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

An enrollee has requested authorization and coverage for coverage for computed tomography (CT) scan of the heart with quantitative evaluation of coronary calcium. Findings:  Two of the three physician reviewers found the patient has a strong family history of early coronary artery disease with multiple close blood relatives having early coronary artery disease or myocardial infarction. She also has evidence of vascular calcium on in the abdominal aorta at a relatively young age. The use of coronary calcium scoring has been recommended as a reasonable test to better assess risk of coronary disease in this intermediate risk population, especially in light of the strong family history of early coronary artery disease. A high calcium score would provide further evidence of a higher risk of coronary artery disease and would assist in determining the need for long-term statin therapy. A calcium score of zero would provide reassurance to continue with non-pharmacological therapies and avoid lifelong statin lipid lowering therapy at this time. Calcium scoring would provide significant clinical information which could impact long-term treatment and outcomes. Therefore, the requested CT scan of the heart with quantitative evaluation of coronary calcium is likely to be of greater benefit than other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 transcranial magnetic stimulation services. The submitted documentation supports the medical necessity of the services at issue. Per the records, the patient made consistent progress while receiving transcranial magnetic stimulation treatment. It appears that the patient made a return to her baseline level or near baseline level at the end the disputed 10 treatments. The exact number of transcranial magnetic stimulation treatments needed for successful depression symptom resolution is not clearly defined in the evidence-based literature. Some patients need more than 30 treatments for successful resolution of their symptoms. The number of sessions often needs to be considered on a clinical basis instead of a numerical basis. In this patients case, she was tolerating treatment well. There is support for the services at issue in this clinical setting. Therefore, transcranial magnetic stimulation services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry 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 Anser IFX. Anser IFX has not definitively demonstrated efficacy for the management of ulcerative colitis. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. Another review reported that there is ongoing debate as to the relevance of antibodies to infliximab development in clinical care and that published studies on this topic lack uniform reporting of outcomeshigh risk of bias was present in all the included studies. All told, the Anser IFX testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the Anser IFX testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for dermatology services on the basis that the services were emergent in nature. Review of the submitted documentation does not demonstrate the patient was experiencing an emergency medical condition on the dates of service at issue. The patients presenting symptoms of alopecia (hair loss), skin irritation and skin lesion were not consistent with an emergency medical condition. The patients symptoms were not acute and did not represent an immediate threat to the patients health. As such, the services were not required for treatment of emergency medical condition as defined above. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral Synvisc One injections. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients osteoarthritis. The submitted documentation does not support the medical necessity of the requested medication. a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Evidence-based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to corticosteroid injections. While medial and/or lateral compartment osteoarthritis is a recommended indication, there is insufficient evidence for other conditions, including patellofemoral arthritis, chondromalacia patella, patellofemoral syndrome, or osteochondritis dissecans. This patient presents with a recurrence of bilateral knee pain. Functional limitations were noted in mobility and activities of daily living. Prior Synvisc injections reportedly resulted in pain reduction and improved functional mobility. However, there is no documentation of a specific clinical examination or discussion of radiographic findings to support the presence of medial and/or lateral compartment osteoarthritis. The treating provider documented a diagnosis of patellofemoral arthritis. Current evidence-based guidelines and literature support the medical necessity of hyaluronic acid injections for the treatment of medial and/or lateral compartment arthritis. However, the medical evidence does not support the medical necessity of these injections for patellofemoral arthritis. Therefore, the requested bilateral Synvisc One injections are not medically necessary for the treatment of the patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: The parent of a minor enrollee has requested authorization and coverage for 172 hours per month of direct one-to-one applied behavioral analysis (ABA) therapy, 14 hours per month of supervision, and two hours per month of parent training. Medical literature regarding the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder show that no correlation between the number of hours provided per week and outcomes. Medical literature further indicate that the age at which ABA therapy was started and duration of treatment was correlated with outcome. This patient has been documented as making significant progress in almost all areas since starting ABA therapy in October 2017. The Health Plan has approved the patient for 96 hours per month of direct one-to-one ABA services, which are appropriate given this patients current behavioral issues. Thus, the requested services of 172 hours per month of direct one-to-one ABA therapy, 14 hours per month of supervision, and two hours per month of parent training are not medically necessary for treatment of this 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 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 Stelara 90 mg every four weeks. The current medical literature supports dose escalation of Stelara in this case. A large randomized controlled trial demonstrated the safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohns disease which was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed. The study showed a 73.7% response rate in patients with anti-TNF-resistant Crohns disease. A significant majority of these patients were able to discontinue steroids. The current medical evidence supports the requested medication dosage in this patients case. Alternative therapies are limited, as the patient has failed treatment with other biologic therapy for Crohns disease. For these reasons, Stelara 90 mg every four weeks is medically necessary for the treatment of this patients Crohns disease.Final Result: The reviewer determined that the requested medication dosage 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Axumin positron emission tomography (PET) scan. The Health Plan has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees who has a history of prostate cancer.Findings:  Fluciclovine, the compound used for PET imaging in the Axumin scan has been approved by the U.S. Food and Drug Administration and included in the National Comprehensive Cancer Network (NCCN) guidelines as a procedure of choice for the evaluation of men with rising PSA following prostatectomy.  The medical literature indicates this agent has proven to be very sensitive in the detection of residual tumor in the prostate bed, lymph nodes and even bones in such patients.  The detection of recurrence allows for targeting the recurrence for therapy and is the best chance for prolonging survival and cure. In this patients case, his steadily rising PSA from an undetectable level to the current level is of concern for recurrence particularly in light of the positive surgical margins.  This patient does not have symptoms of recurrence but rather has a well recognized biomarker causing suspicion of recurrence.  For these reasons, the Axumin PET scan for evaluation of this patients medical condition is likely to be more effective than the available treatment options.  Final Result: Two of the three reviewers have determined 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 reviewers are board certified in diagnostic radiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the MiniMed 670G insulin delivery system with hybrid closed loop technology. Findings:  Two of the three physician reviewers found that a continuous glucose monitoring system is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed, thereby maintaining tight glycemic control and preventing hyperglycemia and hypoglycemia. It can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals and show early morning spikes in blood sugar.  Studies have shown that use of a continuous glucose monitoring system can help optimize glycemic control and can lead to even greater improvement when used in conjunction with insulin pump therapy.  The FDA recently approved the MiniMed 670G device, which is a hybrid closed-loop insulin delivery system for use in patients who are at least 14 years of age with type 1 diabetes. The system uses an algorithm to automatically adjust basal insulin doses based on readings from a continuous glucose monitor. This patient has suboptimal glycemic control with her current insulin pump with a high degree of variability and will likely benefit from the requested device. In sum, the requested MiniMed 670G insulin delivery system with hybrid closed loop technology is likely to be superior over other treatment options.Final Result: The reviewers determined that the requested device 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient has cerebral amyloid angiopathy, a condition associated with multifocal and recurrent hemorrhages. This is a condition in which tight control of arterial hypertension is particularly important. In this case, the patient had functionally plateaued at the essentially dependent level. There had been no consistent, significant progress over multiple weeks. There were no further therapy goals. There were no ongoing skilled nursing needs. She was stable on a continuous gastrostomy tube feed and was not able to safely swallow food orally. She was on anti-hypertensives and clinically stable. She did not require ongoing inpatient care for routine blood pressure monitoring. Therefore, skilled nursing facility services were not and are not medically necessary for the treatment of this patient. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for lidocaine patch. Findings:  The physician reviewer found that the medical records provided for review do indicate the presence of a neuropathic pain condition with associated hyperalgesia/allodynia. The records do not report the specific medications failed, specifically trials of antidepressants and anticonvulsants. The current peer-reviewed medical literature supports that lidocaine patches are primarily recommended for neuropathic pain when trials of antidepressants and anticonvulsants have failed. As the records do not indicate specific antidepressants and anticonvulsants tried and failed, the medical records do not support use of this medication. All told, the requested lidocaine patch is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested medication 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: One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. One Reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing.  One Reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an abdominal panniculectomy. Findings: The submitted documentation supports the medical necessity of the requested services. The records document evidence of an overlapping, symptomatic lower abdominal pannus. She has well-documented functional impairment with chronic rashes, consistent with chronic fungal infections, as well as lower back pain. She has attempted conservative management with topical dermatologic treatment. The medical evidence supports the requested services in this clinical setting. Thus, the requested abdominal panniculectomy is medically necessary for the treatment of this patient.In this patients case, the lower overhanging abdominal pannus is considered an abnormal structure of the body. This overlapping lower abdominal pannus is a result of her treatment of obesity, which is considered a disease. The requested surgery will both improve function and create a normal appearance to the extent possible. Based on the examination and the available photographs, more than a minimal improvement in appearance is expected with the requested services. Therefore, the requested abdominal panniculectomy is reconstructive in nature. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic 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.