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

Findings:  The physician reviewer found that An enrollee has requested reimbursement for DecisionDx-Melanoma test. In reviewing the NCCN guidelines, the recommended therapy for patients with stage I cutaneous melanoma includes review of history, physical examination, and imaging to evaluate certain signs and symptoms. The NCCN indicates that category 1A treatment includes wide excision of the melanoma and consideration of sentinel lymph node biopsy. Furthermore, the NCCN guidelines state that for stage IB melanoma, the probability of a positive sentinel lymph node is greater than 10%. The NCCN guidelines do not endorse use of a gene expression assay to determine the course of treatment for patients with stage I melanoma. Marchetti and colleagues concluded that the prognostic ability of gene expression profiling tests among patients with localized melanoma have been found to be poor at correctly identifying recurrence in patients with stage I disease, suggesting limited potential for clinical utility in these patients. Given these findings, the DecisionDx-Melanoma test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the services at issue were 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that Two out of three physician reviewers found that available treatment options for alopecia areata are limited, especially for patients with diffuse or multifocal involvement. Often, standard therapies such as topical steroids, intralesional Kenalog, contact immunotherapy and conventional immunosuppressants are ineffective and associated with side effects. There is substantial clinical evidence to support the use of oral JAK inhibitors such as tofacitinib for alopecia areata. Jabbari and colleagues found that eight out of 12 patients in their tofacitinib trial demonstrated  50% hair regrowth, as measured by Severity of Alopecia Tool (SALT) scoring. A retrospective study by Liu and colleagues considered patients with alopecia areata and at least 40% scalp hair loss who were treated with Xeljanz. This study found that 77% of patients achieved a clinical response and that 58% of patients experienced greater than 50% change in SALT score over 4 to 18 months of treatment. King and colleagues conducted two randomized, placebo-controlled, phase 3 trials and concluded that baricitinib, an oral JAK inhibitor, was more effective than treatment with placebo with respect to hair regrowth at 36 weeks. Moreover, these results are superior to reports with contact immunotherapy and systemic steroids. Therefore, the requested medication Xeljanz (tofacitinib) 5mg tablets taken twice daily (quantity 60/month) is likely to be more beneficial than any other available standard therapy for the patient's condition.Final Result: The reviewers determined that the requested medication is likely to be more beneficial than any other available standard therapy for the patient's condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for general anesthesia. Marinho and colleagues report that comprehensive dental care under general anesthesia composes an integral part of special care dentistry and may be safely provided in a hospital setting, in both private and public sectors. The authors further note that general anesthesia is considered as an alternative option to facilitate treatment for uncooperative patients who require invasive dental interventions, with multiple dental extractions and restorations being the most frequently performed procedures. Ciftci and Yazicioglu report that medical and mental conditions affect dental treatment modalities. In this clinical setting, treatment of the patient in a surgical facility under general anesthesia is medically indicated. Therefore, general anesthesia is medically necessary for the treatment of 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nerve block injection of knee. Findings:  The physician reviewer found that the patient has chronic right knee pain with previous total joint replacement complicated by infection. The patient has been treated with physical therapy, medication management, and steroid injections with limited benefit. The patients provider has recommended a nerve block injection in the right knee. However, there is a paucity of evidence supporting genicular nerve blocks and subsequent radiofrequency ablation as equivalent or superior to standard of care treatment options. A review by Billesberger and colleagues evaluated genicular nerve radiofrequency ablation and reported that, Despite this therapy being available for decades, there is limited evidence in the literature describing its benefit. Similarly, Cheppalli and colleagues commented that, In our review, we noted that there is a lack of high-quality studies on this topic. The authors concluded that, The available studies are not well structured and do not provide the best evidence. Based on the records for review and medical literature, the requested nerve block injection of knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz 5 mg tablet (60 tablets every 30 days). The records provided for review document that this patient presents with chronic and progressively worsening alopecia areata. Per the provider, the patient is no longer a candidate for treatment with intralesional and topical steroids, which is causing atrophy. The provider has recommended treatment with Xeljanz. As noted in the medical literature, Xeljanz belongs to a class of Janus kinase (JAK) inhibitors that have been demonstrated to be safe and effective in the treatment of patients with moderate-to-severe alopecia (Liu, et al.). In a small study of 90 patients, clinical response was achieved by 77% of patients, with 58% of patients achieving intermediate or complete response over four to 18 months of treatment (King, et al.). The authors concluded that long-term use of Xeljanz was effective and well tolerated for the treatment of patients with severe alopecia areata. Given this support, treatment with Xeljanz is indicated for treatment of this patients severe alopecia areata that has not responded to multiple treatments. Accordingly, the requested Xeljanz 5 mg tablet (60 tablets every 30 days) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that Based on the available records, the EGD with biopsies performed for evaluation of this patient was not medically necessary. Current clinical guidelines recommend EGD for the assessment of patients with upper gastrointestinal symptoms, such as dyspepsia or GERD, when the symptoms are refractory to proton pump inhibitor taken properly for four to eight weeks without adequate response (Katz, et al.). The American Society for Gastrointestinal Endoscopy (ASGE) guidelines state that endoscopy is appropriate when an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful (Early, et al.). The American College of Gastroenterology (ACG) guidelines do not recommend EGD for evaluation of features for dyspepsia patients under the age of 60 to exclude upper gastrointestinal neoplasia. Moreover, the ACG stated that, We recommend dyspepsia patients under the age of 60 should have a non-invasive test for H. pylori, and therapy for H. pylori infection if positive (Moayyedi, et al.). In this case, the records do not include documentation that the patients symptoms were refractory to continuous proton pump inhibitor for at least four weeks. Therefore, the EGD was not medically necessary for evaluation of this patient. With regard to the use of MAC services, the patient has morbid obesity, based on BMI over 35 kg/m2 (Apovian, et al.; Jensen, et al.). Per the most recent ASGE guideline for sedation and anesthesia in endoscopy, elevated BMI is an independent risk factor for hypoxemia during endoscopic procedures (Early, et al.). Based on current medical literature, this patient was at increased risk for sedation-related complications. Thus, the MAC services were medically necessary for this patient. Given these findings, the EGD was not medically necessary for evaluation of this patient while the MAC services were medically necessary for this patient. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for acute inpatient rehabilitation. The records document that this patient was hospitalized with sepsis. The patient presented with an infected surgical wound at the right hip and proximal femur surgical site, as well as pneumonia. The patient underwent definitive surgical intervention, and was started on antibiotics, consistent with the current recommendations in the medical literature and guidelines (Prescott and Angus). The patient briefly required pressor therapy early in the postoperative period, but has been medically stable since that time. Functionally, the patient improved to require standby assistance for transfers and short distance ambulation with a walker. The patient continues to require some additional basic rehabilitation for reconditioning. However, there is a lack of documentation of any complex or intense rehabilitation needs. The patient can receive rehabilitation therapy services in a less intensive treatment setting than acute inpatient rehabilitation. Moreover, the patient does not have any reported ongoing intensive medical or skilled nursing needs that require treatment at the acute inpatient rehabilitation level of care (Mayer, et al.). Given these findings, the requested acute inpatient rehabilitation is not medically necessary for treatment of 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that  The patient has requested authorization and coverage for Ruxience (rituximab-pvvr) infusions (700 mg infused weekly for 4 doses). Gilhus and Verschuuren describe myasthenia gravis as an autoimmune disease that is B-cell mediated, and is associated with antibodies directed against the acetylcholine receptor, muscle-specific kinase (MUSK), lipoprotein-related protein 4 (LRP4), or agrin in the postsynaptic membrane at the neuromuscular junction. Standard pharmacotherapy including acetylcholine esterase inhibitors, corticosteroids, and nonsteroidal immunosuppressive agents, including azathioprine, mycophenolate mofetil, methotrexate, cyclosporine, and tacrolimus, and are usually effective in the treatment of myasthenia gravis. Treatment options are limited for refractory myasthenia gravis, and may include chronic intravenous immunoglobulin (IVIG) or plasma exchange, high-dose cyclophosphamide, rituximab, and eculizumab. As major effector cells in autoimmunity, targeted therapy of B-cells has emerged as a promising approach to treat autoimmune diseases. Rituximab is a monoclonal antibody against the B-cell membrane marker CD20. Choi and colleagues report that repeated low-dose rituximab treatment based on the assessment of circulating B-cell depletion could be a cost-effective therapeutic option for refractory myasthenia gravis. Regarding chronic immunotherapy for myasthenia gravis, Bird notes that rituximab may be used for the treatment of refractory myasthenia gravis. Narayanaswami and colleagues report that rituximab may be an option for patients with refractory myasthenia gravis that fail or do not tolerate other immunosuppressive agents. The optimal dose and dosing interval of rituximab for myasthenia gravis has not been established. A common initial dose is 375 mg/m2 weekly for four doses. Whether and when to repeat rituximab dosing in patients who respond to the initial course is generally guided by clinical symptoms and lymphocyte recovery. Ruetsch-Chelli and colleagues report that the percentage of memory B-cells in whole blood cells can accurately predict clinical relapse in myasthenia gravis patients treated with rituximab. In this case, the patient has autoimmune myasthenia gravis that has been refractory to standard therapy. The provider recommends treatment with rituximab based on increasing B-cell counts and for prevention of clinical relapse of the patients myasthenia gravis. Given that current medical literature supports the potential efficacy of rituximab in patients with refractory myasthenia gravis and that repeat treatment can be guided by circulating B-cells, the requested service is medically indicated. Therefore, Ruxience (rituximab-pvvr) infusions (700 mg infused weekly for 4 doses) 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.
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 Intracept procedure. Current medical literature supports the use of the requested procedure in leading to statistically significant improvement over continuation of standard treatment. Fischgrund and colleagues report that patients treated with radiofrequency ablation of the basivertebral nerve for the treatment of chronic back pain maintained benefits at two years following treatment in both Oswestry Disability Index (ODI) and Visual Analog Scale (VAS). The primary finding correlating to success of the requested procedure is the presence of MRI changes showing edema in the vertebral bodies. In this case, an MRI demonstrated such findings. Therefore, the Intracept procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Intracept procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service 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 orthopedic surgery 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

Findings:  The physician reviewer found that An enrollee has requested reimbursement for three-dimensional (3D) fetal ultrasound. The provider noted that this patient has a history of incompetent cervix and delivery by Cesarean section x 2. The provider noted that the patient underwent evaluation with an abdominal and transvaginal obstetrical ultrasound for evaluation of cervical length. The ultrasound also revealed 3D imaging of the fetal face. As noted by the American Institute of Ultrasound in Medicine (AIUM), limited fetal ultrasound in the second trimester does not require assessment of the fetal face in 3D. This patient underwent ultrasound with 3D imaging of the facial features of the fetus. Although the ultrasound was appropriate to evaluate the patients cervical length, the 3D rendering of the facial features of the fetus is not supported by the guidelines or medical literature. Accordingly, the 3D fetal ultrasound was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the services at issue were 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for SelectMDx genomic testing provided by MDx Health, Inc. The records provided for review document that this patient has a history of elevated prostate specific antigen (PSA) and enlarged prostate. The patient underwent testing with SelectMDx genomic analysis, which demonstrated 38% likelihood of prostate cancer on biopsy, and a 13% likelihood of detecting Gleason score 7 or greater cancer. As noted in the peer-reviewed medical literature, prostate biopsy is an invasive procedure with limited risk for infection, prolonged discomfort, or urinary issues. While reducing unnecessary biopsies drives the use of genomic testing after PSA and Free PSA offer questionable guidance, there is a paucity of support for use of the SelectMDx genomic testing for further evaluation of this patients elevated PSA and enlarged prostate. Although data are emerging which support further study of genomic testing, its use is not likely to yield superior health outcomes in this patients clinical setting based on current studies when compared to the current standard of care including biopsy. All told, the SelectMDx genomic testing provided by MDx Health, Inc. was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the services at issue were 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 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 urology and is actively practicing. Physician reviewer 2 is board certified in urology and is actively practicing. Physician reviewer 3 is board certified in urology with subspecialty certification in in urological surgery 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Omnipod 5 G6 (Gen 5) system and pods. In this case, the patient has type 1 diabetes mellitus. A CGM log shows that, although reasonable overall, the patients recent glycemic control is not optimal based on the recent patterns indicating blood glucose 7% of the time in the very high category above the target range and 24% of time in the high category above the target range. In addition, there were wide fluctuations in blood glucose levels during the monitoring period. In this clinical setting, given that current medical literature supports the use of the requested equipment in improving both glycemic control for pediatric patients and the quality of life for them and their families, the requested equipment is medically indicated. Therefore, an Omnipod 5 G6 (Gen 5) system and pods are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 sub-specialty certification 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.