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

Nature of Statutory Criteria/Case Summary:The parent of an enrollee has requested authorization and coverage for Avastin/Bevacizumab infusion therapy services.Recurrent respiratory papillomatosis (RRP) is an airway neoplasm which is caused by human papillomavirus types 6 and 11. RRP is the most common benign neoplasm of the larynx among children and the second most frequent cause of childhood hoarseness. After changes in voice, stridor is the second most common symptom, first inspiratory and then biphasic. Less common presenting symptoms include chronic cough, recurrent pneumonia, failure to thrive, dyspnea, dysphagia, or acute respiratory distress, especially in infants with an upper respiratory tract infection. Often misdiagnosed, RRP may result in severe airway obstruction and death due to delayed diagnosis. Despite its mostly benign nature, RRP may cause significant morbidity and mortality because of its unpredictable clinical course and especially its tendency, albeit infrequent, for malignant transformation. Hence, treating RRP is an absolute medical necessity and can be life-saving.Bevacizumab has been shown to be effective in small clinical trial and case series. Bevacizumab acts by selectively binding circulating vascular endothelial growth factor (VEGF), thereby inhibiting the binding of VEGF to its cell surface receptors. This inhibition leads to a reduction in microvascular growth of tumor blood vessels and thus limits the blood supply to tumor tissues. Vascular endothelial growth factor-A (VEGF-A) is known to play an important role in the angiogenic response essential for tumor growth in a variety of human and experimental tumors. VEGF-A may play a role in the pathogenesis of recurrent respiratory papillomatosis (RRP). Many pediatric case series have demonstrated rapid response to the bevacizumab and with recurrence free survival. Furthermore, frequent debridement in the airway can cause other secondary issues such as tracheomalacia and broncopleural fistula. Treatment with bevacizumab can help patients avoid such complications in the airway. In this case, this pediatric patient has a diagnosis of RRP and has required regular surgical debridement for recurrent papillomae. The medical literature supports the use of bevacizumab to treat RRP under these circumstances. Accordingly, the requested Avastin/Bevacizumab infusion therapy services are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics, with subspecialty certification in pediatric pulmonology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Supartz injections in both knees. Findings:  The physician reviewer found that he medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of osteoarthritis in both knees and of relief using viscosupplementation three years prior. She has tried and failed other conservative treatments, including oral and topical non-steroidal anti-inflammatory drugs, cortisone injections, physical therapy, and a home exercise program, with the alternative being bilateral total knee arthroplasties. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Supartz injections in both knees are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Manual Test Decipher Prostate Biopsy. The records provided for review demonstrate that this patient presents with T1c prostate cancer with a prostate specific antigen (PSA). The patients provider noted that the patient is being considered for brachy monotherapy after treatment for obstructive voiding. The provider has recommended the Decipher Prostate Biopsy to assist in treatment planning. Recent studies have suggested that the Decipher Prostate Biopsy can predict adverse pathology and unfavorable outcomes in patients following radical prostatectomy. However, the validity of using different degrees of tumor pathology as markers to extrapolate the risk of progression of a tumor in vivo has not been established. Per the National Comprehensive Cancer Network (NCCN), there is a paucity of randomized controlled trials that have thoroughly evaluated the utility of the Decipher Prostate Biopsy test. Similarly, the American Urological Association (AUA) states that, among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. Therefore, the requested Manual Test Decipher Prostate Biopsy is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Manual Test Decipher Prostate Biopsy is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in urology 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: The patient has requested authorization and coverage for  a power wheelchair. Researchers noted that exercise therapy has a beneficial clinical effect on most musculoskeletal conditions. Researchers noted that obesity management requires comprehensive lifestyle approaches, including recommendations for exercise. Researchers examined the possible adverse effects of regular motorized scooter use, noting that physical inactivity increases cardiovascular risk and that scooters may have detrimental long-term effects by increasing cardiovascular risk, particularly insulin resistance. In this case, the patient has multiple chronic medical conditions, including hypertension, congestive heart failure, morbid obesity, and diabetes, and is status post right below knee amputation. He is able to ambulate at home using a walker and his prosthesis, and retains full upper limp strength. The records do not establish upper body impairments that would preclude effective propulsion of an optimally configured manual wheelchair to accomplish mobility-related activities of daily living and instrumental activities of daily living. Given that the patients needs could be met with a combination of walker, prosthesis and manual wheelchair, and that long-term usage of a power wheelchair may be detrimental for his chronic conditions, the requested equipment is not medically indicated. Therefore, a power wheelchair is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested authorization and coverage for physical therapy services. Researchers note that ovarian cancers often present in advanced stages of disease due to a relative absence of symptoms during earlier stages. Researchers note that  peritoneal carcinomatosis are difficult to treat, with recurrences frequently observed, leading to a poor prognosis. Researchers note that management around advanced peritoneal carcinomatosis  revolve around palliation of symptoms and providing support and resources to address emotional and existential concerns. In this case, the patient has ovarian cancer. She benefitted from initial physical therapy. She was discharged from physical therapy services due to having achieved therapy goals that included independent transfers and household level mobility with a walker. While she continued to have mobility deficits, the documentation does not support the necessity of additional physical therapy to improve her clinical course or outcomes. Therefore, physical therapy services are not medically necessary for the treatment of this patient.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: The patient has requested authorization and coverage for a total electric hospital bed, E0265. Gillespie and colleagues report that there is currently no strong evidence of a reduction in pressure ulcers with a 30-degree tilt compared with the standard 90-degree position. Jocelyn Chew and colleagues found that results regarding turning and repositioning schedules for adult bed-bound patients were inconclusive. In this case, the patient had mobility impairments after being newly diagnosed with ovarian/peritoneal neoplastic disease and undergoing treatment, included chemotherapy. At home, she was at risk for pressure injury due to her impaired mobility, aspiration and worsening leg edema. These positioning needs can adequately be met with a semi-electric hospital bed with an appropriate mattress surface. A total electric hospital bed adds an electric height adjustment feature that may be necessary for patients requiring a height adjustment for independent transfers into and out of bed, however, the documentation in this case does not show that this feature is medically indicated for this patient. Therefore, a total electric hospital bed, E0265 is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz XR tablets. Findings: Guidelines for the treatment of rheumatoid arthritis recommend that if disease activity remains moderate to high despite therapy with DMARDs, then tumornecrosis factor inhibitor (TNFi), non-TNF biologic, or tofacitinib may be added to DMARD therapy. The guidelines do not specify an order in choosing the next drug to be added to traditional DMARDs. A study found that tofacitinib monotherapy was associated with reductions in signs and symptoms of rheumatoid arthritis as well as improvement in physical function. In this case, the patient continued to have uncontrolled rheumatoid arthritis disease activity despite DMARD monotherapy, and had failed anti-TNF therapy. The provider added Xeljanz to optimize disease control. The records show that the patient achieved improved disease control using Xeljanz. Given the medical literature, the requested medication is medically indicated in this clinical setting. Therefore, Xeljanz XR tablets are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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. Findings:  The physician reviewer found that the patients American Joint Committee on Cancer (AJCC) stage alone, he had five-year and ten-year melanoma survival rates of 99 and 98% respectively. The gene expression profiling (GEP) test was subsequently performed and yielded a Class 1b score. Based on the GEP score alone, the patients five-year melanoma specific survival would be as high as 97%, signifying a relatively equivalent prognosis for the patient. At this time, there is a lack of evidence indicating that this information can be used in a clinically meaningful way to benefit the patient. The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of cutaneous melanoma do not currently endorse the use of this test, and it is not incorporated into the most widely used treatment and management protocols. Therefore, the DecisionDx-Melanoma gene assay was not likely to have been more beneficial than any other available standard therapy for the patients medical condition.Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma gene assay at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for seat elevation, mounted cup holder, LED lights, and upgraded wheelchair motor (4-pole 12.5 KPH/8 MPH) to be added to his already approved powered wheelchair. In this case, the patient has retained sufficient upper limb function to perform some tasks, such as eating and using a telephone. As such, a mounted cup holder with an adaptive straw is medically necessary as it would allow the patient to hydrate at will, independently, which he would not otherwise be able to do. Researchers note that there is little data available to support standards development related to independent wheelchair transports. While seat elevation may assist a user to independently transfer, the available records do not indicate that this patient  would be able to safely perform independent transfers by utilizing the downhill gradient afforded by a power seat elevation. There is no documentation of any transfer trials with physical or occupational therapy. Optimizing lighting, whether through ambient adaptations or lighting equipment on a wheelchair, are generally highly advisable. However, such measures address environmental concerns and are not medically necessary for mobility-related activities of daily living and thus are not medically indicated. A motor beyond the base group 3 power mobility device motor is likewise not medically necessary for accomplishing mobility-related activities of daily living. Therefore, a mounted cup holder to be added to the already approved powered wheelchair is medically necessary for the treatment of this patient, while seat elevation, LED lights, and an upgraded wheelchair motor (4-pole 12.5 KPH/8 MPH) are not medically necessary.Final Result: The reviewer determined that the requested equipment is partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ NuSpin. A study noted that human growth hormone and human IGF-1 are treatments for growth hormone deficiency, idiopathic short stature, and primary IGF-1 deficiency in children and adolescents. In this case, the patient has a growth hormone deficiency based on low circulating IGF-1 levels, an abnormally low growth velocity despite recent onset of normal puberty, and abnormally low peak circulating serum peaks of GH concentrations. Based on the records, growth hormone treatment is medically indicated for this patient. Therefore, Nutropin AQ NuSpin is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intracept procedure. The records provided for review document that this patient has a history of chronic low back pain. There is evidence of conservative treatment for over six months including exercise, trigger point injections, sacroiliac joint injections, lumbar epidural steroid injections, and facet joint injections. Medications have included naproxen, cyclobenzaprine, gabapentin, and ibuprofen without significant relief. A lumbar magnetic resonance imaging (MRI) scan revealed Modic changes at L5-S1. The provider has recommended the Intracept Procedure of ablation of the basivertebral nerves. Researchers reported on a randomized controlled trial that showed maintenance of clinical improvement at two years following radiofrequency ablation of the basivertebral nerve. The researchers noted that this trial included 140 patients with chronic low back pain that had been present for at least six months with Modic Type 1 or 2 vertebral endplate changes. The researchers reported substantial improvement in patients treated with the Intracept procedure as compared to the standard of care. In this case, the patient has chronic low back pain with Modic vertebral endplate changes at L5-S1. The provider has tried other options with documented failure. The patients pain is chronic and has persisted for longer than six months despite adequate conservative care. As such, the requested Intracept procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Findings:  Two of the three physician reviewers found the requested Intracept procedure is 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 services are 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 orthopedic surgery 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.