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 Botox injection. There is sufficient support for the services at issue in this clinical setting. This patient has spasmodic torticollis and cervical dystonia. She has had pain which has persisted for more than six months. Cervical dystonia is a U.S. Food and Drug Administration (FDA) approved indication for Botox injections. Randomized controlled trials have supported its use in cervical dystonia. Therefore, Botox injection was likely to have been of greater benefit than other treatment options. Findings:  Two of the three physician reviewers found 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.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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: A  enrollee has requested authorization and coverage for traditional acupuncture with electrostimulation. Review of the submitted documentation supports the medical necessity of the requested services. The provider has recommended traditional acupuncture with electrostimulation for treatment of the patients laryngeal spasm and dysphonia. Based upon the documentation provided, this appears to be an initial trial of acupuncture for this patient. Review of the relevant peer-reviewed evidence reveals patients who received acupuncture reported improvements in voice production` in this setting. The patients provider noted that Botox injections would be challenging in this patients case. Studies show that the requested therapy is `comparable to the results achieved with botulinum toxin injection. Consequently, as the patient is significantly symptomatic, a trial of acupuncture with electrostimulation is clinically appropriate and medically necessary.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 oriental 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 10-year-old female enrollee has requested reimbursement for chiropractic services received 9/04/17 through 9/22/17. Upon review of the submitted documentation and relevant literature, the medical necessity of the services at issue is not established. The patient has juvenile idiopathic scoliosis. At present, there is insufficient evidence that the efficacy of non-specific manual therapy in the treatment of patients with idiopathic scoliosis can be reliably evaluated. According to a study, it has not been established that chiropractic care provides benefit in terms of slowing progression of curvature of the spine. All told, the services rendered are not consistent with the standard of care for patients with juvenile idiopathic scoliosis. Thus, the chiropractic services received on 9/04/17 through 9/22/17 were not medically necessary for the treatment of this patient.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 chiropractic medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for dual agent chemotherapy with paclitaxel and bevacizumab. The submitted documentation fails to demonstrate the medical necessity of the requested medication regimen. The combination of paclitaxel and bevacizumab is not considered standard of care in the treatment of recurrent or progressive endometrial cancer. In addition, this patient has progressed on a dual regimen containing paclitaxel. Single agent bevacizumab is considered a standard of care in the treatment of patients with progression on other cytotoxic agents. The medical evidence does not support the combination of paclitaxel and bevacizumab in this setting. Therefore, dual agent chemotherapy with paclitaxel and bevacizumab is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 genetic testing (except the approved BRAF (CPT 81210) and EGFR (CPT 81235)) performed on 7/13/17, and the Guardant360 genetic testing (except the approved BRAF (CPT 81210) and EGFR (CPT 81235)). The National Comprehensive Cancer Network (NCCN) guidelines strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care in this clinical setting. 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. For these reasons, the Guardant360 genetic testing (except the approved BRAF (CPT 81210) and EGFR (CPT 81235)), and the Guardant360 genetic testing (except the approved BRAF (CPT 81210) and EGFR (CPT 81235)) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the Guardant360 genetic testing (except the approved BRAF (CPT 81210) and EGFR (CPT 81235)), and the Guardant360 genetic testing (except the approved BRAF (CPT 81210) and EGFR (CPT 81235)) 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 testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin 20 mg injector for the enrollee's short stature. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication. The patients height is not less than the third percentile for age and gender, his bone age is not delayed, and his IGF-1 level is normal. He does not have known morphological abnormalities of the pituitary gland. Prior to initiation of growth hormone therapy, the patients adult height prediction was not less than 63 inches. Thus, he does not meet the U.S. Food and Drug Administration (FDA) criteria for a trial of growth hormone therapy for idiopathic short stature. The recent slowing of growth is likely to be multifactorial, and poor appetite and stimulant medication may have been contributing to the slowing of growth after discontinuation of growth hormone therapy. Furthermore, children with 22q11 deletion are known to have growth restriction, but growth hormone deficiency is not typical, and short stature associated with 22q11 deletion syndrome is not an approved indication for growth hormone treatment. Therefore, Nutropin AQ NuSpin 20 mg injector is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 63-year-old female enrollee has requested reimbursement for the FoundationOne blood test for evaluation of the enrollees chronic lymphocytic leukemia.  Findings:  The physician reviewer found that Per the National Comprehensive Cancer Network (NCCN) guidelines, patients with CLL with suspected relapse or progressive disease should undergo valuation with Tp53 and FISH chromosomes. Thus, the Tp53 and FISH chromosome portions of the FoundationOne blood testing performed were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the FoundationOne blood test was 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 a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the blood test (Guardant360 biopsy-free tumor sequencing test). The therapy of advanced non-small cell lung cancer has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in adenocarcinomas. Even in patients with stage IV disease, therapy targeted to EGFR with erlotinib can result in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of non-small cell lung cancer has significantly expanded in the past few years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. Generally, KRAS, TP53, and BRAF are included in these panels and are informative.The Guardant360 test analyzes oncogenes and tumor suppressor genes for mutations by next generation sequencing. The results can assist providers in selecting treatment towards these mutations. Von Hoff and colleagues reported on a study of 86 patients where the progression free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors found that the regimen selected by molecular profiling offered a 27% survival advantage. Given this support, the blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the blood test (Guardant360 biopsy-free tumor sequencing test) was 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 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 Mavyret 100 mg-40 mg, three tablets daily for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus, genotype 2a/2c. The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive, genotype 2 patients. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100 mg-40 mg, three tablets daily for eight weeks is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 33-year-old female enrollee has requested reimbursement and prospective authorization and coverage for chiropractic services (manipulation of the spine) for their back pain.  Findings:  The physician reviewer found that guidelines for chiropractic manipulative treatments noted requirement of x-rays for documentation of subluxations. While CMS guidelines do not specify the number of treatment visits recommended, ongoing evaluation and functional improvements must be documented, and any treatments that becomes supportive after no further clinical improvement are expected are considered maintenance therapy. In this case, the patient had subluxation on cervical x-rays and chiropractic treatment provided documented functional improvement. The International Chiropractors Association guidelines suggest up to 60 treatment visits over 20 weeks for axial pain with complicating factors. Thus, chiropractic treatments twice per week for eight weeks and then once a week for the next 12 weeks is within the guidelines recommendations. Thus, chiropractic services (manipulation of the spine) are medically necessary at a frequency of twice per week for eight weeks, then once per week for an additional 12 weeks. Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is a board certified chiropractor 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 Epclusa for 12 weeks. According to 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 life expectancy less than 12 months due to nonliver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin (Feld, et al; Foster, et al). However, the FDA-approved prescribing information for Epclusa states Test all patients for evidence of current or prior hepatitis B infection before initiation of hepatitis C treatment in a black box warning; in this case, the hepatitis B surface antigen has not been tested, and the negative e-antigen and negative surface antibody do not entirely exclude a hepatitis B chronic carrier state. For these reasons, Epclusa is not supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication regimen 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 68-year-old female enrollee has requested reimbursement for the Guardant360 genetic test. The therapy of advanced non-small cell lung cancer has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in adenocarcinomas (Case Study). The mutational landscape of non-small cell lung cancer has significantly expanded in the past few years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences (Case Study). Generally, KRAS, TP53, and BRAF are included in these panels and are informative (Case Study). The Guardant360 test analyzes oncogenes and tumor suppressor genes for mutations by next generation sequencing. The results can assist providers in selecting treatment towards these mutations. Von Hoff and colleagues reported on a study of 86 patients where the progression free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors found that the regimen selected by molecular profiling offered a 27% survival advantage. Given this support, the Guardant360 test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that 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 the three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  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.