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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Zoll LifeVest for treatment of the enrollees tachycardia.  Findings:  The physician reviewers found that In this clinical circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed with continued left ventricular dysfunction demonstrated by an ejection fraction less than 35% despite appropriate treatment. A prophylactic defibrillator before this time has not been demonstrated to improve outcome. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not been met are largely comprised of registry data without adequate control groups. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed, or required explantation. For these reasons, the Zoll LifeVest provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the device at issue was 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and 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 reimbursement for gene panel test (CPT codes 81321, 81235 and 81201) for evaluation of the enrollee, who has a history of brain tumor. Findings:  The physician reviewer found that There is a lack of support for the services at issue in this clinical setting.  FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician or yields a result that is reliably clinically beneficial. There are various nonrandomized studies exploring the value of molecular profiling but these studies are not convincing.  A randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. In addition, recent studies have expressed serious reservations about this approach in general. Accordingly, the gene panel test (CPT codes 81321, 81235 and 81201) provided was not likely to have been of greater clinical benefit over the standard options available for the evaluation of this patients medical condition. Final Result: All three 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services. Findings:  The physician reviewer found that the medical services provided were necessary for treatment of an emergency medical condition. In this case, the patient was diagnosed with a cm paravisceral aortic aneurysm. In this case, the patients condition was emergent. In general, there is no way to know when an aneurysm will rupture. These lesions are best repaired at centers with experience, and by an endovascular route, if possible. In this clinical setting, it was best to wait for the ZFEN graft. Thus, the services in dispute were for emergency care. Given the serious nature of the patients aneurysm, the patient received emergency medical services for an emergency medical condition on the dates of service in dispute. Final Result: The reviewer determined that the patient receives emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in vascular 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: The parent of an enrollee has requested authorization and coverage for Saizen 8.8 mg vial. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patients height is not more than two standard deviations below the mean for age and gender. The records do not document evidence of fall-off in growth velocity prior to initiation of growth hormone therapy, pre-treatment growth factors were normal, weight for height ratio is low, and there are no known morphological age abnormalities of the pituitary gland. Thus, the patient does not meet standard criteria for growth hormone deficiency. Furthermore, the patients adult predicted height is not short enough at this time to consider empiric growth hormone therapy for treatment of idiopathic short stature. The most likely cause of the patients mild delay in bone age is constitutional delay, which may be associated with poor weight gain, as well. The current medical evidence does not support the requested medication in this clinical setting. All told, Saizen 8.8 mg vial is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. This patients sister was diagnosed with breast cancer. However, the records indicate that the sister underwent BRCA1 and BRCA2 testing, which was negative. Thus, BRCA1 and BRCA2 testing were not indicated in this patients case. Per the submitted documentation, this patient was evaluated with further gene testing for PTEN and a panel of genetic mutations. Although these other genes are of interest, they have as yet not been found to be significant enough to be the basis for clinical decisions for the carriers or their family members. Such testing is not included in the guidelines from major organizations. Therefore, genetic testing performed was not likely to have been of superior over other methods of evaluating this patient. Final Result: 2 of 3 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 3 Physician reviewers 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: An enrollee has requested reimbursement for the Oncotype Dx Prostate Assay for evaluation of the enrollees prostate cancer. Findings:  The physician reviewer found that The physician reviewer found there currently are three major approaches to the management of localized prostate cancer. These include surgical prostatectomy, various forms of radiation therapy, and active surveillance with no specific treatment. Recommendations are made as to these options based on risk stratification, which estimates the risk for the future development of progressive cancer. The individuals prostate cancer is evaluated with a combination of clinical features, prostate-specific antigen, and pathologic details, including Gleason grade and the number of biopsy cores that are positive.  Thus, patients can then be placed into one of four general categories: very low risk, low risk, intermediate risk, and high risk. By such categorization, this patient would be placed in the low to intermediate risk category, for whom active surveillance is a recommended option. A further evaluation of prognostication is the use of gene panels of the cancer cells, one of which is Oncotype Dx Prostate Assay. This is a 17-gene panel that may assist in predicting recurrence risk after treatment for prostate cancer. However, at this time, it has not been clinically validated in this setting as beneficial for decision making about treatment or surveillance. Therefore, the superior effectiveness of Oncotype Dx Prostate Assay has not been established. Final Result: Two of three 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Percocet 10 mg/325 mg, quantity of 90 with five refills, OxyContin 10 mg, quantity of 90 with two refills for treatment of the enrollees knee pain status post total knee replacement. Findings:  The physician reviewer found that In the documentation available for review, this patient was treated with medications for post-surgical pain. However, not all non-opioid treatment options have been utilized. There was no documentation of failure of non-opioid medication.  There is considerable morbidity risk even in the post-operative setting with high opioid use given this patients coexisting medical problems and other medications (Wang, et al; Webster, et al). Furthermore, the Centers for Disease Control and Prevention (CDC) require objective treatment goals for pain and function for opiate medications. Also, the need to use opiates as the primary medication treatment strategy for pain has not been established. For these reasons, the Percocet 10 mg/325 mg, quantity of 90 with five refills and OxyContin 10 mg, quantity of 90 with two refills were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the medications at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Final Result: The reviewer determined that the medications at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lyrica for treatment of the enrollees low back pain. Findings:  The physician reviewer found that The records provided for review document that this patient developed chronic back pain radiating to both lower extremities. The patients primary pain generator is musculoskeletal and not neuropathic, post-herpetic or from fibromyalgia. Lyrica is recommended in case of fibromyalgia, neuropathic pain and post-herpetic neuralgia. Therefore, the requested Lyrica is not supported as 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 neurology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast augmentation and gender reassignment surgeries performed at the same time for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that there is support for the requested services in this clinical setting. This patient is documented to have gender dysphoria. The patient has made a request for a combined augmentation mammaplasty and vaginoplasty. Based on the photographs provided, the patients chest contour is consistent with a male chest. The patients breasts and genital/external anatomy should be consistent with the female gender. According to her diagnosis and history, her external anatomy should be more consistent with a male gender than a female. Combining the procedures would decrease the operative time as compared to doing them at separate time, as the augmentation mammaplasty would be a relatively short procedure. Additionally, performing the procedures in this manner would prevent a second surgery and anesthesia, which may reduce the overall risk for this patient. The requested procedures are consistent with services that will assist in providing this patient to achieve a female anatomy. All told, the requested bilateral augmentation mammaplasty and gender reassignment surgery, to be performed at the same time, are medically necessary for the treatment of this 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 plastic 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 authorization and coverage for proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitor type drugs like Repatha or Praluent for treatment of the enrollee who has a reported history of familial hypercholesterolemia. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication. Based on the records provided, the patient has no documented coronary or vascular disease and a very low calcium score of 0. The patients LDL levels are variable as described. Repatha (evolocumab) and Praluent is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol. This patient does not fit any of those criteria. There is insufficient evidence to support a diagnosis of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. These diagnoses require not only elevated LDL-c levels that significantly exceed 180 mg/dl but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a strong family history of coronary disease (younger than 50 years in a second degree relative or aged younger than 55-60 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria. Based on the variable LDL levels, the diagnosis of heterozygous familial hyperlipidemia is not secured by the Dutch Lipid Criteria either.  Moreover, the patients calcium score is 0, predicting a very low 10 year risk of developing coronary disease. In aggregate, the documentation provided does not support the medical necessity for treatment with a PCSK9 inhibitor at this time. For these reasons, PCSK9 inhibitor type drugs like Repatha or Praluent is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication type 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 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: The patient has requested reimbursement for the gene test (Afirma Thyroid Gene Expression Classifier) for evaluation of the enrollees thyroid nodules. Findings:  The physician reviewers found that The Bethesda System recommends a diagnostic hemithyroidectomy for this type of nodule. The recent American Thyroid Association guidelines state that for nodules with atypical of undetermined significance cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. If the genetic test is suspicious, the risk of malignancy increases to greater than 40% and the risk of malignancy decreases to less than 6% with benign findings. In this case, the result of the Afirma Gene Expression Classifier was suspicious for malignancy. This increases the patients risk of malignancy to 40%. This information was important to determine the decision whether to perform thyroidectomy, and if so, the extent of surgery. For these reasons, the gene test (Afirma Thyroid Gene Expression Classifier) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and actively practicing. The reviewer 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.