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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for Guardant360 Liquid Biopsy for a diagnosis of metastatic non-small cell lung cancer. His physician ordered the Guardant360 test to determine if his current treatment regimen was optimized to manage his care. The Guardant360 report indicated somatic alterations were detected in the circulating cell-free DNA isolated from the enrollees blood specimen. The genomic alterations were cancer-associated somatic variants, some of which have been associated with either increased or reduced clinical response to specific treatments. Epidermal growth factor receptor (EGFR) amplification was detected in the circulating cell-free DNA isolated from this enrollees blood specimen for the annotated gene(s). Other alterations found in the report are MET, TP53 and NF1. The Guardant360 found the original EGFR mutation; as well as other mutations with associated approved therapies with clinical trial availability. genotyping of tumor tissue has significant inherent limitations; such as selection bias and the difficulty of obtaining a representative sample. Standards or guidelines for the use of (cfDNA)/circulating tumor DNA testing for genetic alterations do not support Guardant360 testing due to the high false-positive rate of 30% and  the presence of other alterations not related to the tumor. The testing can be used in specific circumstances, as when there is not sufficient tissue for molecular analysis, or the patient is not physically fit for invasive procedures. Professional societies have not established standards or guidelines for the use of (cfDNA)/circulating tumor DNA testing for genetic alterations, due to the high false-positive rate of 30% and  the presence of other alterations not related to the tumor. Several research and development efforts regarding liquid biopsy diagnostics exist, but they lack integration of concepts; including discovery, development, standardization, clinical validation and implementation. Additional studies are needed to determine the efficacy of the Guardant360 in non-small cell lung cancer. Literature does not advocate the use of this testing procedure to formulate conclusions concerning the effect on improvement in health outcomes.Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in medical oncology and one reviewer is board certified in radiation oncology and are 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:  The enrollee requested reimbursement for SPECT Scans. He has a history of head/brain trauma with first injury occurring at the age of four or five, when he hit his head on playground equipment. He hit a parked car in an automobile accident and had a bicycle collision while riding downhill. He was air lifted to a trauma center and was unconscious for three days. He requested an evaluation, as he is curious about his brain health. As part of the evaluation, a resting and a concentration brain single photon emission computed tomography (SPECT) study were performed. The most significant findings were the irregularly decreased activity in the anterior poles, moderately decreased activity seen in the temporal lobes bilaterally in both scans, and the milder decreases in the frontal, parietal and occipital lobes; suggestive of a brain injury. Moderately increased activity was noted in the right basal ganglia and in the focal left region of the thalamus at rest. Moderately decreased activity was noted in the inferior orbits of the prefrontal cortices bilaterally. The medical literature notes that SPECT-CT is where two different types of scans are taken and the images or pictures from each are fused or merged together. The fused scan can provide more precise information about how different parts of the body function and can more clearly identify problems, such as tumors or Alzheimers disease. The enrollee underwent the SPECT studies to improve his marital relationship based on improvement of their brains.  However, literature does not support the use of SPECT studies for improvement of the enrollee's brain health. The scientific evidence and peer-reviewed literature does not support a result of improvement in health outcomes to support this service. Literature from a professional society indicates a single-photon emission computed tomography (SPECT) scan is appropriate for individuals with suspected dementia, with localizing epileptic foci preoperatively, for diagnosing encephalitis, for mapping of brain perfusion during interventions, for detecting and evaluating cerebrovascular disease, or for predicting the prognosis of individuals with cerebrovascular accidents.  Other findings with SPECT brain perfusion imaging, for indications such as neuropsychiatric disorders and chronic fatigue syndrome, have not been fully characterized.Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in psychiatry and are 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 enrollee is requesting authorization and coverage for chemical dependency group classes. for the treatment of cannabis use, referred by a court mandate.  The intake assessment indicates a maximum of two months of abstinence in the past 12 months and a maximum of one year of abstinence since initiating substance use.  His speech and behavior were disorganized. However, he was able to track conversations, but was restless and nervous. He had a restricted affect and expressed paranoid ideations. Per the enrollee, he was diagnosed with schizophrenia, undifferentiated. Assessment showed the enrollee met DSM-V criteria for cannabis use disorder, moderate.  The provider recommended the day treatment level of care, cognitive approach to chemical dependency.  Some of the behaviors noted during the chemical dependency group class included disengagement from the group, not completing workbook assignments and laughing during class inappropriately.  His marriage and family therapist recommended a reassessment by psychiatrists and mental health care providers before returning to the chemical dependency group class. Per assessment/intake documentation, the enrollee denied use of any substances, except nicotine and cannabis.  He reported smoking one-half pack per day of cigarettes and marijuana weekly since age 12, but denied any use in the previous 30 days.  In the absence of reported substance use, his presentation suggests the possibility of psychotic symptoms. Olanzapine was reportedly prescribed; however, there is insufficient evidence in the record of his last psychiatry visit or compliance with his medications.  In addition, cigarette smoking decreases Olanzapine levels.  In regard to the enrollees presentation during chemical dependency group classes, schizophrenia can impact multiple areas of cognition; such as processing speed, attention, working memory, visual learning and memory, verbal comprehension and social cognition. Based on the information in the record, this enrollee is not able to participate in chemical dependency classes in his current condition. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.  Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Synvisc-One injection in the right knee only. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether a Synvisc-One injection in the right knee only is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient had an excellent response to prior viscosupplementation. Furthermore, her options are limited. The patient has tried and failed conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, a Synvisc-One injection in the right knee only is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has received lasting benefit from prior viscosupplementation with Euflexxa. Furthermore, his remaining treatment options are limited. The patient has tried and failed other conservative treatments including physical therapy and medication, with the alternative being bilateral total knee arthroplasties. For these reasons, the requested Euflexxa injections in both knees are medically necessary for 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a pigmented lesion assay. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) TNM system that defines cutaneous melanoma stages 0-IV. While the majority of clinical stage I patients will be disease-free at five years, some stage I patients will develop advanced disease. The DermTech pigmented lesion assay (PLA) is a non-invasive gene expression test that can help providers guide pigmented lesion management decisions and rule out melanoma. The assay analyzes samples for expression of two key genes, PRAME and LINC00518, which are known to be overexpressed in melanoma. The test result is positive or negative based on the detection of one or both genes. PLA positive cases are generally biopsied to establish the histopathologic diagnosis, while PLA negative findings are considered for ongoing monitoring. However, the current gold standard for melanoma diagnosis remains visual inspection with histopathology, which has a relatively low negative predictive value of approximately 83%, confirmed in clinical studies and current practice. All told, the pigmented lesion assay 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 pigmented lesion assay 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 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 dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for four hours per week of applied behavior analysis (ABA) services for six months. A definition of medical necessity that includes health-care services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are: (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on the current information provided for review, there is a lack of updated diagnostic information and treatment plan. Thus, the requested services are not required to meet the essential health needs of the patient and are not consistent with the diagnosis of the condition for which they are required. The patient needs an updated diagnostic make-up and treatment plan to meet the criteria outlined. In the absence of a current diagnostic work-up and treatment plan, the patient does not meet the criteria for medical necessity. Therefore, four hours per week of ABA services for six months are not medically necessary for 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 a licensed B.C.B.A board certified in psychology 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 patient has requested authorization and coverage for jaw surgery, reconstruction midface, LeFort I without bone graft and bilateral sagittal osteotomies with bone grafting. The etiology of maxillofacial skeletal deformities may be either congenital or acquired. Deformities may be evident at birth or may manifest during subsequent growth and development, creating functional and/or degenerative problems. The records provided for review document that the patients maxillofacial skeletal deformity is not amenable to correction with orthodontics alone. The proposed surgery will result in improved musculoskeletal and dento-osseous relationships. This correction will improve the patients mastication, associated temporomandibular joint and muscular disorders, and signs and symptoms of sleep disordered breathing. The requested surgery is medically necessary and appropriate for the diagnosis of the patients condition, and is within generally accepted standards of medical care in the community. In addition, the requested surgery is reconstructive in nature. The patient has an abnormal structure of the body, caused by congenital and developmental abnormalities. Moreover, the requested surgery is being performed to improve function. Furthermore, the requested procedures will provide a more than minimal improvement in the appearance of the patient. Therefore, jaw surgery, reconstruction midface, LeFort I without bone graft and bilateral sagittal osteotomies with bone grafting, are medically necessary and reconstructive in nature for 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: The patient has requested authorization and coverage for skilled nursing facility (SNF) services, including physical therapy, occupational therapy, and speech therapy. The records provided for review document that this patient presented with major trauma status. She sustained multiple fractures and organ damage, requiring blood transfusions. The patients providers state that she is not ready for home-based therapy. She remains at high risk for falls, is unable to adequate feed herself and take medications, and requires skilled rehabilitation services. All told, the requested SNF services, including physical therapy, occupational therapy, and speech therapy, are medically necessary for 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 internal medicine with expertise in skilled nursing facilities 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 Synvisc Syringe injections in the left knee. Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, viscosupplementation has been tried and found to be beneficial for the last five years. Additionally, the patients options are clearly limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. Under these circumstances, Synvisc Syringe injections in the left knee 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 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.