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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for an additional eight hours of neuropsychological testing (CPT 96133 - 4 units and CPT 96139 - 8 units), for a total of 27 hours of testing. The diagnosis of attention deficit hyperactivity disorder (ADHD) is based on upon clinical evaluation. The American Academy of Pediatrics guidelines for the diagnosis and treatment of ADHD recommends, To make a diagnosis of ADHD, the primary care clinician (PCC) should determine that Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria have been met, including documentation of symptoms and impairment in more than one major setting (i.e., social, academic, or occupational), with information obtained primarily from reports from parents or guardians, teachers, other school personnel, and mental health clinicians who are involved in the child or adolescents care. The PCC should also rule out any alternative cause. In this case, the patient has been approved for 19 hours for neuropsychological testing to include the Connors Continuous Performance Test 3 (CPT 3) and Connors Continuous Auditory Test of Attention (CATA), as well as the Behavior Assessment System for Children 3 (BASC-3). These tests are supplementary and not fundamental to the diagnosis of ADHD. Per the reviewers calculations based on a review of test publishers websites, the proposed list of tests does not require more than 19 hours of testing, which includes administration, scoring, and reporting time. Medical documentation does not substantiate additional testing needs or rationale for additional time. Therefore, an additional eight hours of neuropsychological testing (CPT 96133 - 4 units and CPT 96139 - 8 units), for a total of 27 hours of testing are not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5mg tablet twice daily.Findings: Three out of three physician reviewers found that the requested Xeljanz 5mg tablet twice daily is likely to be more beneficial than any other available standard treatments for the patients medical condition.The available treatment options for alopecia areata (AA) are quite limited. This is especially true for diffuse/multifocal involvement, where standard therapies such as topical steroids, intralesional kenalog, contact immunotherapy and conventional immunosuppressants (systemic steroids, methotrexate and cyclosporine) are more often than not less than satisfactory and associated with side effects. Although there is no significant data yet from randomized clinical trials (which are currently underway), there is substantial clinical evidence to support the use of oral JAK kinase inhibitors such as tofacitinib for alopecia areata. In one open label pilot study, 8 out of 12 patients demonstrated approximately 50% hair regrowth as measured by Severity in Alopecia Tool scoring. Another retrospective study consisted of patients with alopecia areata with at least 40% scalp hair loss who were treated with tofacitinib. This study found that 77% achieved a clinical response and that 58% of patients had an approximately 50% change in SALT score. There have been minimal adverse effects reported to date. Moreover, these results are superior to reported results for contact immunotherapy and systemic steroids. Thus, the requested Xeljanz 5mg tablet twice daily is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested medication is likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator Inspire device. Findings:  The physician reviewer found that this patient has a history of obstructive sleep apnea without nasal obstruction. A drug-induced sleep endoscopy (DISE) showed no concentric collapse at velum and primarily anterior posterior collapse. The patient has not been able to tolerate treatment with a continuous positive airway pressure (CPAP) device. The Inspire device is a U.S. Food and Drug Administration (FDA) approved device for the treatment of OSA device (Van de Heyning, et al.; Strollo, et al.; Steffen, et al.). The patient is a candidate for the Inspire device given his intolerance to CPAP, anterior posterior collapse without evidence of concentric collapse, no central apnea, and an apnea/hypopnea index (AHI) of 45.7 events per hour, which is within FDA criteria with more than 15 and 65 or fewer events per hour. Therefore, the requested implantation of hypoglossal nerve stimulator Inspire device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested implantation of hypoglossal nerve stimulator Inspire device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services 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 and 2 are board certified in otolaryngology and are actively practicing. Physician reviewer 3 is board certified in otolaryngology with subspecialty certification in sleep medicine 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 continued inpatient treatment.Cellulitis is an infection of the deep dermis and subcutaneous tissue, presenting with expanding erythema, warmth, tenderness, and swelling. The diagnosis of cellulitis is based primarily on history and physical examination. The majority of cases of cellulitis are nonculturable and therefore the causative bacteria are unknown (Raff, A., and Kroshinsky, D.). Cellulitis is a frequent cause of hospital admission of adult patients (Collazos, J., et al.). In this case, the submitted documentation does not support that the patients request for continued inpatient treatment is medically necessary. The patient has been assessed and followed by Infectious Disease specialists, and there is no evidence of an abscess or deep soft tissue infection in the patients current records. A recent Infectious Disease note indicates that the patient was able to be discharged and no longer needed an acute level of care. At that point in time, the patient needed only outpatient follow-up and continued intravenous antibiotic therapy. These services may be provided in a skilled nursing facility or in a patients residence with nursing care assistance with the intravenous (IV) antibiotics. Under these circumstances, continued inpatient treatment is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Findings:  The physician reviewer found that the patent has chronic medical conditions, but no new, significant medical issues. As of late November 2020, he was largely independent to supervision level for basic self-care and household level mobility, as well as with small sets of stairs. He was familiarized with the hip precautions but still required some verbal cues. The patients rehabilitation continued with additional progress and his family was trained. By the first date of the Health Plans denial, the patient could have reintegrated to the community with occasional custodial level assistance, community-based therapy, and nursing services. There are no documented therapy, nursing or medical issues that would have required ongoing SNF level care services by the date of . Further rehabilitation to potentially help the patient improve to ambulating without an assistive device could have been pursued in the community setting. For patients undergoing major lower limb joint arthroplasty, the standard of care includes aggressive pain management and early mobilization and rehabilitation (Masaracchio, et al.). Many patients can be discharged home safely following short-term rehabilitation on the acute post-surgical ward followed by outpatient care following total joint arthroplasty (Basques, et al.; Fleischman, et al.). The data do not generally support the benefit of long-term inpatient rehabilitation programs in the setting of total joint arthroplasty (Mak, et al.; Hutchinson, et al.; Naylor, et al.). Given these findings, the SNF services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture services. Findings:  The physician reviewer found that acupuncture treatment is a reasonable option for a patient with chronic pain. However, additional acupuncture should only be provided based on progressively greater, incremental objective gains. Moreover, passive care such as acupuncture should be combined with active care such as conditioning with an aerobic and stretching exercise program. Resolution of symptoms, intolerance, lack of measurable improvements or non-compliance with aerobic and strengthening exercises are reasons to discontinue treatment. Although the provider reported that prior acupuncture care as beneficial in improving this patients ability to perform activities of daily living, the records do not include specifics with pre- and post-acupuncture baselines for comparison purposes. The provider did not chart the total number of sessions completed or any measurable, progressive, significant, objective functional improvement to support additional acupuncture services. For these reasons, the requested acupuncture services are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in oriental 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: An enrollee has requested authorization and coverage for Calmare Scrambler therapy. Researchers report that neuropathic corneal pain (NCP) can be extremely challenging to manage, and evidence-based clinical recommendations for the management of patients with NCP are scarce. In providing guidelines for the diagnosis and treatment of patients with NCP, the authors do not mention Scrambler therapy as a management option. Researchers noted that while there is no consensus in potential treatment strategies of NCP, nortriptyline appears effective in relieving NCP symptoms in patients with centralized component and insufficient response to other systemic and topical therapies. In this case, the patient has reported ocular neuropathic pain and photophobia. Current medical literature does not support the use of Scrambler therapy in this clinical setting. Therefore, Calmare Scrambler therapy is not likely be more beneficial than any other available standard service for the patients medical condition.Findings:  Three of the three physician reviewers found the requested Calmare Scrambler therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service 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: Physician reviewers 1, 2, and 3 are board certified in ophthalmology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prolaris genetic testing. The three current options for the management of localized prostate cancer include surgical prostatectomy, radiation therapy and similar techniques, and surveillance. A risk stratification analysis based on clinical and pathologic factors may predict a patients risk for progressive cancer and assist in making treatment recommendations. In this case, the records noted a diagnosis of malignant neoplasm of prostate and an elevated prostate-specific antigen (PSA) level of 3.97. A biopsy reported adenocarcinoma in the left lateral apex and the right apex and elements of Gleason 3+3 and 3+4 disease. In this clinical setting, the National Comprehensive Cancer Network (NCCN) recommends molecular-genetic testing, such as Prolaris genetic testing, as an aid in making therapeutic recommendations. Therefore, Prolaris genetic testing was likely to be more beneficial for the evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Prolaris genetic testing was likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service 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: Physician reviewer 1 is board certified in internal medicine with sub-specialty certification in medical oncology and actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with sub-specialty certifications in medical oncology and hematology 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: The patient has requested reimbursement for all or any of the family psychotherapy services provided. Researchers note that couple-based therapies for posttraumatic stress disorder (PTSD) may be potentially beneficial for reducing symptoms. Family psychotherapy may be helpful as an adjunct to individual psychotherapy for both PTSD and major depressive disorder, generally over 12 to 16 weekly sessions. In this case, the patient has diagnoses of PTSD and major depressive disorder, and attended family psychotherapy from July 2019 through March 2020. Given that the provider recommended and referred the patient for family psychotherapy, the intervention was medically indicated. However, two sessions on the same day are not standard of care and were not medically indicated. Therefore, the family psychotherapy services, one session for each date of service at issue, were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were partially 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Zoll LifeVest. The records provided for review document that this patient has a potentially reversible cardiomyopathy due to rapid atrial fibrillation. Her left ventricle ejection fraction (LVEF) was low and she has symptoms of congestive heart failure (CHF), which support that she is at higher risk for sudden cardiac death. However, she does not require a permanent implantable cardioverter defibrillator (ICD) until cardioverted to normal sinus rhythm and treated with medical therapy. During this treatment period, the patients ventricular function may recover and eliminate the need for a permanent defibrillator. Given the patients increased risk of sudden cardiac death and the possibility of improvement of left ventricle function with medical therapy, the use of the LifeVest was reasonable based on published guidelines. Given this support, the Zoll LifeVest was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the Zoll LifeVest 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 services at issue were 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 internal medicine with subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a positron emission tomography (PET) scan of the brain. Functional neuroimaging such as PET scanning is used in several disease processes including frontotemporal dementia but are not alone diagnostic. In the setting of corticobasilar degeneration diagnosis is achieved through clinical measures and tissue analysis. There is evidence to support that PET imaging can provide additional insight into the evaluation of certain neurocognitive disorders. However, the records do not support that PET imaging was indicated in lieu of standard testing for evaluation of this patients medical condition. All told, the PET scan of the brain performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the PET scan of the brain 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 treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in neurology with subspecialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 2 is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 3 is board certified in neurology 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.