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 reimbursement for the additional physical therapy (PT) sessions for treatment of the enrollees intradural pilocytic astrocytoma.  Findings:  The physician reviewer found that the additional physical therapy sessions provided were medically necessary for the treatment of the patients medical condition. There is sufficient medical literature supporting the services at issue in this clinical setting. One study systematically reviewed the evidence for the efficacy of different rehabilitation strategies on functional ambulation following spinal cord injury. The study notes that rehabilitation strategies that facilitate repeated practice of gait offer the greatest benefits to functional ambulation in sub-acute or chronic spinal cord injury. Supportive devices may augment functional ambulation particularly in people with incomplete spinal cord injury. Another study performed a literature review on interventions for gait in patients with pediatric spinal cord impairments. The study reports that it is important to identify individual patient characteristics and goals appropriate for each intervention to guide clinical practice. Determining the appropriate orthotic support for each child, and incorporating treadmill training or electrical stimulation, is recommended. Moreover, the authors indicate that intensive gait training, including practice overground, results in notable improvements, with a trend for greater gains with greater total training durations. In this case, the patient is active and highly motivated to obtain the best possible outcome of his therapy. He plays sports including tennis. He indicates that he wants to be able to walk without a limp. In addition, his physical therapy goals are aimed at improving the strength in his right leg, and to enable him to walk without an obvious limp, using the least restrictive orthosis available. These goals are realistic, and per the records submitted they have not yet been met. However, the patient is making progress towards these goals. For the reasons provided, the additional physical therapy sessions provided have been established as medically necessary for treatment of the patients medical condition. Final Result: The physician 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 physician reviewer is board certified in pediatrics and neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Gene Expression Assay. Findings:  The physician reviewers found that the current 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 states 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. In sum, DecisionDx-Melanoma Gene Expression Assay was not likely to have been of greater benefit than other available methods of evaluating this patient. Final Result: The reviewers determined 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for a sleep study. The clinical documentation provided for review noted that the patient underwent a home sleep test. However, this type of testing is limited in utility to the evaluation of obstructive sleep apnea (OSA). In this case, there was no documentation of a thorough sleep evaluation nor is there documentation of any signs or symptoms of OSA. In the absence of any clinical signs and symptoms to suggest the presence of OSA, the performance of a home sleep study is not consistent with the generally accepted standards of practice. As no clinical signs or symptoms of OSA were reported to warrant a home sleep study, the sleep study provided in this case was not medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that the diagnostic procedure at issue was not medically necessary for evaluation 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 sleep 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene panel testing for evaluation of the enrollees risk for cancer. Findings:  2/3 of the physician reviewers found that There is support for the testing at issue in this patients case. The documentation noted that her mother developed breast cancer at age 53. Additionally, the patients mother reportedly tested positive for ATM mutation. The medical evidence supports the gene panel testing in this clinical setting. Thus, gene panel testing (BRCA testing and MyRisk) performed was likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: 2/3 of 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing. Findings:  Three physician reviewers found the prognosis of cutaneous melanoma has classically been determined by applying the staging system defined by Balch. Mitotic index has also been thought to add to these statistics. As per these criteria, this melanoma would be classified as T1a, or stage 1A, with an expected ten-year survival of approximately 88%. DecisionDx-Melanoma testing is a study of 31 genes in an individuals cancer cells. It then classifies that tumor into either class 1 (with a greater than 90% distant metastasis free rate at five years) or class 2 (with a 65 to 80% distant metastasis free rate at five years). A study reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma testing classification, in patient undergoing sentinel node sample, which was not done in this patient. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is unproven whether the assay can be used to make clinical decisions. That would be particularly true in this patient, given her excellent prognosis. In sum, the superior effectiveness of the gene testing has not been established.Final Result: The 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: 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: An enrollee has requested reimbursement for the laboratory testing services of quantitation of therapeutic drug and immunoassay for analyte other than infectious agent antibody or infectious agent antigen.Findings:  Three physician reviewers found the laboratory testing services of quantitation of therapeutic drug and immunoassay for analyte other than infectious agent antibody or infectious agent antigen was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The medical literature concluded that patients with moderate-to-severe Crohns disease that was resistant to tumor necrosis factor (TNF) antagonists had an increased rate of response to induction with ustekinumab, as compared with placebo. However, there is limited evidence based recommendations to measure drug levels in patients being treated with ustekinumab. Specifically, target drug levels have not been established and there is a lack of data demonstrating improved health outcomes based on drug levels. Further, the American Gastroenterological Association (AGA) has stated that there is very low evidence to support measuring drug levels in patients failing therapy. For these reasons, the laboratory testing services of quantitation of therapeutic drug and immunoassay for analyte other than infectious agent antibody or infectious agent was 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 laboratory testing services of quantitation of therapeutic drug and immunoassay for analyte other than infectious agent antibody or infectious agent antigen was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg/mL Sureclick Pen Injector for treatment of the enrollees hyperlipidemia. Findings:  The physician reviewer found that based on the records provided the patient presents with increased coronary risk, dyslipidemia and intolerance to statin medication and Zetia. Repatha is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL-cholesterol. This patient does not fit either of these categories based on the documentation provided. Specifically, there is no documentation of clinical atherosclerotic heart disease and no documentation to confirm heterozygous familial hypercholesterolemia. The latter diagnosis requires not only elevated LDL-cholesterol levels that significantly exceed 180 mg/dL but also a combination of physical examination findings, a strong family history of coronary disease and documented genetic defects related to cholesterol metabolism according to published criteria.  Protein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have not been studied in other patient populations such as this patient. In addition, current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Therefore, the request for Repatha 140 mg/mL Sureclick Pen Injector is not medically necessary for treatment of the 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma.Findings: There is a lack of support for the services at issue in this clinical setting. This patient has been diagnosed with 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. In sum, DecisionDx-Melanoma assay was not likely to have been of greater benefit than other available modalities for evaluating this patient.Final Result: The reviewers determined that DecisionDx-Melanoma assay was likely to be more beneficial than the available standard therapy for evaluation of patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a stress echocardiogram. The submitted documentation fails to demonstrate the medical necessity of the requested services. In this patients case, the records document some coronary risk and paroxysmal atrial fibrillation.  There is no documentation of chest pain or other symptoms suspicious of coronary ischemia, and no documented ischemic electrocardiographic changes. In this circumstance, a screening stress echocardiogram is not recommended and not considered standard accepted practice in the medical community. Current guidelines endorsed by several national organizations do not consider screening stress echocardiography appropriate in this setting. All told, the requested stress echocardiogram is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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: An enrollee has requested authorization and coverage for L4-L5 decompression with coflex stabilization device placement for treatment of the enrollee, who has a history of left lower extremity pain and weakness. Findings:  2/3 of the physician reviewers found that the physician reviewer found current evidence-based literature and long-term studies support the use of coflex interlaminar stabilization with decompression as a safe and efficacious alternative to decompression and/or lumbar fusion for the treatment of lumbar spinal stenosis and low-grade spondylolisthesis. This patient presents with persistent and worsening low back pain radiating into the left lower extremity with give-way weakness, numbness and tingling. She had significant functional limitations in activities of daily living. Clinical examination findings have documented motor and sensory deficits consistent with imaging evidence of severe central canal stenosis and left neural foraminal narrowing at L4-L5 with left L4 nerve root impingement. She has failed physical therapy, medications, and activity modification. The medical evidence supports the requested services in this clinical setting. All told, L4-L5 decompression with coflex stabilization device placement is likely to be of greater benefit than other treatment options. Final Result: 2/3 of 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacroiliac joint fusion surgery for treatment of the enrollee who has a history of low back pain. Findings:  2/3 of the physician reviewers found that Sacroiliac fusion is used to immobilize the diseased joint that transmits weight from the spine to the pelvis. The medical evidence indicates that prevention of motion is the only treatment that durably alleviates the pain in the affected sacroiliac joint when non-operative therapies have failed. The recommended sacroiliac joint fusion surgery is in accordance with guidelines and policy statements of major societies. The International Society for the Advancement of Spine Surgery, North American Spine Society and National Institute for Health and Care Excellence (NICE) support the use of fusion for degeneration of the sacroiliac joint where conservative management has failed.  There are also prospective randomized clinical trials on which these guidelines are based. Lastly, these guidelines are also consistent with common community and academic practice patterns. The gold standards of failed non-surgical therapy and response to injections of the sacroiliac joint have been met in this patients case. The requested services are consistent with guidelines, data and medical standards referenced above. In summary, sacroiliac fusion is likely to be more beneficial in the treatment of this patient than other treatment options. Final Result: 2/3 of 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 reviewer number one is board certified in neurological 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.Physician reviewer number two is board certified in neurological 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.Physician reviewer number three is board certified in neurological 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.