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

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the Oncotype Dx Colon Cancer Assay testing. Findings: The physician reviewer found that in the peer-reviewed medical literature, there is a paucity of medical literature demonstrating that molecular markers are useful in treatment determination and prognosis in patients with colon cancer. The American Society of Clinical Oncology (ASCO) guidelines do not address use of this assay. In addition, the National Comprehensive Cancer Network (NCCN) guidelines state that there are insufficient data to recommend the use of multi-gene assays, such as the Oncotype DX assay, to determine adjuvant therapy. Accordingly, the Oncotype Dx Colon Cancer Assay testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the Oncotype Dx Colon Cancer Assay testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the nasal/sinus endoscopy, surgical balloon dilation. Findings:  The physician reviewer found that according to the medical reports submitted, this patients symptoms included nasal congestion and episodes of recurrent sinusitis. The patient was shown to have enlarged inferior turbinates. Traditionally, endoscopic endonasal surgery, ethmoid sinus surgery, and maxillary sinus surgery are the mainstays of surgical intervention for the treatment of chronic sinus disease. However, there was no documentation in the medical reports submitted that the patient had evidence of continuous sinus disease other than nasal congestion. Overall, this patient does not meet the clinical criteria for surgical treatment of the paranasal sinuses. Given these findings, the nasal/sinus endoscopy, surgical balloon dilation was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer found that a portion of the nasal/sinus endoscopy, surgical balloon dilation was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: One reviewer is board certified in otolaryngology and is actively practicing. One Reviewer is board certified in otolaryngology and is actively practicing.  One Reviewer is board certified in otolaryngology 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 Mavyret for eight weeks. According to recent guidelines, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The guidelines recommend that non-cirrhotic treatment naive genotype 1b patients should be treated with Mavyret for eight weeks. This recommendation is based on multiple high quality clinical trials showing cure rates of over 90%, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage.  Guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Mavyret for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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 gastroenterology 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 parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment in a locked facility. The submitted documentation supports the medical necessity of the services at issue. The American Academy of Child and Adolescent Psychiatry and American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System is an important tool for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 5. The patient continued to have suicidal ideation with intent and plan. In terms of functional status, the records support a score of 3. The patient has chronic deficits in interpersonal relationships. With regards to comorbidity, the records support a score of 3. The patient has comorbidities of major depressive disorder, posttraumatic stress disorder, and cluster b traits. The patient also has been experimenting with alcohol and marijuana. The patient did not have any medical problems which required 24-hour monitoring. With regards to environmental stress of the recovery environment, the records support a score of 4. The patients father was murdered. The patient has posttraumatic stress disorder from this incident and has not been able to process this. In terms of environmental support, the records support a score of 2. The patient has a supportive mother who is willing to participate in treatment. With regards to resiliency, the records support a score of 4. The patient was hospitalized three times in the prior month and continued to have suicidal thoughts with intent and plan and symptoms of depression. In terms of acceptance and engagement, the records support a score of 2. The patient is cooperative with staff and engages with treatment. Thus, the records support a composite score of 23. Based on these criteria, the patient meets criteria for continued residential treatment. Therefore, residential treatment in a locked facility was and is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with expertise in child and adolescent psychiatry 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: A 48-year-old female enrollee has requested authorization and coverage for Avonex. Findings:  The physician reviewer found that Avonex is U.S. Food and Drug Administration (FDA) approved and has been demonstrated to be effective in the treatment of MS. Avonex has been shown to reduce relapses and disability progression. Studies show interferons are similar efficacy to glatiramer. Avonex is an intramuscular injection, rather than subcutaneous, which has not been noted to cause injection site reactions. Moreover, Avonex is a weekly treatment rather than three times a week, which encourages patient compliance. All told, Avonex is medically necessary for treatment of this patients MS. 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 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: 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 oral surgery under general anesthesia performed in a surgical setting.  The submitted documentation supports the medical necessity of the requested services. Tooth number is in need of extraction. This impacted tooth with an anomalous position and shape is preventing eruption of his adjacent permanent teeth and normal development of his anterior maxilla. Given the anatomic position of this tooth and the nature of the procedure, general anesthesia is indicated. Due to the patients age and the invasive nature of the procedure, it is not likely that he will be capable of cooperating during surgery. General anesthesia with the presence of an anesthesiologist is indicated for the safety of this patient. All told, oral surgery under general anesthesia performed in a surgical setting is 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 oral and maxillofacial 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). The Health Plan has denied this request indicating that the requested diagnostic procedure is not medically necessary for evaluation of the enrollees knee pain.Nationally recognized evidence based medical guidelines recommend MRI of the knee for patients with acute trauma to the knee or if suspected posterior knee dislocation or ligament or cartilage disruption. For children or adolescents with nontraumatic knee pain, MRI is the next study after nondiagnostic radiographs, if internal derangement is suspected. Medical literature  reported an increasing number of individuals between the ages of 5-18 with a corresponding increase of acute and chronic injuries. MRI was recommended in this pediatric population because of its lack of ionizing radiation and assessment of the physis, apophysis, and adjacent soft tissues.  In this patients case, the records document a persistent right knee pain, intermittent swelling, and a marked limp. The patient has been unable to successfully participate in sports activities. Conservative treatment has included at least four months of activity modification, icing, nonsteroidal anti-inflammatory drugs (NSAIDs), and observation without improvement in symptoms. An initial x-ray was reported within normal limits. Clinical examination findings have been reported consistent with possible meniscus tear. As such, current evidence based medical guidelines and the medical literature support the use of MRI in this clinical setting to rule out internal derangement. Therefore, the requested MRI has been demonstrated as medically necessary for the evaluation of this patients medical condition.Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for custom orthotics. The sesamoid bones are part of the big toe metatarsophalangeal joint and are contained within the tendons of the flexor halluces brevis. They form a portion of the plantar plate. There are two sesamoids on each foot, and they articulate with the plantar facets of the metatarsal head. The function of the sesamoids is to distribute weight. Sesamoiditis is a painful condition that may or may not be associated with trauma. Conservative treatment includes decrease in activity, and custom insoles are often beneficial. Injections followed by excision are utilized for those that fail more conservative management strategies. Surgical management should only be used in cases refractory to all other therapies. This patient has tried conservative therapies, with little relief. She has used shoes inserts, but not custom orthotics, without significant benefit. As a last resort prior to recommending surgical intervention, custom orthotics have been prescribed. Based on the current standard of care as well as her failure to respond to all other conservative measures, the requested custom orthotics are medically necessary.Final Result: The reviewer determined that the requested equipment 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 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 estrogen cream compounded with Aquaphor ointment 41%. The Health Plan has denied this request indicating that the medication is not medically necessary for treatment of the enrollees vaginitis and vulvovaginitis.The patient reported that she needs a compounded product using Aquaphor as carrier medium to treat her symptoms of vaginal pain and irritation.  However, the medical records do not document that the patient has tried and failed standard treatments.  Per the U.S. Food and Drug Administration (FDA) recommendations, compounded products should be reserved for patients who have demonstrated failure of FDA approved products and for which there is no alternative.  In this case, there is limited data to support the superiority of compounded estrogen preparations.  Per the medical evidence, there is an uncertainty as to the purity and potency of such products. Therefore, the requested estrogen cream compounded with Aquaphor ointment 41% 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 obstetrics and gynecology 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 Euflexxa injections. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees osteoarthritis.The submitted documentation supports the medical necessity of the requested medication. A study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Current medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. There is no maximum amount of injections established by high-quality scientific evidence. This patient presents with significant left knee pain that is limiting her activities of daily living. Clinical examination findings are consistent with reported bone-on-bone right knee osteoarthritis. Reasonable conservative treatment, including medications and activity modification, have failed to provide adequate symptom relief. Prior viscosupplementation has been performed on at least two prior occasions, with good benefit and 50% pain reduction for at least six months. The medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given the previous response, repeat viscosupplementation injections are indicated. Therefore, the requested Euflexxa injections 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:  An enrollee has requested reimbursement for platelet-rich plasma treatment. Findings:  Two of the three physician reviewers found there is a lack of support for the services at issue in this clinical setting. Moraes and colleagues reviewed 17 randomized and two quasi-randomized trials with 1,088 participants. The authors concluded that there is currently insufficient evidence to support the use of platelet-rich plasma therapies for treating musculoskeletal soft tissue injuries. The trials covered eight clinical conditions, including Achilles tendinopathy. Di Matteo and colleagues concluded that there was a paucity of high-level literature regarding the application of platelet-rich plasma in the management of patellar and Achilles tendinopathy. In this patients case, she underwent debridement of the left Achilles tendon with platelet-rich plasma treatment. Per the medical literature, there is insufficient evidence to support the use of platelet-rich plasma treatment in Achilles tendinopathies. There is no compelling rationale presented to support platelet-rich plasma injection over standard therapy in this patients case. Therefore, platelet-rich plasma treatment was not likely to have been superior over other available treatment options. 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 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.