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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment from the date of service in question forward.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical records do not support active suicidal ideation during the several weeks prior to the last authorized date.  The records indicate the patient was open in her individual, group, and family therapy sessions.  She was noted, on numerous occasions, to be open when discussing very sensitive information regarding her past traumatic experiences.  She was not displaying significant or severe behavioral problems during the disputed period.  She was noted to be cooperative in therapy and was insightful into her need for treatment and her behaviors.  The records indicate that she requires additional treatment to further improve her social functioning, anxiety, family relationships, and trauma related issues.  However, it appears that she no longer needed the restrictiveness of a residential psychiatric treatment facility as she has stabilized enough to transition to a less restrictive setting.  Outpatient treatment and least restrictive options are considered first lines of care.  There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting. The records indicate that the patient could have been treated in a less restrictive setting safely and effectively as of the date of service.  All told, residential treatment from the date of service in question forward was not and is not medically indicated 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 physician 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage of Epclusa. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  Per the guidelines, patients with cirrhosis are high priority for treatment, and should be re-treated after failure of an NS5A inhibitor such as Harvoni.  After failure of an NS5A inhibitor, AASLD/IDSA guidelines recommend re-treatment with Epclusa and ribavirin for 24 weeks. The guidelines state that retreatment with sofosbuvir/velpatasvir plus ribavirin for 24 weeks should be considered in genotype 1 patients who have not responded to prior NS5A-based therapy. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Forteo 20 mg. Findings:  The physician reviewer found that the patient presents with severe osteoporosis and has a history of fractures. The patient has a T-score of -3.7 and her fracture risk is high. The standard of care in this clinical setting is treatment with Forteo. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 consultation with a bariatric surgeon for evaluation of the enrollees morbid obesity. Findings:  The physician reviewer found that there is support in the medical literature for the medical necessity for a consultation with a bariatric surgeon in this clinical setting. The patients diagnosis of morbid obesity is confirmed by her weight and her BMI of 41.9 kg/m2. The medical necessity of bariatric surgery is still not determined at this point, as there is no documentation of a multidisciplinary evaluation which would include a dietary evaluation and psychological evaluation. However, a referral to a bariatric surgeon to begin this process of evaluation is appropriate and medically indicated. All told, the requested consultation with a bariatric surgeon is medically necessary for the 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 certified in surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for consultation with a neurosurgeon. Findings:  The physician reviewer found that the provided documentation does not support the medical necessity for the requested services in this clinical setting. The record notes that the patient was seen and evaluated by a board certified fellowship trained spine surgeon. The patients cervical spine x-rays were reviewed and interpreted by this provider. A cervical examination was performed.  The surgeon recommended an ACDF at C5-6. As such, the documentation fails to support a medical reason for an evaluation of this patient by a neurosurgeon. Therefore, the consultation with a neurosurgeon is not medically necessary for the evaluation of this patients medical condition. 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 neurological 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 an enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) level of care services. Findings: The physician reviewer found that based on the available documentation, the PHP level of care services provided on the date of service in question forward were not and are not medically necessary for treatment of this patients medical condition. Due to the patients minimal behavioral health treatment history and his presentation, the American Academy of Child and Adolescent Psychiatry (AACAP) recommends treatment in a less restrictive setting than PHP. The patient could receive effective treatment on an intensive outpatient basis due to his lack of current self-harm behaviors, and lack of active suicidal or homicidal ideation. The supplied documentation does not indicate that he is having severe mood swings, or other severe psychiatric symptoms. In addition, the patients score on the child and adolescent level of care utilization system (CALOCUS), the patient is a candidate for treatment with intensive outpatient services. Thus, the requested PHP level of care provided from on the date of service in question forward were not and are not medically necessary. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient psychiatric services from the date of service in question, forward. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. There was no evidence of suicidality. However, the patient remained unpredictable in her behavior, episodically aggressive, and unable to care for herself.  She was severely cognitively impaired.  She was oriented to person only, and she wandered.  She did not appear to have auditory hallucinations. It is unclear if she had visual hallucinations as she was observed to pick at objects in the air.  Her speech was nonsensical.  She had impaired attention and concentration, and poor insight and judgment.  She was receiving medication as needed for agitation. However, there were no medication changes after a later date.  By that time she had become more directable and her sleep had improved. Although she was still unpredictable, her aggressive behaviors had decreased.  At that point, inpatient level of care was no longer medically necessary. Therefore, acute inpatient psychiatric services from the date of service in question to the later date were medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Specifically, acute inpatient psychiatric services from the date of service in question to the later datewere medically necessary, but not thereafter. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in geriatric 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 Oncotype DX testing for prostate cancer. Findings:  Three physician reviewers found that several tissue-based molecular assays have been developed in an effort to improve decision making in newly diagnosed men with prostate cancer considering active surveillance as well as in previously treated men who are considering adjuvant therapy or treatment for recurrence.  Men with clinically localized disease may consider the use of tumor-based molecular assays.  Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups.  These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. This patient meets the National Comprehensive Cancer Network criteria for Oncotype DX testing.  In sum, Oncotype DX testing performed was likely to have been superior over other methods of evaluating this patient. Final Result: 2 of 3 reviewers determined that the services at issue were 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 physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: An enrollee has requested authorization and coverage for a second Urolift procedure. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient has a history of benign prostatic hyperplasia previously treated with Urolift procedure. His prostatic urethra was noted to be open after the procedure. He continues to have symptoms.  The patients provider has recommended an evaluation, including cystoscopy, which the patient has not performed.  Without performing a repeat cystoscopy, it would not be possible to determine if his prostatic urethra is open or closed.  All told, the requested second Urolift procedure is not medically indicated for the treatment of this patient. Final Result: The reviewers determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in urology 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 surgery to remove the enrollees Lap-band.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Per the submitted documentation, the patient desires removal of the Lap-band and conversion to sleeve gastrectomy.  However, there is no documentation of a dietary evaluation or an updated psychological evaluation to support that this patient is an appropriate candidate for revisional surgery.  Just as with primary bariatric surgery, the completion of an updated multidisciplinary evaluation is necessary to determine if this patient would be an appropriate candidate for bariatric surgery.  In this patients case, there is no specific anatomic or technical complication to justify removal of the Lap-band at this time.  All told, the requested surgery to remove the patients Lap-band is not medically indicated for the 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 physician reviewer is board certified in 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: A female enrollee has requested reimbursement for fecal calprotectin testing. Findings:  Three physician reviewer found that fecal calprotectin testing may be ordered to determine whether inflammation (disease activity), such as inflammatory bowel disease, is present as a cause for gastrointestinal symptoms such as diarrhea.  The use of fecal calprotectin testing to diagnose change in bowel habits has not been subsequently accepted.  The impact of this testing on management and its appropriateness in guiding therapy decisions in patients with unexplained diarrhea has not been demonstrated. The findings can be redundant with standard methods of diagnosis, such as colonoscopy or sigmoidoscopy, or other serum markers of inflammation. Guidelines on the diagnosis and management of diarrhea do not recommend calprotectin as part of the investigation.  Furthermore, clinical studies do not support a standardized action, such as empiric use of antibiotics or empiric therapy for inflammatory bowel disease, for a positive result.  For these reasons, fecal calprotectin testing performed was not likely to have been superior over other methods of evaluating this patient. Final Result: 3 of 3 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 reimbursement for deoxyribonucleic acid (DNA) analysis of stool samples. Findings:  Three physician reviewers found that the records fail to demonstrate the superior effectiveness of the services at issue.  Conventional assessment of colorectal cancer risk largely involves detection of non-dysplastic adenomatous polyps. Toward this end, the efficacy of computed tomography (CT) colonography, of the Cologuard assay, and of detection of occult blood in stool is traditionally compared against the gold standard, optical colonoscopy.  Cologuard is a stool DNA test that includes molecular assays for DNA mutation and methylation biomarkers.  Given the low sensitivity of Cologuard in detecting adenomas, the service under consideration is not as beneficial as any established alternatives.  The available records do not support that effective conventional screening strategies are contraindicated in this case.  In sum, DNA analysis of stool samples performed was not likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: 2 of 3 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: An enrollee has requested authorization and coverage for hospital stay services. Findings:  The physician reviewer found that this patient presented with a history consistent with gastrointestinal bleeding, suggestive of an upper gastrointestinal tract source (with melena), and syncope. Thus, close monitoring was warranted.  The bleeding source was initially unknown, and there was potential that bleeding would become rapid and result in sudden decompensation.  Additionally, the finding of ischemic colitis warranted surgical exploration, and Entamoeba histolytica was found, which warranted antibiotic therapy.  Intensive care unit stay was appropriate immediately after surgery given perioperative hemodynamic instability.  For these reasons, inpatient admission, surgical exploration, and intensive care unit stay are supported as medically necessary.  The hospital stay was also necessary after the patient began eating, as she was reported to have blood in stool at that time.  However, the dates of these interventions, other than the date of admission , are not ascertainable from the provided medical records.  The records are also lacking information and dates to support the reason for ongoing hospital admission after the patient began eating and the hematochezia ceased.  For these reasons, the medical necessity of hospital stay services has not been established. 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 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.