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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant gene test. The Health Plan has denied this request as investigational for treatment and evaluation of the enrollees colon cancer. Findings:  It has not been established if molecular markers are useful in treatment determination (predictive markers) and prognosis other than for KRAS, NRAS, and BRAF mutation testing and Microsatellite Instability (MSI) or Mismatch Repair (MMR) Testing. This is supported by both the NCCN and ASCO Guidelines. Multiple clinical trials that are attempting to validate this personalized or precision medicine approach are in various stages of development and execution. Although preliminary data from some of these efforts have fueled excitement about the value and utility of these studies, their execution has also provoked many questions about the best way to approach complicating factors such as tumor heterogeneity and the choice of which genetic mutations to target. In addition, liquid biopsies have not been well studied outside of non-small cell lung cancer. To date it is unclear if molecular profiling is beneficial in identifying potential targets for treatment and, if targets are identified, if targeted treatment is beneficial.Final Result: All three 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/QualificationsAll three reviewers are board certified in internal medicine with a sub-specialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent enrollee has requested authorization and coverage for two, four pack boxes of epinephrine 0.15 mg/0.15 mL injectable autoinjector, not from a lot containing particulate matter. The first-line of treatment for patients experiencing anaphylaxis is epinephrine. Studies of anaphylaxis have identified important risk factors. Based on a national registry, several risk factors for anaphylaxis from foods have been identified. As anaphylactic episodes might require more than one dose of epinephrine, all patients should carry two packs of epinephrine auto-injectors. This patient has experienced prior severe allergic reactions and remains at high risk for anaphylaxis. Accordingly, the requested two, four pack boxes of epinephrine 0.15 mg/0.15 mL injectable auto-injectors, not from a lot containing particulate matter, are supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication quantity 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 allergy and immunology with expertise in pediatric allergy and immunology 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 Orthovisc injections to the right and left knee. The submitted documentation demonstrates the medical necessity of the requested services. The current literature supports the use of viscosupplementation for osteoarthritis of the knees. The current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. In this patients case, prior viscosupplementation was beneficial. Therefore, the requested Orthovisc injections to the right and left knee are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral gonadal vein embolization.Findings:  Two of three physician reviewers found that this patient had clinical findings and imaging studies suggestive of pelvic congestion syndrome with vulvar varices. Gonadal vein embolization is an appropriately accepted practice in the medical community. Case reports have shown the benefit of this procedure. As in this case, when vulvar varices are present, the medical evidence shows that treatment of ovarian vein reflux leads to reduction in the size of vulvar varicosities.  Gonadal vein embolization is safe, well-tolerated, and allows for a minimally invasive approach. Therefore, bilateral gonadal vein embolization was likely to have been superior over other available treatment options. Final Result: The reviewers determined that the services at issue were 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 obstetrics and gynecology 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 authorization and coverage for Supartz injections in both knees. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. However, there is a lack of studies supporting a role for hyaluronic acid injection more frequently than six months. The patient underwent injections and presented to his provider three months later, requesting repeat Supartz injections. This suggests that the injections completed did not result in substantial lasting relief for this patient. Based on the foregoing discussion, the Supartz injections in both knees are not likely to be more beneficial for treatment of the patients knee pain with osteoarthrosis than any available standard therapy.One reviewer found that the Supartz injections in both knees are likely to be more beneficial for treatment of the patients knee pain with osteoarthrosis than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is 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 has requested authorization and coverage for Botox injections for treatment of migraine headaches. The submitted documentation supports the medical necessity of the requested medication. The records support a diagnosis of chronic migraine and failure of at least two preventive medications. There is no evidence to support requiring the failure of multiple preventatives before Botox would be useful. The clinical trials did not require this, though the patients often had failed previous preventative medications. The efficacy of Botox is independent of failure of prior preventatives. In this context, Botox is neither experimental nor investigational. It is medically necessary for treatment of chronic migraines, as it is the only FDA approved treatment for this condition. Therefore, Botox injections are medically necessary for 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 upheld. Credentials/Qualifications: The reviewer is board certified in 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 the platelet rich plasma injections provided on multiple dates. The Health Plan has denied this request as investigational for treatment of the enrollees large-cell lymphoma tumor of the abdomen. Findings:  Three physician reviewers found that the use of platelet rich plasma is not considered a standard of care for the treatment of lymphoma and is not supported by the National Comprehensive Cancer Network Guidelines. A search of the medical literature in numerous research sources failed to reveal any medical literature to support the use of platelet rich plasma for use in the treatment of lymphoma. There are standard methods by which to stage and treat diffuse large B-cell lymphoma. Advanced cases will require multi-agent chemotherapy with rituximab and CHOP, cyclophosphamide, doxorubicin, vincristine, and prednisone. Platelet rich plasma has no role in the treatment of lymphoma and has dubious indications. Therefore, the platelet rich plasma injections were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: All three 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/QualificationsAll three reviewers are board certified in internal medicine with a sub-specialty in medical oncology and hematology 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: enrollee has requested authorization and coverage for hypoglossal nerve stimulation.  Findings:  The physician reviewer found that the patient has obstructive sleep apnea and has not been able to tolerate the CPAP device due to nasal obstruction. The patient had a drug-induced sleep endoscopy which showed anterior-posterior collapse and no concentric collapse. Per the records, at this time, the patient has not had treatment for his nasal obstruction to allow him to tolerate the CPAP device (nasal pillows). The medical evidence supports treatment of his nasal obstruction prior to pursuing the requested services. Therefore, hypoglossal nerve stimulation is not likely to be more effective than other treatment options. Final Result:  Two of 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: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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 gene testing (fetal sex and fetal chromosomal microdeletions genomic sequence analysis, circulating cell-free fetal DNA in maternal blood) for their medical condition of pregnancy.  Findings:  The physician reviewer found that Three physician reviewers found that the current medical evidence supports cell-free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. Given this patients case, the aneuploidy risk warranted cell-free DNA testing for aneuploidy. However, testing for sex chromosomes and microdeletion syndromes was not indicated. Given the rarity of these conditions, the detection rate is significantly lower than for trisomy 21 and 18. The American College of Obstetricians and Gynecologists does not support routine screening for microdeletions. Therefore, the superior efficacy of gene testing (fetal sex and fetal chromosomal microdeletions genomic sequence analysis, circulating cell-free fetal DNA in maternal blood) has not been established. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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 DecisionDx-Melanoma Genetic Testing. The DecisionDx-Melanoma Genetic Testing claims to determine risk of recurrence for early melanoma stage I and stage II. However, in stage I and II melanoma, there is a lack of data to support using adjuvant therapy regardless of recurrence risk. Hence, the use of genetic testing to help determine the risk of recurrence is of limited value. In addition, the follow-up of melanoma patients, regardless of the risk of recurrence is standard and is summarized in National Comprehensive Cancer Network (NCCN) guidelines. The NCCN guidelines state that the follow-up of melanoma patients is not tailored to each patient, rather global to all patients with melanoma. For these reasons, the DecisionDx-Melanoma Genetic Testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the DecisionDx-Melanoma Genetic Testing 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 DecisionDx-Melanoma Genetic Testing 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Prolia injections every six months. Findings:  The physician reviewer found that Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy. In postmenopausal women with osteoporosis, Prolia reduces the incidence of vertebral, non-vertebral, and hip fractures. In this case, there is a history of wrist fracture and worsening of osteoporosis despite treatment with other agents. As such, the request for Prolia is medically appropriate. Therefore, Prolia injections every six months 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 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: A male enrollee has requested authorization and coverage for the LINX procedure. There is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. Further, the guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. One best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Overall, the currently available peer-reviewed literature does not support LINX over standard available interventions. Thus, the LINX procedure is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.One reviewer found that the LINX procedure is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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: The parent of an enrollee has requested authorization and coverage for orthodontic braces. The submitted documentation fails to demonstrate the medical necessity of the requested services. In order to assess the need for orthodontic treatment, there are many objective tools. One commonly used tool is the handicapping labio-lingual deviation index, as used in this patients case. Convention states a score of over 26 on the handicapping labio-lingual deviation index is a severe malocclusion requiring intervention and thus defining medical necessity for orthodontic treatment. In this patients case, the handicapping labio-lingual deviation index was computed by the treating orthodontist to be 24 and computed on review to be 21, below the threshold for medical necessity. The treating orthodontist describes pressure placed on the posterior teeth due to the described crossbite. However, the radiographs provided show a level occlusal plane in the posterior segment which would minimize any of the described traumatic pressure in protrusion. There is a lack of support for the requested services in this clinical setting. All told, orthodontic braces 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 dentistry 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.