Persius/hicric huggingface dataset:
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 Benesch boot for treatment of the enrollee's congenital metatarsus adductus.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment. It is well noted in the medical literature that the standard of care for mild metatarsus adductus is observation, and the majority will resolve without any intervention.  In fact, even physical therapy to stretch the foot in the opposite direction could result in a curvature of the foot in the opposite direction. The literature states that typically orthotics have been shown to be of benefit only in cases of moderate to severe conditions.  Surgery is typical only in cases of severe metatarsus adductus, and generally only after failure of serial casting. The records do not document that the patients condition has been classified as either moderate or severe. All told, the requested Benesch boot is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gene panel testing to screen for fragile X for evaluation of the enrollee's pregnancy.Findings: The physician reviewer found that Fragile X is the most common cause of inherited intellectual disabilities. Some authors suggest routinely offering fragile X carrier screening to all women because of the high prevalence of the condition and the high sensitivity of the screening test. While there is different language used in published guidelines for testing for fragile X carrier status, a common recommendation is that testing should be offered when there is a family history of undiagnosed intellectual disability.  In this case, the patient reports two paternal family members with autism.  Since the cause of autism is often uncertain, the patient meets the low threshold for offering testing. Thus, the requested gene panel testing to screen for fragile X is likely to be superior over other methods of evaluating this patient.Final Result: All three physician reviewers determined that the requested services are 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: All three physician reviewers are board certified in obstetrics and gynecology and are actively practicing. The reviewer is an 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 skilled nursing facility services for four (4) additional weeks for treatment of the enrollees hip fracture status post open reduction with internal fixation (ORIF).  Findings:  The physician reviewer found that the request for skilled nursing facility level of care for four (4) more weeks are not medically necessary for treatment of the patients medical condition. As the patient remained at toe-touch down weight bearing for the lower extremity which can be considered more restrictive and difficult to maintain than non-weight bearing and is intended to prevent both traction and compressive forces across the injured limb. She also had upper extremity restrictions and comorbid cardiac disease which were additional limiting factors. The patient reached a plateau consistent with her ongoing orthopedic precautions with no change planned in her orthopedic status for at least several weeks. Continued care would be at a custodial level and a periodic reassessment of her condition would be expected to determine the potential for measurable gains within a reasonable and predictable period of time. Discharge was medically appropriately as she reached a plateau consistent with her orthopedic precautions. In sum, the patient does not meet criteria for continued SNF level care. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain 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 Afirma Gene Expression Classifier test performed for the evaluation of the enrollees thyroid nodule. Findings: Three physician reviewers found that the Afirma Gene Expression Classifier test performed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The cytopathology of the 3.6 cm thyroid nodule was consistent with atypia of undetermined significance. The risk of malignancy is 5-15% in atypia of undetermined significance (Cibas, et al; Haugen, et al). The American Thyroid Associations guidelines for nodules with atypia of undetermined cytology state that 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. Informed patient preference and feasibility should be considered in clinical decision-making. If genetic testing is suspicious, the risk of malignancy increases to 40% (Haugen, et al; Alexander, et al). In this case, the result of the Afirma Gene Expression Classifier was suspicious for malignancy. This information was important to determine the decision whether to perform thyroidectomy, and the extent of surgery. There are multiple peer reviewed scientific articles supporting the benefits of the genetic test in thyroid nodules (Cibas, et al; Haugen, et al; Alexander, et al). In conclusion, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All 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: All three physician reviewers number are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is 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 an ultrasound for evaluation of the enrollees left breast pain. Findings:  The physician reviewers found that the American College of Radiology (ACR) has rated the various modalities in terms of appropriateness to screen for breast cancer. An ultrasonography is noted to be usually inappropriate for breast cancer screening in patients with an average risk.  In conclusion, while breast ultrasound is a useful adjunct to mammography, its diagnostic accuracy alone is poor, and it is not recommended as a screening modality. Thus, the request for an ultrasound of the breasts is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the requested service is 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 number one, two, and three are board certified in diagnostic radiology 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: A parent of an enrollee has requested reimbursement for the GeneSight attention deficit hyperactivity disorder (ADHD) testing for evaluation of the enrollee's major depressive disorder and ADHD. Findings: Three physician reviewers found that there is a lack of evidence that supports use of generalized pharmacogenetic testing in this clinical setting. Only a small portion of genetic markers are estimated to have a direct impact on drug response, which is likely influenced by environmental, genetic, and gene-environment interactions. Overall, current pharmacogenetic testing is not specific enough to provide accurate responses about expected drug responses. Moreover, there is a paucity of data to support MTHFR polymorphism testing in this patients evaluation. The American College of Medical Genetics (ACMG) recommends against testing patients for MTHFR variants, including those with known family history of polymorphisms, given the lack of clinical utility with such testing. All told, the GeneSight ADHD testing (to see how the patients body breaks down a drug) provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All 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 physician reviewer number is board certified in psychiatry and is actively practicing. Two physician reviewers are board certified in clinical genetics 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory tests received for evaluation of the enrollees family history of rhizomelic chondrodysplasia punctate 1 (RCDP1). Findings:  Three physician reviewers have found that RCDP1 is a condition that impairs the normal development of many parts of the body. The major features of this disorder include skeletal abnormalities, joint deformities, distinctive facial features, intellectual disability, respiratory problems, cataracts, cardiac anomalies, cryptorchidism and seizures. Because of their severe health problems, most people with rhizomelic chondrodysplasia punctata survive only into childhood. However, a few individuals with milder features of the condition have lived into adulthood (Cim, et al; Duker, et al). Prenatal diagnosis of RCDP1 has tremendous clinical benefit. Early detection in pregnancy allows for the appropriate care team to be in place at the time of delivery. This care team would include orthopedic surgery, ophthalmology, neonatal intensivists, pediatric surgery and pediatric neurology. Early diagnosis of RCDP1 allows for the appropriate healthcare team to be in place at the time of delivery in order to address the multiple congenital complications present. Therefore, laboratory tests received were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three physician 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: Two reviewers are board certified in pediatrics and clinical genetics and are actively practicing. One reviewer is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and is 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 caudal epidural with ultrasound imaging for treatment of his low back pain with bilateral lower extremity radicular pain.Findings: The physician reviewer found that the literature does support a home exercise program after physical therapy independent of an epidural can give a patient lasting results (Koc, et al). This is part of the recommendation of having active exercise with the physical therapy. Although this patient has participated in physical therapy in the past, the records indicate the most recent treatment was in 1998. There is mention of exercise but there is no documentation of a current home exercise program following an adequate course of physical therapy. Accordingly, the request for a caudal epidural with ultrasound imaging is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested service 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 anesthesiology with sub-specialty certification in pain 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cytogenic microarray testing for evaluation of enrollee who presented at eight weeks with a nonviable pregnancy.Findings: Three physician reviewers found that the American College of Obstetricians and Gynecologists (ACOG) does not recommend routinely assessing chromosomal microarray analysis because there is insufficient evidence to support its use. There are special circumstances when this analysis has been found to be useful. For example, this analysis has been found to be useful when structural abnormalities have been identified on ultrasound.  Of note, this analysis has been noted to be deficient in identifying triploidies of which partial moles are included. In this patients case, the early fetal demise could be sufficiently examined with routine chromosomal analysis. Therefore, the cytogenic microarray testing performed was not likely to have been superior to the standard options for the evaluation of this patient.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: All three physician reviewers 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing provided for evaluation of the enrollees lung cancer. Findings: Threee physician reviewers found that multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample, instead of doing the tests sequentially. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients, thus facilitating prompt treatment or protocol inclusion. The National Comprehensive Cancer Network Non-Small Cell Lung Cancer Guidelines Panel strongly endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. For the treatment of patients with advanced non-small cell lung cancer, broad molecular profiling is considered a standard of care.  In sum, genetic testing provided was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: All three reviewers determined that the services at issue were 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: All three 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections in both knees for treatment of the enrollees bilateral knee osteoarthritis. Findings:  The physician reviewer found that As evidenced by this patients history of significant benefit from prior injections, the current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. Colleagues reported on a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors noted that that the current highest level of evidence suggests that viscosupplementation is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Intraarticular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Overall, 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. In light of the foregoing, the requested hyaluronic acid injections are supported as medically necessary for treatment for management of the patients osteoarthritis of the knees. 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.
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 treatment of the enrollees heterozygous familial hypercholesterolemia.  Findings: The physician reviewer has found that the request for Repatha has not been established as medically necessary for treatment of the patients medical condition. Based on the records provided for review, the patient is a 55-year-old male with hyperlipidemia but no documented clinical cardiovascular disease, only mild carotid plaquing. The documentation also does not support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. These diagnoses require not only elevated LDL cholesterol levels that significantly exceed 180 mg/dl but also a combination of physical exam findings, a strong family history of coronary disease and documented genetic defects related to cholesterol metabolism according to published criteria. Repatha is a PCSK9 inhibitor indicated 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 these criteria. Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Finally, there are other statin medications such as pitavastatin and fluvastatin that have lower side effect profiles and have not been documented to be tried or not tolerated in this patient. Therefore, the requested medication 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.