Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for D7240, removal of tooth #58 and #59 for treatment of her maxillary incisor supernumerary teeth. Findings:  The physician reviewer found that the medical literature and the documentation provided support the dental necessity for the services at issue in this clinical setting. The Health Plan denied the services at issue due to the patients age. The Health Plan requires patients undergoing these procedures must be 14 years old. However, removal of the supernumerary teeth is indicated prior to closure of the apex of the central incisors which usually occurs between the ages of eight and nine. The literature demonstrates that supernumerary teeth are common causes for delayed eruption of maxillary incisors. Well accepted approaches to the management of these teeth include removal when it is clear that the eruption of the central incisors will be blocked and before the apex of the permanent incisor is complete. The records provided demonstrate that the supernumerary teeth in this patients case were impeding the eruption of teeth #8 and #9. Given this information, the removal of this patients supernumerary teeth was reasonable and necessary. Final Result: The reviewer determined that the services at issue were dentally 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 facial and maxillary 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 reimbursement, prospective authorization and coverage for residential treatment center services provided.  Findings:  The physician reviewer found that according to Walsh and colleagues A [partial hospitalization program] PHP is appropriate when meal supervision is needed without requirement for 24-hour supervision. PHP admission generally requires that patients be at or above minimally acceptable weight (e.g., greater or equal to 80% of ideal body weight) and maintain other evidence of medical stability. The patient did not meet the criteria for orthostatic hypotension. The patient was medically stable, did not have any suicidal or homicidal ideation, and did not have any psychosis, hallucinations, or paranoia that would require 24-hour observation. The patient was motivated for treatment. Therefore, the patient could have been treated in a lower level of care. Final Result: The reviewer determined that the services at issue were not and 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 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: An enrollee has requested authorization and coverage for speech therapy for treatment of his phonological childhood onset fluency disorder. Findings:  The physician reviewer found that the medical records include a neurologists evaluation which states that the patient likely suffered perinatal hypoxia which manifested as left cerebral hemispheric damage. There was also evidence of motor coordination abnormalities. Therefore, the patients current speech disorder likely originated from cerebral hypoxia. Since the patients speech disorder is likely due to a hypoxic event, the requested speech therapy services are medically necessary. 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 physical medicine and rehabilitation 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 Genotropin (somatropin [rDNA origin] for injection) 5 mg/mL for treatment of his short stature. Findings:  The physician reviewer found that the Genotropin (somatropin [rDNA origin] for injection) 5 mg/mL was and is medically necessary for treatment of the patients medical condition. The patients pre-treatment height was below the 1st percentile. In addition he had poor growth velocity, his adult predicted height was more than two SDs below the average U.S. male adult height, and he had low serial IGF-1 levels. Although he passed GH provocative testing, he meets criteria for GH treatment based on the U.S. Food and Drug Administration (FDA) approved indication for idiopathic short stature. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than two SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SD below the mean for age; (4) low serum IGF-1 and/or insulin-like growth factor-binding protein 3 (IGFBP-3); and/or (5) other clinical features suggestive of GH deficiency. This patient does meet most of the above criteria, and his adult predicted height of 61 inches is short enough to warrant GH therapy based on current FDA standards for treatment of idiopathic short stature.  Final Result: The reviewer determined that the medication at issue was and 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 with sub-specialty certification in pediatric endocrinology 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 DecisionDX-Melanoma multivariate gene expression assay for evaluation of his cutaneous melanoma. Findings:  Three physician reviewers found that The staging and prognosis of cutaneous malignant melanoma is classically determined by the system spelled out by Balch. There may be some further value in adding the mitotic rate to this system.  According to the Balch staging, this melanoma would be classified as a T3a stage IIA. There is no information in the records submitted as to whether he had sentinel node done. DecisionDX is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 or class 2 (with a distant metastasis free five year survival of about 90% versus. 65-80%. Gerami and colleagues reported on 217 cases, with good correlation between DecisionDX data and prognosis in patients undergoing sentinel node biopsy. However, it is unclear how the five year DecisionDX data compares to the ten year Balch data and whether it can be used to make clinical recommendations. Researchers reported on 156 cases but there was not sufficient follow-up to determine the actual value of the test. The National Comprehensive Cancer Network guidelines state that there is interest in these types of assays, but they can only be used in the context of a clinical trial.  At present, the available studies do not show that there is expected clinical benefits from using DecisionDX assay. 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 49-year-old male enrollee has requested authorization and coverage for Vemlidy. Findings:  The physician reviewer found that : guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir (Viread and Vemlidy) compared with alternatives for the treatment of chronic hepatitis B . In comparison with tenofovir disoproxil fumarate (Viread), which the patient takes, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with fewer side effects, including osteopenia and renal disease. For this reason, the request for Vemlidy is medically necessary for the treatment of this patients chronic hepatitis B. 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: An enrollee has requested authorization and coverage for Sovaldi 400 mg and Daklinza 60 mg for 12 weeks for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks and Sovaldi with Daklinza for 12 weeks are both recommended as first-line regimens for non-cirrhotic treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate (98%), and ALLY-3 for Sovaldi with Daklinza, which showed a 97% cure rate in non-cirrhotic patients. In this case, due to the patients lack of fibrosis stage 2 or higher, criteria for Epclusa is not met per the Health Plan policy. As such, Sovaldi and Daklinza is medically necessary and the only available treatment recommended by the guidelines. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medications 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Foundation One gene testing for evaluation of the enrollee's pigmented villonodular synovitis (PVNS). Findings:  Three reviewers found that PVNS is a rare disease which results in proliferation of the synovial tissue. It is a result of hypervascular proliferative synovium containing multi-nucleated giant cells, macrophages, and hemosiderin. Since the giant cells express osteoclasts, the abnormal proliferation of the synovial tissue results in destruction of adjacent bone. The optimal treatment option is surgical resection but there is a high risk of recurrence. Since PVNS is a rare disease treatment options are in limited. Due to the high risk of recurrence, radiation therapy is also considered a treatment option and is associated with a decrease in the rate of recurrence. Due to the patients sub-optimal results with radiation and surgery, novel therapeutic options were evaluated. A translocation of the colony stimulating factor 1 (CSF1)-COL6A3, t(1;2)(p13;q35) is associated with overexpression of CSF1 gene and results in CSF1 receptor (CSF1R) and recruitment of CSF1R-expressing cells of the mononuclear phagocyte lineage that make up the tumor mass of PVNS. A phase I/II and II study demonstrated that PLX3397 is an active CSF1R inhibitor in tumors expressing elevated levels of the CSF1 gene. These studies demonstrated a response rate of 25%. Given the patients sub-optimal results with radiation and surgery, the Foundation One gene testing was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for at least six months of the following services: 17.2 hours per month of direct applied behavioral analysis (ABA) therapy, 4.3 hours per month of supervision and 8.6 hours per month of parent training for treatment of his autism.  Findings:  The physician reviewer found that there is sufficient medical literature supporting ABA therapy as an effective treatment for children with autism. However, based on the records submitted for review, the therapeutic services provided do not appear to be consistent with ABA therapy. There is no evidence of direct or indirect oversight by an analyst certified by the Behavioral Analyst Certification Board (BACB). Further, there does not appear to be any documented use of either a validated assessment tool or a defined functional assessment. Given that the services are not consistent with community standards for the delivery of ABA therapy, the request for at least six months of the following services: 17.2 hours per month of direct ABA therapy, 4.3 hours per month of supervision and 8.6 hours per month of parent training has not been established as medically necessary.  Final Result: The reviewers 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Alkeran and Thalomid. Findings:  the physician reviewer found that the requested medications were removed from the list of treatment options in the National Comprehensive Cancer Network (NCCN) guidelines. For non-transplant candidates, the regimens that are no longer recommended by the NCCN panel include all melphalan containing regimens, thalidomide/dexamethasone, and vincristine/doxorubicin/dexamethasone (VAD). As such, Alkeran and Thalomid are no longer considered the current standard-of-care for patients diagnosed with MM, either due to concerns for toxicity and/or the availability of more effective regimens. The literature reports that melphalan-based regimens can lead to significant cytopenias and may limit subsequent use of newer medications. Alkeran could be expected to worsen this patients condition. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial is upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in hematology and medical oncology 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 LifeVest external cardiac defibrillator. Findings:  The physician reviewers found that there is potential for recovery of left ventricular function over time with medical therapy and there was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed where continued left ventricular dysfunction ejection fraction is less than or equal to 35% is documented to persist in spite of appropriate treatment. A prophylactic defibrillator, wearable or implantable, before this time has not been demonstrated to improve outcome. Studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed due to infection, or required explanation. Final Result: The reviewers determined that the requested device is 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: the physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary The parent of an enrolleee has requested reimbursement for psychiatric residential treatment center (RTC) services provided. Findings:  The physician reviewer found that Review of the submitted documentation indicates the patient was approved for admission to a RTC on transfer from another facility, and at the recommendation of the previous facility. The patient continued to meet criteria for continued stay in a RTC as the enrollee was expected to have continued weekly psychiatric evaluations, was making progress toward established goals, and was being cooperative. However, the patient  had demonstrated significant progress toward goals of emotional regulation and relationships. The goal of improved trust within the family could better be met with intensive outpatient program (IOP) treatment, and multisystem therapy delivered in a less restrictive environment. The enrollee had begun to lose trust and confidence in the staff, became uncooperative with treatment, and stated that the patient believed that they would would always be in an inpatient facility. For these reasons, the medical records demonstrate that the psychiatric RTC services provided  were medically necessary for treatment of this patients behavioral condition but not thereafter.  Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing for evaluation of her cutaneous melanoma.  Findings:  Two physician reviewers found that the DecisionDx melanoma assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx melanoma 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 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: Reviewers 1, 2, and 3 are board certified in dermatology and is actively practicing. The reviewers are expert sin 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.