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

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Mavyret . The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus.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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. trial showed a 95% cure rate with eight weeks of treatment guidelines showing reduced survival with delayed treatment For these reasons, the requested treatment with Mavyret is supported as medically necessary for the treatment of the 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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-UM for their condition of choroidal melanoma. Findings:  The physician reviewer found that An enrollee has requested reimbursement for the DecisionDx-UM. Findings:  Three physician reviewers found cytogenetic testing of choroidal melanoma has been an established method of laboratory evaluation of melanomas for 10 years. The medical literature supports the routine use of this testing for patients with uveal melanoma. The current standard of care is to adjust a patients monitoring and surveillance based on the genetic profile of the tumor. Patient counseling and eligibility for clinical treatment trials are based heavily on the tumor genetic profile. The current medical evidence supports the testing at issue in this clinical setting. Therefore, DecisionDx-UM (CPT 84999) was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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

The parent of a four-year-old male enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy with eight hours per week of supervision, and two hours per week of parent training for treatment of the enrollees autism spectrum disorder.   Findings:  The physician reviewer found that The request for 40 hours per week of ABA therapy with eight hours per week of supervision, and two hours per week of parent training is not medically necessary for the treatment of the patients medical condition. There is a lack of documentation provided to support the requested frequency of ABA hours in this clinical setting. The patient presents with a history of autism, mental delay, anxiety and a sensory processing disorder.  The patient is likely to benefit from an early intervention pre-kindergarten program in conjunction with ABA therapy. In addition, the Health Plans authorization of 25 hours per week of direct ABA service with a paraprofessional weekly, with four hours of supervision, and one hour of parent training is medically necessary and appropriate in this clinical setting. 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 pediatrics and neurology with special qualification in child 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: An enrollee has requested authorization and coverage for a power scooter. The requested power scooter is not medically necessary for treatment of this patients medical condition. The documentation indicates that the patient has chronic pain and a history of falls. However, the providers evaluation indicates the patient is independent with mobility with an assistive device. The evaluation revealed that a four wheeled wheelchair would be appropriate. The documentation does not reveal that the patient is unable to participate in one or more mobility-related activities of daily living (MRADLs), such as toileting, feeding, dressing, grooming, and bathing at home. The documentation does not reveal that the mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted walker or manual wheelchair. The documentation does not support that a power operated scooter is medically necessary for this patient.Final Result: The reviewer determined that the requested device 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: A male enrollee has requested reimbursement and prospective authorization and coverage for mental health and substance abuse residential treatment center (RTC) services. Findings:  The physician reviewer found that records provided for review document that this patient continued to experience cravings, mainly in the moderate range. He was not a danger to himself or others, nor was he aggressive or violent. He was cognitively intact and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the RTC level of care. He was medically and psychiatrically stable. There was no evidence of a high degree of impulsivity, agitation, mania, hallucinations, or any other significant symptom that would interfere with his care. Although remaining depressed and anxious, and reporting sleep disturbance at three to four hours, these issues did not require the RTC setting for monitoring. Naltrexone was not started until after the date of service in question. He was not on a complicated medication regimen. His doses of trazodone and Vistaril remained unchanged. He was cooperative, motivated and was noted to be working the program. Although the patient had a potential for relapse, he has a history of a long period of sobriety, and extensive experience with 12 step programs. He planned to discharge to sober living. Although he continued to report feelings of guilt, remorse, and repetitive thoughts of his sisters death, he could have received further treatment on an ambulatory level of care such as PHP. He no longer met clinical guidelines for RTC level of care. For these reasons, the RTC services provided from the date of service in question, forward were not and are not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue 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 with sub-specialty certification in addiction 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 male enrollee has requested authorization and coverage for Humatrope . The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature. The request for Humatrope, is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient is underweight and under height for his age, due to constitutional delay, inadequate caloric intake necessary to meet his energy needs in the setting of ADHD, anxiety, the stimulant medications. In addition, the patients height is not more than two SDs below the mean for age and gender. The patient has a predicted adult height that is within normal limits for an adult U.S. male. Therefore, the medical necessity for the requested medication has not been established in this clinical setting. 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 a 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar surgery. Findings:  The physician reviewer found that the documentation provided for review does not support the medical necessity of the requested services. Numerous studies have demonstrated the role of surgical decompression in this patient population; however, few have investigated the utility of fusion in patients without underlying instability. The inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. This patient presents with severe back pain radiating into the right lower extremity in an S1 distribution. Functional limitations are noted in activities of daily living. She is unable to walk without crutches. Clinical findings document motor deficits, reflex changes, and sensory deficits consistent with imaging evidence of L5-S1 disc protrusion with right S1 nerve impingement. There is also imaging evidence of minimal degenerative disc changes at L3-4, L4-5 and L5-S1. She has failed long term reasonable and/or comprehensive non-operative treatment, including physical therapy, epidural steroid injections, activity modification, and medication. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There are plausible apparent discrepancies between the radiologist and the providers description of normal versus flat back alignment of the lumbar spine. In addition, the prior deferred surgically proposed procedures were considered for L3-S1 and most recently have been considered for L2-S1. At the present time, the rationale for these discrepancies have not been provided and/or is not apparent. Therefore, the requested lumbar surgery is not medically necessary for treatment of the patients medical condition. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral knee injections with Euflexxa. Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. A systematic review was conducted of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvement in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested bilateral knee injections with Euflexxa is supported as medically necessary for treatment of this patients knee osteoarthritis. 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 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: A female enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) (CPT 90868). Findings:  The physician reviewer found that TMS therapy provided was not and is not medically necessary for treatment of the patients major depressive disorder. TMS is endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population. A typical treatment course of TMS consists of 30 to 40 sessions spanning four to six weeks. According to studies, the standard regimen is treatment courses up to six weeks in duration. The authors stated that Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. The authors suggest that an extended treatment course of one to two weeks may be appropriate for patients who experience only partial improvement and the clinician believes that a clear plateau of benefit has not been obtained. In this case, the patient started TMS therapy and had already utilized this additional time frame. At this time, there is a lack of adequately powered, controlled studies showing the benefit of longer courses of TMS therapy. In sum, based on the documentation provided in context of the relevant literature and practice standards, the TMS services provided from the date of service in question, forward, were not and are not medically necessary for treatment of the patients major depressive disorder. Final Result: The reviewer determined that the services at issue 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
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. The Health Plan has denied this request indicating that the requested medication is not medically necessary 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Gene Assay testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. Findings:  Three physician reviewers found the medical evidence does not support the services at issue in this clinical setting. This patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines note while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Therefore, DecisionDx-Melanoma Gene Assay testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 62-year-old male enrollee has requested reimbursement for the gene assay (CPT 84999). Findings:  Three physician reviewers found that The National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered the standard of care in the treatment of patients with melanoma. The utilization of DecisionDx-Melanoma gene assay is not expected to impact the treatment or health outcome of the patients melanoma. Therefore, the gene assay (CPT 84999) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 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 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.