Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 12 rental units of high frequency chest wall oscillation (HFCWO) system, E0483 for treatment of the enrollees chronic obstructive pulmonary disease. Findings:  The physician reviewer found that The documentation provided does not support the medical necessity for the requested equipment in this clinical setting. The medical literature suggests the following criteria as indications for the use of HFCWO: documented need for airway clearance, a diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disorder with inability to clear secretions, or inability to use other airway clearance devices such as inspiratory valves, manual chest percussion, or postural therapy. The records provided do not indicate that this patient meets the criteria as noted in the medical literature. While this patient may have severe COPD with frequent exacerbations requiring hospitalization, the etiology of these exacerbations are unclear, with some reports related to airway clearance and in other instances related to noncompliance. There is no documentation provided that indicates the patient has bronchiectasis, evidence of recurrent infections or current use of airway clearance devices. Moreover, there is minimal evidence in the literature that indicate the use of HFCWO benefit patients with COPD exacerbations. Therefore, 12 rental units of HFCWO system-E0483 is not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin 2.0 mg for treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting. This patients growth velocity was poor, IGF-1 level was low, and her adult height prediction was more than two standard deviations below her mid-parental target height. Although she did not undergo provocative growth hormone testing, she meets generally accepted criteria for growth hormone treatment. According to the Pediatric Endocrinology Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; growth velocity less than the 25th percentile for bone age; bone age more than two standard deviations below the mean for age; low serum IGF-1 and/or IGFBP-3; and/or other clinical features suggestive of growth hormone deficiency. This patient meets most of the above criteria, and her adult predicted height of 59 inches is short enough to warrant a trial of growth hormone therapy based on current U.S. Food and Drug Administration standards for treatment of idiopathic short stature. All told, Nutropin AQ NuSpin 2.0 mg is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for one additional speech therapy session per week (total of two sessions per week) for treatment of the enrollees delayed receptive/expressive language secondary to autism spectrum disorder. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested additional speech therapy session. Children with autism benefit with improved receptive language skills with the use of an AAC device. The medical literature shows that the use of AAC device can improve verbal output in children with autism. The study by colleagues looked at the challenges with assessing language in children with severe speech problems. The authors reported that testing using an AAC device may more accurately provide information on cognitive and receptive language skill. In this case, given the patients current language ability he is expected to benefit from the AAC device. Moreover, the use of an AAC requires consistency and experience. Thus, two speech therapy sessions per week is clinically indicated for this patient to work on his use of the AAC device. For the reasons stated, one additional speech therapy session per week (total of two sessions per week) is medically necessary for treatment of the patients medical condition. 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 sub-specialty certification in developmental and behavioral pediatrics 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 hyaluronan (Orthovisc) injections in the left knee for treatment of the enrollees grade 4 patellofemoral arthritis. Findings:  The physician reviewer found that Review of the current medical literature indicates continuing support for viscosupplementation of the knees for osteoarthritis. In particular, patients who have benefited from prior injections are likely to respond in a similar positive fashion to the repeat series of injections. Bowman and colleagues reported findings that support viscosupplementation for pain relief as well as improving function in osteoarthritis of the knees with the objective being to delay the total knee arthroplasty. In light of the foregoing, the requested hyaluronan (Orthovisc) injections in the left knee are supported as medically necessary for treatment of this patients left knee osteoarthritis and anterior cruciate ligament disruption. Final Result: The reviewer determined that the requested service 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 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 reimbursement for positron emission tomography scan of the brain for evaluation of the enrollee who presented for progressive memory loss. Findings:  The physician reviewer found that According to the American Academy of Neurology, they recommend structural neuroimaging with either a non-contrast head computed tomography or MRI in the routine initial evaluation of all patients with memory loss and possible dementia. However, it does not recommend any further imaging beyond that. This patient received an MRI in the work up of her complaints as well as an EEG, and these were considered to be normal by the provider. The use of PET scan is typically utilized to help in differentiating neurodegenerative dementia and not part of the recommended work up. There is no documented evidence of existing dementia in the provided records. This patients history, physical examination, and work up to date did not provide an indication for PET scan. As such, PET scan of the brain (CPT 78608) was not medically necessary for the evaluation of this 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 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: The patients parent has requested authorization and coverage for Nutropin AQ NuSpin 10 mg pen injector for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that This patient is underweight for height and has mild constitutional delay. However, the records do not support a diagnosis of growth hormone (GH) deficiency as an explanation of his relative short stature. His height is not more than two standard deviations below the mean for age and gender, his peak GH response on provocative GH testing was normal, and he has no known morphological abnormalities of his pituitary gland. Although his predicted adult height is more than two standard deviations below his mid-parental target height, it falls within the range of normal for U.S. adult males. Thus, GH therapy with the requested Nutropin AQ NuSpin 10 mg pen injector is not medically necessary for 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for peripheral bone density testing for possible osteoporosis.  Findings:  The physician reviewer found that There is a lack of support for the superior efficacy of the services at issue in this clinical setting. While the heel bone density screening test may be good at predicting fracture risk and is a reasonable test when trying to assess the patients risk factors for low bone mineral density (BMD), this test is not likely to be more beneficial than the available standard methods of assessing BMD risk. The medical literature show evidence that dual-energy x-ray absorptiometry (DXA, DEXA) scan of the hip yields better results when assessing for future risk fracture. As such, the peripheral bone density testing was not likely to have been more efficacious when compared to other standard modalities of evaluating this patients medical condition. Final Result: All three 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 number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 endocrinology, diabetes and metabolism 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 endocrinology, diabetes and metabolism 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 of Zepatier 50-100 mg tablets for 12 weeks for treatment of the enrollees hepatitis C virus. 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50-100 mg tablets 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. 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: The patient has requested authorization and coverage for methadone. Findings:  The physician reviewer found that while methadone has been used as second-line therapy for moderate to severe chronic pain, the documentation does not support the medical necessity for this medication. Methadone has the potential for adverse effects including respiratory depression and adverse cardiac events. Per the Centers for Disease Control and Prevention (CDC) opioid prescribing guidelines, providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. Additionally, providers should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. Furthermore, the CDC recommends that if benefits do not outweigh harms of continued opioid therapy, providers should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. There is no evidence of electrocardiogram (EKG) monitoring in this patient during her course of methadone treatment, evidence of significant objective and measurable functional improvement on methadone, or significant objective measurement of pain relief on methadone at the 30 mg daily dose. The documentation does not reveal that a pain management physician has been prescribing the patients methadone or the results of a first-line trial with Desipramine. Thus, the requested methadone is not supported as medically necessary for treatment of this 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 patient has requested authorization and coverage for Accucheck Aviva Test Strips for treatment of the enrollees type 2 diabetes mellitus with other diabetic neurological complication. Findings:  The physician reviewer found that according to the American Diabetes Association a patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include efficacy, hypoglycemia risk, history of atherosclerotic cardiovascular disease, impact on weight, potential side effects, renal effects, delivery method (oral versus subcutaneous), cost, and patient preferences. This patient reportedly has had difficulty using and maintaining the covered Fora meter. Thus, the patient should be provided with a meter with which she is comfortable using properly. Improper use will only cause more clinical and economic problems due to inaccurate readings. There are brands that are considered equally reliable and accurate, and the peer-reviewed literature does not demonstrate that the Accucheck Aviva brand is medically necessary. All told, the medical literature does not support the requested Accucheck Aviva Test Strips as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 endocrinology, diabetes and metabolism 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 genetic testing to assess cancer risk for evaluation of the enrollees risk for cancer. Findings:  The physician reviewer found that The documentation provided does not support the medical necessity of the requested services in this clinical setting. The patients mother was diagnosed with breast cancer and she reported that other family members were also diagnosed with cancer. The patients mother was the appropriate person to test for hereditary predisposition. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers. The results of the mothers genetic testing were negative for many of the known syndromic disorders. As such, there is a lack of indication to test this patient. Therefore, the genetic testing to evaluate this patients risk of cancer is not medically necessary. 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 internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Guardant360 test for evaluation of the enrollees lung adenocarcinoma. Findings:  The physician reviewer found that In the peer-reviewed medical literature, Guardant360 testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as Guardant360 test, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is insufficient to support the use of Guardant360 test in lieu of standard testing. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the Guardant360 test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of 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 reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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.