisc injections per knee, every 6 months, for both knees. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. In this case, the patient presents with chronic bilateral knee pain. Functional limitations are noted in the patients walking tolerance. Clinical exam findings have been consistent with x-ray evidence of severe osteoarthritis with complete loss of medial joint space on the right (bone-on-bone), greater than 50% loss of medial joint space on the left, and moderate lateral and patellofemoral compartment degenerative changes bilaterally. Reasonable conservative treatment, including medication, activity modification, ice, and corticosteroid injections have failed to provide adequate symptom relief. The patient has undergone bilateral viscosupplementation injections every 6 months with decreased pain and improvement in functional mobility documented. Given the patients previous response, and to assist in delaying total knee replacement, three Orthovisc injections per knee, for both knees, are indicated at this time. However, the medical necessity of future Orthovisc injections cannot be established at this time. Current evidence-based literature would support future Orthovisc injections for both knees if there is documented significant improvement in symptoms for six months or more, and symptoms recur. Therefore, the portion of the request that is for three Orthovisc injections to both knees at this time is medically necessary. However, the portion of the request that relates to future repeat injections should be based on documented positive response to the present series of injections for at least 6 months, and it is therefore not medically necessary at this time.Final Result: The reviewer determined that a portion of the requested services is 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Rezum procedure. Findings:  Two of the three physician reviewers found that as there is increasing evidence of benign prostatic hyperplasia obstructed outflow and increasing post-void residual, it is appropriate to address this trend that is not improving on medical therapy. There is sufficient support for the minimally invasive Rezum procedure in this clinical setting. Three-year data show non-inferiority to transurethral resection of the prostate, with less risk of worsening impotence, retrograde ejaculation, and incontinence. Therefore, the requested Rezum procedure is likely to be superior over other treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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 FoundationOne Heme test. FoundationOne is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the FoundationOne assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment. A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the FoundationOne Heme test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the service 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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.