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

Nature of Statutory Criteria/Case Summary: The parent of a two-year-old male has requested authorization and coverage for a Bantam stander for the treatment of the enrollee who has been diagnosed with microcephaly and global developmental delay.  Findings:  2/3 of the physician reviewers found that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The device will enable the patient to assume a variety of functional positions and facilitate weight-bearing on his long bones.  This is likely to decrease the risk of osteoporosis as well as  decrease the risk of developing contractures of the hip, knees and ankles. There will also be a decreased risk of pressure sores. Appropriate positioning will aid the maintenance of normal gastrointestinal function. Colleagues describe the beneficial effects of dynamic standing to increase cortical bone mineral density. Additionally, Hough and colleagues showed a large and significant effect on the lumbar spine when increasing static standing time. For these reasons, a Bantam stander is likely to be more effective for treatment of this patients medical condition. Final Result: 2/3 of the reviewers determined that the requested equipment is 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 pediatrics and neurology with special qualification in child 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.Physician reviewer number two is board certified in pediatrics and neurology with special qualification in child 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.Physician reviewer number three is board certified in pediatrics and neurology with special qualification in child 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: An enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the utilization of ABA therapy for the treatment of autistic adults, several medical studies demonstrate efficacy in relation to life skills, personal appearance, and toileting. According to the National Institute for Health and Care Excellence (NICE) guidelines for ASD in adults, ABA also plays an important role in the treatment of aggression and outburst behaviors in adults. In this case, the patient presents with frequent episodes of self-harm, along with occasional aggression toward others. These behaviors place the patient at an increased risk for injury. In addition, the Behavior Analyst Certification Board indicate that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. 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 pediatrics with sub-specialty certification in developmental-behavioral 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Elidel 1% cream for treatment of the enrollees seborrheic dermatitis. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The patient has tried and failed therapy with ketoconazole cream and desonide cream.  Thus, he has already tried and failed therapy with a topical steroid and a topical antifungal cream, and he has involvement of the face.  Long-term use of topical steroids on thin skin, such as on the face, can lead to skin atrophy and other side effects including telangiectasias.  In this clinical setting, Elidel 1% cream is likely to be safe and effective in the long-term. Therefore, Elidel 1% cream is 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 dermatology 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 Repatha Sureclick 140 mg for treatment of the enrollees hyperlipidemia. Findings:  The physician reviewer found that based on the records provided the patient is a female with known cardiovascular disease, severe hyperlipidemia and documented intolerance to multiple statin medications and Zetia. The intolerance reported is consistent with published criteria that lists severe myalgias as an occasional reported intolerance. Repatha is a PCSK9 inhibitor studied in and approved for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol. Repatha has been demonstrated in the peer-reviewed literature to improve patient outcome in this clinical setting. Thus, the use of Repatha Sureclick 140 mg is medically reasonable and appropriate for treatment of this patients medical condition.  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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 18 hours per week of additional applied behavioral analysis (ABA) therapy services for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the patient has made progress in many areas, but continues to demonstrate significant delays in social skills and adaptive skillsets along with significant outbursts of aggression. The patient continues to require a high level of behavioral support as evidenced by the multiple treatment goals set forth by his provider. Failure to demonstrate progress in these areas places the patient at an increased risk for injury, and makes it increasingly difficult to be successful in more generalized environments. The Behavior Analyst Certification Board indicates that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Given the support in medical literature and the documentation submitted for review, the request for 18 hours per week of additional ABA therapy services are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral 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 reimbursement for gene test provided for evaluation of the enrollee who has a family history of von Hippel-Lindau syndrome. Findings:  The 3 physician reviewers found that there is sufficient support in the medical literature for the services at issue in this clinical setting. VHL syndrome is inherited in an autosomal dominant manner. Approximately 80% of individuals with VHL syndrome have an affected parent and about 20% have VHL syndrome as the result of a de novo pathogenic variant. The offspring of an individual with VHL syndrome are at a 50% risk of inheriting the VHL pathogenic variant. In this patients case, little is known regarding the VHL status of the patients father, making it difficult to quantify the patients risk of being affected with VHL.  However, given the family history of VHL, a history of hypertension and hypercholesterolemia in the patients father (VHL status not reported) and recurrent abdominal pain in the patient, VHL syndrome is a diagnostic concern.  While this diagnosis seems unlikely given the lack of accompanying features (none reported), the diagnosis of VHL is established by genetic testing even when clinical and radiographic features are inconclusive.  Testing for VHL should begin with sequence analysis of VHL, followed by gene-targeted deletion/duplication analysis, both of which were conducted in this case. The use of these technologies (sequencing and deletion/duplication testing) represents the standard of care and is not investigational. All told, the gene test provided was likely to have been more effective than any available methods for the evaluation of this patient. Final Result: The 3 reviewers determined that the  services at issue were likely to have been 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 medical genetics and genomics 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 medical genetics and genomics 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 medical genetics and genomics 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 (unlisted molecular pathology) for evaluation of the enrollee, who had an elevated prostate-specific antigen (PSA) level. Findings:  The 3 physician reviewers found that the Confirm MDx testing is a multiplex polymerase chain reaction (PCR) assay measuring DNA methylation of three biomarkers associated with prostate cancer: GSTP1 APC and RASSF1. Two recent studies have suggested that Confirm MDx can accurately predict the need for repeat biopsy in a patient with negative biopsy results. However, these studies are recently published and need continued validation from widespread clinical use. The clinical utility awaits evaluation by a prospective, randomized clinical trial which is currently recruiting (PASCUAL study). While Confirm MDx may eventually have a role in treatment decision making for patients with prostate cancer risk, there is limited data on clinical outcomes to currently support routine use.  At this time, the superior efficacy of gene testing (unlisted molecular pathology) provided has not been established. Final Result: The 3 reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in urology 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 urology 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 urology 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 of Harvoni for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated. These guideline recommendations are based on multiple randomized clinical trials. The Health Plans preferred medication, Zepatier, has already been requested and denied.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is needed in this patients case. All told, treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 14-year-old male enrollee has requested authorization and coverage for orthodontic treatment including D0330 (panoramic x-ray), D0340/D0350 (cephalometric images), D0470 (diagnostic casts), D8080 (comprehensive orthodontic treatment), D8670 (periodic orthodontic treatment), D8680 (orthodontic retention) for treatment of the enrollees dental issues. Findings:  The physician reviewer found that as the need for orthodontic treatment can involve subjective assessments, there have been several objective tools developed as a means of comparing need for treatment. One such tool is the HLD. With the HLD, a score typically greater than 25 qualifies for treatment as a severe need. In this case, the corrected score was computed at 20, which is well under the threshold for treatment. There are several factors provided to exempt this score and qualify automatically based on medical or dental conditions. However, the documentation provided does not describe any conditions which would supersede and support an indication for the requested treatment. While this patient would benefit cosmetically and would show an improvement in chewing with orthodontic treatment, the records provided for review do not meet the threshold of medical necessity. For these reasons, the requested orthodontic treatment including D0330 (panoramic x-ray), D0340/D0350 (cephalometric images), D0470 (diagnostic casts), D8080 (comprehensive orthodontic treatment), D8670 (periodic orthodontic treatment), D8680 (orthodontic retention) has not been demonstrated to be medically necessary for treatment of the patients medical condition. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the WalkAide functional electrical stimulator (FES) for treatment of the enrollees hereditary spastic paraplegia. Findings:  The physician reviewer found that the request for the WalkAide FES is not medically necessary for treatment of this patients medical condition. A review of the peer-reviewed medical literature reveals that the WalkAide can be used in spinal cord injury patients for walking in the home after the patient has completed an adequate trial of physical therapy with the device over a period of three months. This trial period can allow the patients provider to properly evaluate the patients safety and ability to use the device for the long-term. A review of the literature also states that patients require muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an upright support posture independently prior to using the WalkAide device. The documentation reveals that the patient has only had a two week trial of this WalkAide device and does not include objective documentation of objective measurable functional improvement. The records indicate that the patient has difficulty maintaining her posture for stance due to equinovarus deformity. She also has significant lower extremity spasticity as noted in her providers documentation. Furthermore, the literature does not support that a FES has been proven to be effective for ambulatory function and muscle strength for progressive diseases in patients without spinal cord injury. All told, the requested WalkAide FES is not supported as medically necessary. Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) scan of the heart for evaluation of the enrollees family history of heart disease.  Findings:  The 3 physician reviewers found that based on the records provided the patient is a male with a family history of coronary disease, no documented cardiac symptoms, and a normal cardiovascular physical examination. In this circumstance, guidelines for the evaluation and management of coronary risk recommend using the combination of clinical risk profiling in conjunction with a basic lipid analysis. Current guidelines by the American College of Cardiology and American Heart Association do not recommend screening with coronary calcium scanning in this setting. Therefore, the request for CT scan of the heart is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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.