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

Nature of Statutory Criteria/Case Summary: The enrollee is has requested reimbursement for genetic testing that was performed. The Health Plan has denied this request, indicating that the service at issue was investigational for the evaluation of the enrollees melanoma.Findings:  Two out of three physician reviewers found that the genetic testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The standard protocol based on National Comprehensive Cancer Network (NCCN) guidelines for an intermediate thickness tumor does not include a work-up with molecular genetic testing. Currently, the protocol is for a wide local excision and a sentinel node biopsy and the decision to pursue medical treatment is based on the results of these tests. Studies showed metastasis free survival was 31% and the overall survival was 49% at 5 years in 64 patients who had sentinel lymph node biopsy (SLNB) negative results but class 2 gene expression profile (GEP) test results. Cox multivariate analysis comparing the GEP test to SLNB showed the GEP test to be the only independent and highly significant prognostic factor (Swetter, et al). This patient had a negative SLNB and intermediate thickness tumor. It was medically reasonable to add the results of the DecisionDx testing to help guide treatment.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: There is limited high-grade literature regarding the efficacy of various conservative management options in the setting of knee pain attributed to chondromalacia patellae and patellofemoral pain syndrome. There is some low-grade evidence that exercise is better than no exercise for the pain related to these conditions. However, there is a lack of data that there is demonstrable functional improvement with exercise. There is also no clear indication what types of exercise may be most appropriate, although strengthening of the hips and quadriceps is generally recommended. Given this patients prior treatment and progress, these exercises do not require additional formal physical therapy services. The patient underwent sufficient therapy to have been transitioned to an independent exercise program. Moreover, she does not have impairments that would preclude performance of an appropriate independent exercise program. While she has continued to have symptoms and poor tolerance to independent exercise, formal therapy is not expected to improve her clinical course or outcomes. Thus, the requested physical therapy is not medically necessary for treatment of this patients knee pain. 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 physical medicine and rehabilitation 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: Dental anesthesia may be indicated for patients with documentation of a failed attempt at local anesthesia and light sedation, when treatment is not feasible based on the medical needs of the patient, or if the patient requires extensive treatment that cannot be rendered under local anesthesia. While dental anesthesia has been shown to be safe and effective, the current standard is to use the lowest level of anesthesia necessary to provide dental care. The records provided from the patients dentist do not document a dental examination, provide a diagnosis, or report a reason for treatment. The patients mother states the patient would be unable to cooperate with treatment without anesthesia. However, multiple visits with the primary care provider describe the patient as cooperative. In the absence of documentation of a failed attempt at treatment with a lower form of anesthesia or conscious sedation, and no report from the treating dentist demonstrating an examination was performed and the patient was unable to cooperate for treatment, the requested dental anesthesia is not supported as 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 dentistry 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 American Society of Interventional Pain Physicians (ASIPP) guidelines on opioids for chronic non-cancer pain recommend methadone only for use after failure of other opioid therapy and only by clinicians with specific training in its risks and uses, within FDA recommended doses. In addition, researchers performed a review of the evidence supporting methadone for chronic non-cancer pain in adults. The researchers concluded that there is limited evidence of the efficacy of methadone for chronic non-cancer pain and no conclusions can be made regarding differences in efficacy or safety between methadone and placebo, other opioids, or other treatments. In this case, the patient has been treated with hydrocodone and oxycodone for breakthrough pain. However, there is no documentation that he has tried and failed other long acting pain medications as recommended by the ASIPP guidelines. Based on these findings, the requested methadone 10 mg is not medically necessary for management of this patients chronic pain.Final Result: The reviewer determined that the requested methadone 10 mg is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 chronic migraines. The patient has previously tried and failed topiramate, beta-blocker, Botox, and nortriptyline. Her current medications include Amerge, butalbital, and Microgestin FE. The patient discontinued taking butalbital due to a concern for possible medication overuse headache. The patient has completed a migraine disability assessment (MIDAS) and a headache diary, which documents she has 14-15 headache days a month. Her provider recommended erenumab (Aimovig). The Health Plan has denied the request for Aimovig, indicating the patient has medication overuse headache, and that the requested medication is only for use with migraines. In the analysis of patients in the clinical trials of Aimovig, data shows that there is statistically significant efficacy in patients with acute medication overuse headache. Additional studies on calcitonin gene-related peptide (CGRP) monoclonal antibodies included patients with medication overuse headache in the trials for Aimovig. The authors found that the efficacy was as good as, or better than, in patients who did not have medication overuse headache. This patient has high-frequency episodic migraine/chronic migraine. She has been treated with more than four preventive agents, including beta-blockers, Topamax, and Effexor, which were not successful. The records indicate the patient has been tried and failed on Botox. A CGRP monoclonal antibody, such as Aimovig is appropriate for this patient given her frequent migraines, which have persisted despite treatment with multiple preventative medications. Therefore, the request for Aimovig is medically necessary for treatment of this patients chronic migraines. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee is a male who has requested authorization and coverage for a WalkAide System, Bioness L300. The Health Plan has denied the requested device as investigational for treatment of the enrollees foot drop.Findings:  Three physician reviewers found that Current data suggest that ankle foot orthoses (AFO) have equally positive combined-orthotic effects as functional electrical stimulation on key walking measures for foot-drop caused by stroke. There is a paucity of peer-reviewed medical literature showing that a functional electrical stimulation device such as the WalkAide System, Bioness L300 is more beneficial for hemiparesis with foot drop than a conventional device such as a standard AFO. In this case, the gait dysfunction and safety concerns are secondary to foot drop, which is equally addressed with the AFO and the WalkAide System, Bioness L300. Therefore, the WalkAide System, Bioness L300 is 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 device is 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage of speech therapy services. In the medical literature, it is recommend that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism. The authors noted that further development of therapy plans and interventions targeting pragmatics is strongly needed. Researchers estimated that 44% of children with autism are bullied at school. The authors reported that this is frequently due to patients difficulty interacting appropriately with others. Researchers discussed methods of exploring deficits in pragmatic language in children with autism using the Pragma test, the Social Interaction Deviance Composite of Childrens Communication Checklist-2, and the Theory of Mind subtest of the Developmental Neuropsychological Assessment, Second Edition. The results showed that children with autism differed from typically developing children in questions demanding context utilization. This patient has autism and mild-to-moderate sensorineural hearing impairment. He has deficits in articulation and in the appropriate social use of pragmatic language. With significant impairment in his pragmatic language and articulation, he will have difficulty interacting with his peers and navigating his was through activities of daily living. Given the support in current literature, the requested speech therapy services twice weekly are medically necessary for treatment of the patients medical condition.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 neurology with special qualification in child neurology and in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cryosurgical ablation of a kidney tumor.Findings:  Two out of three physician reviewers found that standard partial nephrectomy of the tumor with preservation of normal renal parenchyma is the preferred management strategy for solid renal mass suspicious for malignancy in patients who are candidates for definitive treatment per American Urological Association (AUA) recommendations. Partial nephrectomy is associated with favorable oncologic outcomes and minimizes the risk of chronic kidney disease or progressive chronic kidney disease. Thermal ablation (cryotherapy or radiofrequency ablation) is an alternative to partial nephrectomy for patients who are poor surgical candidates for definitive surgery. In this case, the patient had normal kidney function prior to surgery and no documentation of active illness or being a poor candidate for standard surgical therapy. Therefore, the cryosurgical renal ablation that was performed was not likely to have been more beneficial for treatment of the patients medical condition than any available standard treatment. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in nephrology 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: A 48-year-old female enrollee has requested reimbursement for the laboratory test to monitor infliximab serum levels and test for anti-infliximab antibodies. Findings:  Two physician reviewers found that the laboratory test to monitor infliximab serum levels and test for anti-infliximab antibodies was not likely to have been more beneficial than other available standards of treatment for the patients medical condition. Monitoring patients on infliximab with measurement of infliximab levels and antibodies to infliximab continues to be an area of intense investigation. In general, infliximab levels correlate inversely with disease activity. However, there are no controlled data which have identified the optimal drug level and the issue remains speculative. The algorithmic approach has not been validated prospectively and there appears to be no impact on clinical efficacy compared to empiric dose titration. AGA guidelines indicate that there is a very low quality of evidence to support reactive drug level monitoring. In this case, the patient was diagnosed with small bowel Crohns disease and managed on thiopurine and infliximab. Budesonide was added to the patients medication regimen to maintain disease control. The patient underwent testing for infliximab levels and antibodies to infliximab to determine if her disease was under adequate control. This reactive drug level monitoring, however, has low quality of evidence to support its use, as indicated in AGA guidelines. Therefore, the laboratory test to monitor infliximab serum levels and test for anti-infliximab antibodies provided was not likely to have been more beneficial than other available standards of treatment for the patients medical condition. Final Result: Two of the three physician reviewers found that he requested the laboratory test to monitor infliximab serum levels and test for anti-infliximab antibodies providedas not likely to have been more beneficial than other available standards of treatment for the patients medical condition.  Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with a subspecialty certification in gastroenterology, and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of naproxen and esomeprazole magnesium (Vimovo) DR. Findings: The physician reviewer found that the submitted documentation does not support that the requested medication is medically necessary. The American College of Physicians Best Practice Advice for Clinical Guidelines recommends prescribing generic medications. The long-term use of proton pump inhibitors has the potential for serious side effects. Current research indicates that chronic acid suppression can potentially lead to an increased occurrence of bone fractures. Medical literature does not demonstrate that the addition of esomeprazole in combination with naproxen, in the same pill, increases the effectiveness of naproxen. There is no documentation that the patient has gastrointestinal issues that would require the use of a proton pump inhibitor. Therefore, the requested Vimovo DR medication is not 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 anesthesiology with subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is requesting authorization and coverage of past and future psychotherapy sessions provided once per week. At issue in this case is whether individual psychotherapy sessions provided once per week were and/or are medically necessary for the treatment of the patients medical condition. Findings:  The physician reviewer found that the patient is being treated for generalized anxiety disorder and attention deficit/hyperactivity disorder. The records document that the patient had made adequate progress with treatment. She has no urges to harm herself or others. She did not have any difficulties with psychosis or unstable medical issues. The patient was able to perform activities of daily living. The record noted that her therapy goals were a psychodynamic approach to look at factors involved in the family dynamic. Additional issues in therapy have included identification of sources of strength and support, continuing to manage high levels of anxiety surrounding family relationships, and improving her sense of security in regards to family relationships. There is no documentation of the patient showing symptoms or issues related to a mental health condition which would require once weekly therapy level of care. Based on the record, this patient has been doing well and has not demonstrated any acute symptoms. There is no plan of titration or termination of therapy, and no specific measurable goals have been stated. Decreasing the frequency of therapy sessions is reasonable based on the patients symptomatology. Although, there are no national criteria for psychotherapy frequency, this patients psychological state is stable, and psychotherapy can be titrated down with development of a plan for termination. Therefore, individual psychotherapy sessions, both past and future, provided once per week were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry 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.