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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fertility preservation services. With current technology, sperm and embryo, as well as oocyte cryopreservation, are considered standard practice and are widely available. Such treatment is considered the standard of care by the American Society of Clinical Oncology and the American Society for Reproductive Medicine and has been shown to be successful. In this case, the patient's fertility status after breast cancer treatment with chemotherapy is uncertain. Therefore, in order to preserve this patients fertility, it was medically necessary for the patient to undergo fertility sparing treatments. Accordingly, the fertility preservation services at issue (ovarian stimulation, oocyte retrieval, oocyte fertilization and storage of oocytes and/or embryos) were medically necessary because of the treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary because of the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 patient has requested reimbursement for the genetic testing services provided by Esoterix Genetic Laboratories. Findings:  Two physician reviewers found that while hypercoagulable states can be found in patients who have had an ischemic stroke, widespread testing for these disorders is limited by a number of considerations. These factors include a relatively low prevalence of thrombophilias, and alteration of the sensitivity and specificity of the tests involved in the setting of an acute ischemic event. As discussed in the medical literature, it remains unclear whether inherited thrombophilias predispose patients to stroke as with deep venous thrombosis. Given the absence of data in the peer-reviewed medical literature demonstrating improved health outcomes with this testing, the genetic testing services provided by Esoterix Genetic Laboratories were not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.One reviewer found that genetic testing services provided by Esoterix Genetic Laboratories were likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with subspecialty certification in hematology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for general anesthesia services provided during wisdom teeth extraction.  Findings:  The physician reviewer found that The submitted documentation does not support that the services at issue were medically necessary. The American Academy of Pediatric Dentistry (AAPD) guidelines for general anesthesia outline four indications for general anesthesia (GA) in pediatric dentistry: 1) Patients exhibiting physical, intellectual, or medically compromising conditions, for which dental treatment under local anesthesia cannot be expected to provide a humane and successful result; 2) Patients demonstrating dental treatment needs for which local anesthesia is indicated, but is ineffective because of acute infection, anatomic variation or allergy; 3) An extremely uncooperative, fearful, anxious or uncommunicative patient with dental needs of such magnitude or clinically apparent and functionally threatening to the well-being of the individual that treatment should not be postponed or deferred; or 4) Patients who have sustained extensive oral-facial and/or dental trauma, for which treatment under local anesthesia would be ineffective or compromised.In this case, the necessity for general anesthesia is not substantiated in the records available for review. Wisdom teeth are typically extracted under local anesthesia or with moderate sedation. There is no rationale presented to justify the use of general anesthesia in this case. There is no documentation that indicates that the patient has a physical, intellectual, or medically compromising condition. There is no documentation that the patient had an acute infection, anatomic variation or allergy that would make local anesthesia ineffective. There is also no documentation that general anesthesia was required either due to the patient being extremely uncooperative, fearful, anxious or uncommunicative, or due to patient having sustained extensive oral-facial and/or dental trauma. Therefore, the general anesthesia services provided during wisdom teeth extraction were not medically necessary for treatment of 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 anesthesiology, with subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee have requested reimbursement for allergy testing. The Chronic Urticaria (CU) Index is an in vitro basophil (leukocyte) histamine release assay in which patient serum is mixed with donor basophils and the released histamine levels are measured through a quantitative enzyme immunoassay. A CU Index value greater than or equal to 10 indicates that the patient has either an autoimmune basis for urticaria or an alternate histamine releasing factor. Current data suggests that a prospective study on use of the CU Index is warranted to validate preliminary findings and to further evaluate its clinical utility. At this juncture, serum immunoglobulin G4 (IgG4) food subclass sensitivity testing is not considered a clinically useful for evaluating for atopic dermatitis due to ingested food, or for identifying food allergy that may be contributing to atopic dermatitis. Overall, IgG and IgG subclass antibody testing for evaluating food allergy and food allergy related conditions, such as atopic dermatitis, lack sufficient quality control to support use on a routine basis. Given these findings, the allergy testing was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three physician reviewers found the allergy testing was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the allergy testing was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in allergy and  immunology with subspecialty certification in pediatrics and are actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in allergy and  immunology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation with a surgical provider appropriately qualified to perform laser spine surgery. The medical literature reveals that for the small minority of low back pain patients with severe or progressive motor weakness, or signs and symptoms of cauda equina syndrome, urgent evaluation by a neurosurgeon or orthopedic surgeon with experience in back surgery is indicated. There is no evidence that early referral for surgery, in the absence of severe or progressive neurologic deficits, improves outcomes for lumbar disc prolapse with radiculopathy or symptomatic spinal stenosis. There are no published trials comparing other minimally invasive techniques (eg, laser-assisted discectomy) versus open discectomy, microdiscectomy, or nonsurgical therapy.In this case, there is little clinical documentation regarding prior treatment and no documentation of any prior surgical consultation. In addition, the medical literature does not support that laser spine surgery would provide any benefit over other approaches (open surgery, microdiscectomy) if surgical intervention is medically necessary. The submitted records do not detail extenuating circumstances to support laser spine surgery over other possible approaches. Under these circumstances, the requested consultation with a qualified laser spine surgical to determine if laser spine surgery is appropriate is not medically necessary for treatment of the patients medical condition at this time.Final Result: The reviewer determined that the requested service 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 family 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: An enrollee has requested reimbursement for SBRT services. The submitted documentation supports that the services at issue were medically necessary. Retrospective studies and phase II studies have demonstrated that SBRT is efficacious in patients with an oligometastatic disease with encouraging results. The current guidelines for treatment of cancer allow for the ablative treatment of up to five metastases in patients with an oligometastatic presentation. In this case, the patient presented with an oligometastatic disease in five sites and no signs of clinical progression elsewhere in the body. The patients colorectal histology, her young age, and the finding that she had no signs of distant progression after chemotherapy are all prognostic factors that correspond with cases in which past studies have shown benefit from aggressive local control with stereotactic radiotherapy. Accordingly, the Stereotactic Body Radiation Therapy (SBRT) services at issue were medically necessary to treat the patients medical condition.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 radiation 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a whole body positron emission tomography (PET). There are specific indications for a PET imaging study according to radiologic and oncologic practice standards. The first indication is in the diagnostic setting to evaluate for possible malignancy in an indeterminate lesion, evaluate metastases in the setting of unknown primary malignancy, identify an appropriate biopsy site in the setting of suspected malignancy, and evaluate for occult malignancy in the setting of increased tumor markers. PET can also be used in the staging of a malignancy, as well as in the evaluation of treatment response, suspected recurrence, or disease surveillance. In this patients case, there is no indication that malignancy is suspected. The patient has been evaluated by otolaryngology and orthopedic surgery and the providers have not noted concern for the possibility of malignancy. Moreover, the patient underwent evaluation with computed tomography (CT) of the abdomen and pelvis in April 2018 which was interpreted as negative. Given these findings, the requested PET is not medically necessary for evaluation of this patients multiple chronic conditions. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of 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: Overturned Decision of Health Plan

The enrollee has requested reimbursement for inpatient psychiatric treatment services provided and prospective authorization and coverage for inpatient psychiatric treatment services. Based on the documentation provided for review, this patient demonstrates multiple risk factors for suicide after discharge from the hospital and is at continued risk of danger to self. Specifically, these risk factors include diagnoses of mood disorder and borderline personality disorder coupled with a history of multiple suicide attempts and non-suicidal self-injury. In addition, the patient has engaged in self-harm and made one suicide attempt while in the hospital and continues to require intermittent one-to-one observation for safety. Moreover, the patient has required inpatient treatment more than once over the past year despite treatment at the IOP and PHP levels of care. According to the American Psychiatric Association (APA) guidelines, this patient is at an elevated risk for suicide compared to the general population given the history of gender dysphoria and presence of a mood disorder. Thus, the inpatient psychiatric treatment services provided and prospective inpatient psychiatric treatment services were and are supported as medically necessary for treatment of this patients behavioral health issues.Final Result: The reviewer determined that the services at issue were and 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

Nature of Statutory Criteria/Case Summary: The enrollee has requested viscosupplementation with Hymovis injections of both knees. As noted in the medical literature, viscosupplementation with intraarticular hyaluronic acid provides a moderate symptomatic benefit to knee osteoarthritis patients without major safety concerns. Overall, there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis. Further, the benefits of hyaluronic acid are long-lasting when compared to intraarticular corticosteroids. Researchers found evidence from clinical studies of repeat courses of intraarticular hyaluronic acid. Hymovis is a new generation hyaluronic acid with distinctive viscoelastic and rheological properties, which has been approved by the U.S. Food and Drug Administration (FDA) for treatment of osteoarthritis of the knees. Results from the studies confirm that Hymovis alleviates knee pain since the first treatment cycle. The patients treated with two cycles of intraarticular injections of Hymovis have a progressive pain reduction that is maintained up to one year after the treatment. Hymovis is effective and safe in symptomatic treatment of painful knee osteoarthritis. In light of the foregoing, the request for Hymovis injections of both knees is medically necessary for treatment of this patients osteoarthritis of the knees.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for botulinum toxin (Botox) injections.Findings:  Three physician reviewers found that the current medical evidence supports the services at issue in this patients case. Botox injections have been demonstrated to be effective for the treatment of chronic migraine. This patients records document the diagnosis of chronic migraine, and she experienced a reduction of headache days per month following treatment with Botox injections. The U.S. Food and Drug Administration has approved Botox injections for the treatment of chronic migraine. In sum, botulinum toxin (Botox) injections were and are likely to be more efficacious than other available treatment modalities. Final Result: The reviewers determined that the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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 is requesting surgery for an exploratory laparotomy or an exploratory laparoscopy for the removal of scar tissue and mesh implant. The Health Plan has denied the surgery as not medically necessary for the treatment of the patients medical condition.The records indicate no overt complication of any prior abdominal surgery identified. Scar tissue cannot always be identified in any meaningful way on diagnostic studies and is often a diagnosis of exclusion, however, treatment for scar tissue alone is not always successful and can often result in new or different scar tissue formation and/or inadvertent injury of a healthy organ. Given that there is no medical evidence provided on any diagnostic study to clearly support re-exploration, laparotomy or laparoscopy for the purpose of lysing scar tissue or removal of implanted mesh (the removal of which would result in hernia formation) is not supported at this time. Therefore, the Health Plans denial should be upheld.Final Result: The reviewer determined that the requested surgery 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 general 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 the bone density test.Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. As noted by the medical literature, peripheral bone density testing may be used for diagnosing osteoporosis when the hip and lumbar spine cannot be measured or are uninterpretable. According to the International Society for Clinical Densitometry (ISCD), central dual-energy x-ray absorptiometry (DEXA) measurements at the spine and femur are the preferred method for making therapeutic decisions. Per ISCD, peripheral DEXA devices are not clinically useful in monitoring the skeletal effects of presently available medical treatments for osteoporosis. This patient had an established diagnosis of osteoporosis, and she has been treated with bisphosphonates. Per the current medical evidence, peripheral bone density testing may be used for the diagnosis of osteoporosis in patients when the hip and lumbar spine cannot be measured or are uninterpretable, which is not documented in this case. In sum, the bone density test was not likely to have been of greater benefit than other methods of evaluating this patient.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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.