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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with hypertension. An echocardiogram revealed moderately reduced systolic function and an ejection fraction of 35%. The patient underwent cardiac catheterization due to chest pain. The report noted non-obstructive coronary artery disease. The patient was noted to have a history of hypertension, hyperlipidemia, and coronary artery disease. There was no report of chronic congestive heart failure (CHF) symptoms or signs of CHF in the physical examination. The patient was being treated with Coreg, Lipitor, and lisinopril. The patient has requested authorization and coverage for Entresto. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Entresto is medically necessary for the treatment of the patients medical condition. Entresto is an angiotensin receptor-neprilysin inhibitor (ARNI). Yancy and colleagues reported, In patients with chronic symptomatic reduced ejection fraction New York Heart Association (NYHA) class II or III who tolerate an angiotensin-converting-enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), replacement by an ARNI is recommended to further reduce morbidity and mortality. In this case, the patient does have a reduced ejection fraction; however, the only reported symptom noted was chest discomfort, which places him in the NYHA class I (asymptomatic with regard to heart failure symptoms). There was no report of symptoms of CHF in the medical records and no signs of CHF reported in the physical examination. The medical evidence does not support the requested medication in this clinical setting. Therefore, Entresto is not medically necessary for the treatment of this 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of chest with and without contrast.The submitted documentation does not support that the requested services are medically necessary. Conservative management with NSAIDs, aggressive pulmonary hygiene, early ambulation, and physical therapy remains the mainstay for the management of acute musculoskeletal injuries. In this case, the patient presented with acute chest wall pain after falling in the bathtub. Cross-sectional chest CT imaging is negative for acute osseous, pulmonary parenchymal, pleural, or pulmonary vascular processes. Though chest MRI may be appropriate for the further evaluation of vascular, pleural, space-occupying, and neurological abnormalities within the thorax, there is no documentation to support such indications in the patient at the current time. Under these circumstances, magnetic resonance imaging (MRI) of the chest with contrast is not medically necessary to treat the patients medical condition. In addition, magnetic resonance imaging (MRI) of the chest without contrast is also not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certifications in pulmonary disease and critical care 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly cognitive behavioral therapy (CBT), weekly eye movement desensitization and reprocessing (EMDR), and 24 sessions of weekly vision therapy. Based on the available documentation, the request for weekly CBT is medically necessary for treatment of this patient. The patients symptoms include anxiety, panic, binocular vision dysfunction, and insomnia. Weekly appointments with a therapist for CBT is indicated to address this patients current symptomatology. Although an intensive outpatient program (IOP) would allow visits that are more frequent with a psychiatrist and therapist, long-term continuity with a therapist and psychiatrist is central for this patients recovery. However, the requested EMDR therapy is not medically necessary for this patient. EMDR is supported as effective for the treatment of patients with post-traumatic stress disorder (PTSD). The records provided for review do not document a history of PTSD or that PTSD is central to the patients current symptomatology. Moreover, vision therapy is not appropriate for treatment of this patients symptoms. There is a paucity of support in the peer-reviewed medical literature to support a role for vision therapy in this clinical setting. The requested 24 sessions of vision therapy is not medically necessary for treatment of this patient. Given these findings, weekly CBT is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested weekly CBT is 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 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 a dotatate positron emission tomography (PET) scan. Recurrence of neuroendocrine tumors after resection is common, even more so in cases with nodal metastases. Early detection of tumor recurrence is critical to determine treatment planning. Currently, there is a lack of consensus for follow-up imaging of neuroendocrine tumors for the detection of recurrence. However, dotatate PET imaging has become increasingly used for the monitoring of certain neuroendocrine tumors, specifically somatostatin receptor imaging. In correlation with tumor biomarkers, dotatate PET can help determine the presence of recurrence. This patient has elevated tumor biomarkers as well as symptoms, which may suggest recurrence. Conventional computed tomography (CT) is nonspecific and would be less likely to differentiate post-surgical changes from tumor recurrence. The National Comprehensive Cancer Network (NCCN) guidelines suggest that dotatate PET can be useful in this clinical setting. Therefore, the requested dotatate PET scan is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 Nerlynx (neratinib) tablets. There are several effective antibodies for the treatment of patients with HER2 positive breast cancer. Researchers concluded that Nerlynx plus capecitabine is active against refractory, HER2-positive breast cancer brain metastases. The U.S. Food and Drug Administration (FDA) initially approved Nerlynx for extended anti-HER2 adjuvant therapy. In February 2020, the FDA expanded this approval to include for metastatic breast cancer, when used along with Xeloda, as is being recommended in this patient. Moreover, this patients records document treatment and progression, or intolerance to, lapatinib, tamoxifen, and radiation therapy as well as Herceptin. Given the support in the medical literature and FDA approval, the requested medication regimen including Nerlynx with Xeloda is appropriate for treatment of this patients breast cancer with brain metastasis. Therefore, the requested Nerlynx (neratinib) tablets are medically necessary for 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 internal medicine with subspecialty certification in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for facial feminization surgery. The World Professional Association for Transgender Health (WPATH) acknowledges that, for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATH further states that although facial feminization procedures are labeled purely aesthetic, these procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. Medical literature notes that facial feminization surgery, like genital surgery, improved mental health-related quality of life. The patient meets the WPATH criteria for gender dysphoria and indication for facial feminization surgery based upon clinical documentation of persistent gender dysphoria. The patients providers support the presence of masculine facial features, which contribute to the patients gender dysphoria. Given these findings, the requested facial feminization is 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 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

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Based on the assessment, RTC level of case services were medically necessary. Further, Level 3.5 programs are designed to serve patients with specific functional limitations that need safe and stable living environments to develop sufficient recovery skills so they do not relapse. The duration of treatment depends on an individual patients progress in acquiring basic living skills and adequate coping and recovery skills. This patient required treatment through discharge to develop these skills to avoid relapse upon transfer to a less restrictive setting. Given these findings, the RTC services provided were medically necessary for 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 with expertise in addiction 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

An enrollee has requested reimbursement for Decision-Dx Genetic Testing. The American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. In the current AJCC staging system, Clarks level has prognostic significance only in patients with very thin melanomas, which is defined as a Breslow depth less than 1 mm. The DecisionDx-Melanoma gene expression profile (GEP) test is an expression assay designed to predict distant metastasis in stage I and stage II melanoma patients. Evidence from five cohort studies suggested that the test has prognostic value for assessing recurrence-free survival, distant metastasis-free survival, and overall survival. This patient presented with a tumor with a Breslow depth of 0.9 mm. According to the results of analysis of this patients analysis performed with DecisionDx-Melanoma, the tumor was classified as a low risk of near-term metastatic disease. Therefore, additional testing in this clinical setting was not expected to add novel useful data relevant to this patients decision planning. For these reasons, the Decision-Dx Genetic Testing 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

The patient has requested reimbursement for a wearable cardioverter defibrillator LifeVest provided by Zoll. Based on the records provided for review, this patient has severe non-ischemic cardiomyopathy with class II congestive heart failure that persisted despite goal-directed medical therapy. The current guidelines state that a wearable cardioverter defibrillator may be indicated for patients with a left ventricle ejection fraction (LVEF) under 35% when an implantable cardioverter defibrillator (ICD) cannot be placed, needed to be significantly delayed due to infection or other medical condition, or required explantation. This patient met the criteria for an implantable defibrillator. There is no documentation of a need to delay ICD placement or that the patient had a contraindication to ICD placement. In this clinical setting, the appropriate course of action would be for the patient to undergo ICD placement in lieu of using an external wearable cardioverter defibrillator. Given these findings, the wearable cardioverter defibrillator LifeVest provided by Zoll was not medically necessary for treatment of this patient. Final Result: The reviewer determined that the device at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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

An enrollee has requested authorization and coverage for the medication Harvoni for 12 weeks. Guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommend treatment for all patients who have hepatitis C. Benefits from early therapy have been demonstrated, and these definitive guidelines no longer suggest that treatment should be a function of the presence of liver damage. The AASLD/IDSA guidelines note, More importantly, from a medical standpoint, data continue to accumulate that demonstrate the many benefits, both intrahepatic and extrahepatic, that accompany hepatitis C eradication. Therefore, the panel continues to recommend treatment for all patients with chronic hepatitis C infection, except those with a short life expectancy that cannot be remediated by hepatitis C treatment, liver transplantation, or another directed therapy. The selection of Harvoni is also appropriate according to these guidelines. Therefore, the requested medication, Harvoni for 12 weeks, is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in infectious 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: Upheld Decision of Health Plan

The parent of an enrollee has requested authorization and coverage for upright magnetic resonance imaging (MRI) with flexion/extension and a 3D computed tomography (CT) scan with rotational views. In this case, supine flexion/extension MRI of the cervical spine and dynamic radiographs have been recommended and performed yielding essentially normal results. All of the patients imaging and physical examination findings to date have not shown evidence for ligamentous instability at the craniocervical junction. Furthermore, upright MRI and CT with rotational views are not necessary for further evaluation of the patients symptoms, as she has already undergone extensive imaging of the brain and spine which have yielded essentially normal results. Therefore, the requested upright magnetic resonance imaging (MRI) with flexion/extension is not medically necessary to treat the patients medical condition. In addition, the requested 3D computed tomography (CT) scan with rotational views is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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

An enrollee has requested reimbursement for inpatient hospitalization.The submitted documentation does not support that the services at issue were medically necessary. Inpatient care is necessary when a patient's signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when a patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for a patient to remain in the acute inpatient setting. In this case, the patient was admitted to the hospital in stable condition, and her pain was controlled with oral pain medications. The patient did not require any urgent surgery or procedures, her vital signs were stable, and there was no evidence of shock or significant dehydration or bleeding. While the patient did have contrast leak into her right arm when imaging was performed that caused pain and swelling, this was noted to be resolved and the patients pain was relieved by having the patients arm elevated. The patient was able to tolerate an oral diet and was discharged home the day after admission. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Under these circumstances, the inpatient hospitalization at issue was not medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine 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.