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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Foundation One genetic testing for evaluation of his lung cancer.  Two physician reviewers found that the testing at issue was likely to be more effective for this patient than other available options. The therapy of advanced NSCLC has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in adenocarcinomas. Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of NSCLC has significantly expanded in the past 2-3 years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. It is generally accepted that the panel of mutations typically analyzed in NSCLC are mutually exclusive somatic driver mutations. In addition, anaplastic lymphoma kinase (ALK) mutation or rearrangement is present in another subset of NSCLC that may be amenable to targeted therapy with crizotinib. Moreover, the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. Thus, the Foundation One genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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 medical oncology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for evaluation of his elevated prostate specific antigen (PSA).  Three physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available treatment options. The American Urological Association (AUA) and National Comprehensive Cancer Network (NCCN) guidelines do not recommend use of prostate cancer antigen 3 (PCA3) testing for screening or diagnosing prostate cancer. In addition, there is a lack of clinical studies demonstrating that PCA3 testing is sufficiently accurate to diagnose or exclude the presence of prostate cancer. Therefore, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: 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: All three reviewers are board certified in urology and are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested knee replacement surgery without the requirement to first quit smoking for treatment of his left knee degenerative joint disease.   Findings:  The physician reviewer found that the requested total knee arthroplasty at the left knee is supported as medically necessary for treatment of this patients advanced degenerative osteoarthritis. Imaging has been obtained which confirm advanced changes. There has been a trial and failure of treatment with standard therapies. The patients BMI and weight is not a contraindication to surgery. According to the medical literature, obesity does provide a greater risk of perioperative complications but the studies quoted describe morbid obesity. This patients BMI is not considered morbidly obese. Further, nicotine addiction is not cited in the medical literature as a contraindication to total knee arthroplasty. The medical literature noted that for some patients addicted to nicotine, smoking cessation is impossible for them to achieve. While it would have both general health and positive microvascular changes, in this patient it is not achievable and should not be a contraindication to a total knee arthroplasty. Given that this patient has been treated with adequate conservative measures, the requested knee replacement surgery without the requirement to first quit smoking is medically necessary for treatment of this patients advanced degenerative osteoarthritis.Final Result: The reviewer determined that the requested surgery 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 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 the services of an anesthesiologist during a colonoscopy for treatment of her medical condition.  The physician reviewer found that the services of an anesthesiologist were not medically necessary for the patients screening colonoscopy. The patient did not present with a significant history that would require services of an anesthesiologist. The standard of care for administering monitored anesthesia care for a minimally invasive procedure, such as a colonoscopy is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. A colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with propofol. McQuaid and Laine performed a systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in esophagogastroduodenoscopy (EGD) or colonoscopy. The authors concluded that moderate sedation provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. Midazolam-based regimens have longer sedation and recovery times than propofol. For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition. 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 anesthesiology with sub-specialty 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: Overturned Decision of Health Plan

A female enrollee requested genetic testing for cancer for medical evaluation of the enrollee, who has a family history of uterine cancer.  Findings:  The physician reviewer found that screening for germline mutations in colon cancer susceptibility genes is warranted in select patients in order to identify the presence of the hereditary non-polyposis colorectal cancer (HNPCC) or Lynch syndrome.  All told, the requested genetic testing for cancer is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:    An enrollee has requested Orenitram for treatment of his pulmonary arterial hypertension.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  There are numerous medications that are approved by the U.S. Food and Drug Administration (FDA) for the treatment of patients with primary pulmonary hypertension, including Letairis, Opsumit and Tracleer.  The Health Plan has denied coverage for Orenitram and reported that there are preferred drugs such as Letairis which the patient has not tried first.  The Health Plan is within standard of care to require a trial of one of its preferred drugs for the treatment of pulmonary hypertension.  There is no documentation that the requested medication Orenitram is superior with respect to the long-term health outcome to other FDA approved medications (or combination of medications) to treat primary pulmonary hypertension.  All told, the requested medication Orenitram is not medically indicated 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested neurolysis lumbar or sacral facet joint (CPT 64635) for treatment of her back pain.  Three physician reviewers found that sacroiliac joint pain after fusion is seen in a fairly significant proportion of patients.  Additionally, post lumbar laminectomy syndrome with epidural scarring is also a common phenomenon.  In this patients case, magnetic resonance imaging (MRI) showed scarring of involvement of the first sacral nerve on the left side.  Per the clinical notes, the provider performed a diagnostic block on one occasion.  To confirm the proper diagnosis and manage with radiofrequency neurotomy, controlled diagnostic blocks must be performed and also the pretreatment physical examination should be more detailed.  The current medical evidence does not support the requested services in this clinical setting.  Therefore, the superior efficacy of neurolysis lumbar or sacral facet joint (CPT 64635) has not been established.  Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine and are 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:  An enrollee has requested Opana ER for treatment of his back pain. The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for Opana ER has not been established. Such narcotics are presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. The patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. In addition, high dose opiates may also cause adverse outcomes and therefore Opana ER is not indicated. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. For the reasons provided, the patients request for Opana ER is not medically necessary.   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 sub-specialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers found the submitted documentation supports the medical necessity of the requested medication.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The current medical evidence supports the requested treatment regimen in this clinical setting.  All told, Harvoni for eight weeks is medically indicated for the treatment of this patient. Final Result: Three reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested speech therapy at the frequency of 3-4 times per month for treatment of the enrollees autism spectrum disorder and reduced receptive, expressive and pragmatic language skills.  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. Bitterman and colleagues examined the experiences of preschoolers with autism spectrum disorders (ASDs). The authors found that 86% of preschoolers with ASDs were receiving direct speech therapy in the preschool years. In addition, according to Myers and colleagues People with ASDs have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. This patient presents with considerable language delays. The speech therapy evaluation documented his speech skills were at the 6-9 month level. The patient was recommended for speech therapy at the frequency of 3-4 sessions per month. Initially, his speech therapy sessions did not go well as he was hyperkinetic and not engaged in therapy and as a result speech therapy sessions were decreased. However, subsequent speech therapy sessions went much better as a high chair was utilized which allowed the patient to stay more focused during activities. In this case, speech therapy at the frequency of 3-4 sessions per month is medically necessary and appropriate in this clinical setting. 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 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:  An enrollee requested inpatient hospital services for treatment of his angina.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  In this circumstance of unstable angina despite optimal medical therapy, it is reasonable to expect that on presentation with chest pain that a hospital admission would be medically necessary.  Specifically, it would not be expected that observational level of care would be sufficient and it would not be expected for the patients hospital length of stay to be less that one day or spanning less than two midnights.  Patients with unstable angina usually require intravenous therapy that is not able to be safely provided at an observational level of care as well as advanced procedures that require hospital admission.  The current medical evidence supports the services at issue in this clinical setting.  All told, inpatient hospital services provided were medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 cardiovascular 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested bilateral breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Per the medical literature, breast tomosynthesis has been associated with a decrease in callbacks and increase in detection of small cancers.  The medical records noted heterogeneously dense breast tissue.  Thus, the addition of breast tomosynthesis to screening mammography was likely to have been more beneficial to the patient than digital screening without added tomosynthesis.  Therefore, the medical records demonstrate the superior effectiveness of bilateral breast tomosynthesis performed.Final Result: Three reviewers determined that the services at issue were 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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:  An enrollee has requested Botox injections for treatment of his facial pain.  Two physician reviewers found that the Botox injections were not likely to be more effective for this patient than other available options. There is a lack of medical literature supporting the safety and efficacy of Botox injection for treatment of the patients medical condition. Furthermore, there is a lack of controlled studies supporting the safety and efficacy of Botox injection for refractory facial pain. For the reasons provided, the Botox injections at issue were not likely to be more effective than other modalities.  Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in neurology and are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the testing serum infliximab (Remicade) levels and antibodies to infliximab (Anser IFX assay) for evaluation of her Crohns disease. Two physician reviewers found that assessing measurements of infliximab levels and antibodies with the Anser IFX assay remains unproven. In general, infliximab levels correlate inversely with disease activity. However, the target level of infliximab necessary to achieve clinical benefit remains unknown. There is a lack of controlled data which have identified the optimal drug level. Antibodies are often transient and may not be neutralizing in some patients. Further, therapeutic levels likely vary between patients. Based on these findings, the testing serum infliximab levels and antibodies to infliximab (Anser IFX assay) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result:  Two 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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.