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

An enrollee has requested reimbursement for myRisk hereditary cancer genetic testing performed by Myriad Genetics Laboratories, Inc. This patient was diagnosed with breast cancer and she has an extensive family history of cancer. Current data suggest that several cancer syndromes, including hereditary breast and ovarian cancers, are indications for genetic testing. Testing to isolate high-risk gene mutations in families has improved the outcomes of genetic counseling, surveillance, and prophylactic treatment measures. Evolving research has demonstrated that in addition to high-risk genes, other genes contribute to the familial cancer predisposition, which lends support for the clinical utility of gene panels such as the myRisk hereditary cancer genetic testing. Gene panel testing offers a reliable and expedited approach for the diagnosis for heritable cancer syndromes. Therefore, the myRisk hereditary cancer genetic testing performed by Myriad Genetics Laboratories, Inc. was 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in genetics 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 enrollee requested authorization and coverage for the medication Xifaxan, 550mg tablets. The patient was having abdominal pain and bloating. A breath test was performed and was positive for bacterial overgrowth. The patients physician has advised treatment with Xifaxan. Alimentary Pharmacology and Therapeutic reported in an article entitled Systematic Review with meta-analysiss that rifaximin is effective and safe for the treatment of small intestine bacterial overgrowth that the results of the  meta-analysis provide evidence that rifaximin is clinically effective in eradicating small bowel intestinal overgrowth. The World Journal of Gastroenterology reports in an article entitled Use of rifaximin in gastrointestinal and liver disease that rifaximin has been shown to normalize the hydrogen breath test and improve symptoms in small intestinal bacterial overgrowth. The peer-reviewed scientific literature supports the use of rifaximin for small intestinal bacterial overgrowth. Clinical response rates to small intestinal overgrowth have been shown to be superior with rifaximin as compared to other antibiotics. Therefore, the medication Xifaxan is medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the medication Xifaxan, 550mg tablets are medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified 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 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 Synvisc One injection (HCPCS code J7325) in each knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a long history of osteoarthritis of both hips and both knees. The patient benefitted from viscosupplementation with Synvisc One. The patient reported having difficulty walking up and down the stairs to his residence. Given the patients prior positive response, the requested Synvisc One injection (HCPCS code J7325) in each knee 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 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 authorization and coverage for surgical implantation of a hypoglossal nerve neurostimulator device (CPT 64568 and 0466T). This patient has obstructive sleep apnea (OSA) and no nasal obstruction. The patients drug induced sleep endoscopy (DISE) showed no concentric collapse at velum and primarily anterior posterior collapse with improvement using jaw thrust. The patient has not been able to tolerate treatment with continuous positive airway pressure (CPAP) and oral appliances have not been substantially effective. The Inspire device is a U.S. Food and Drug Administration (FDA) approved device for the treatment of OSA device. This patient is a candidate for the Inspire hypoglossal nerve neurostimulator device given his intolerance to CPAP, anterior posterior collapse, and no central apnea. Moreover, the patient has an apnea/hypopnea index (AHI) of 41.7, and a body mass index (BMI) of 29, which meet the current FDA criteria. For these reasons, the requested surgical implantation of a hypoglossal nerve neurostimulator device (CPT 64568 and 0466T) 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 surgical implantation of a hypoglossal nerve neurostimulator device (CPT 64568 and 0466T) 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 reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology with subspecialty certification in sleep medicine and is actively practicing. Physician reviewer 3 is board certified in otolaryngology 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: The parent of an enrollee has requested reimbursement and authorization and coverage for Visual Communication Analysis with Self-Determination Theory (SDT) services (five days per week, 2.5 hours per day), and Visual Communication Analysis with Self-Determination Theory (SDT) Supervision services (three hours per week).In this case, there are anecdotal reports from the patient's parents and Visual Communication Analysis therapist that the patient's maladaptive behaviors have decreased, and his ability to identify letters has increased during the time that he has received Visual Communication Analysis. No plan for parent training is provided. Under these circumstances, the submitted documentation does not support that Visual Communication Analysis and Self-Determination Theory are medically necessary for the patient. Therefore, Visual Communication Analysis with Self-Determination Theory (SDT) services (five days per week, 2.5 hours per day) and Visual Communication Analysis with Self-Determination Theory (SDT) Supervision services (three hours per week) were not, and are not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and 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 neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with right knee osteoarthritis and left knee pain with moderately advanced arthritis. On 10/23/19, the patient received a right knee steroid injection. The provider recommended physical therapy, focusing on strength and range of motion of the lower extremities. The patient reported being unable to ambulate due to bilateral knee pain. The patient was noted to be severely deconditioned and morbidly obese. The patient has received viscosupplementation injections in the past, with good results. Physical examination findings included tenderness over the knee medial and lateral joint lines. Left knee steroid injection was administered. The patient has requested authorization and coverage for Euflexxa injections in both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Euflexxa injections in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of benefit from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, including corticosteroid injections, with the alternative being bilateral total knee arthroplasties. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections in both knees are medically necessary for the 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for hydroquinone cream 4%. The patient was seen for a rash on her legs, which was thought to be due to mosquito bites. Physical examination showed multiple papular eruptions throughout the legs. She was given a prescription for hydroxyzine. The notes otherwise do not mention hydroquinone, other than it was prescribed for a rash and nonspecific skin eruption. Hydroquinone is a cosmetic bleaching agent. It is not medically necessary for any skin condition. Furthermore, there is minimal provided information in the clinic notes regarding the use of this medication. Therefore, the requested medication, hydroquinone cream 4%, is not medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for oral and maxillofacial procedures. This patient has ectodermal dysplasia, which is a hereditary disorder, characterized by morphological and functional hypoplasia of ectodermally derived organs and tissues. The primary dental-related features of ectodermal dysplasia patients include the congenital absence of multiple teeth and an abnormal tooth shape. Treatment strategies for missing teeth include approaches such as removable partial or complete dentures, tooth-supported fixed partial dentures, overdentures, and implant-supported prostheses. Reports have shown that an implant-retained prosthesis is an ideal option, when possible. This patients provider noted that this is the best option in this patients case. Moreover, the requested treatment will provide more than a minimal improvement in the appearance of the patient and will attempt to create a normal appearance to the extent possible. Given these findings, oral and maxillofacial are 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 oral and maxillofacial 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient behavioral health treatment level of care. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying LOCUS guidelines, this patient met the criteria for inpatient behavioral health treatment level of care provided for a portion of her admission. On the first date of the Health Plans denial, the patient was at some risk of self-harm (score 2), given her disorganization. The patient demonstrated serious functional impairment (score 5) as she was unable to perform activities of daily living. The records document that she was disorganized and psychotic. The patient was unable to work and was non-compliant with her medications without support. The patient had a minor comorbidity (score 2) with documentation of a urinary tract infection. The patients recovery environment was highly stressful (score 4) as there was severe marital discord between the patient and her spouse. The patients recovery environment was minimally supportive (score 4) as her husband did not want her to return home and she had limited other familial support. A shelter was considered as a disposition option. The patient has exhibited poor response to treatment (score 4) as she has been hospitalized at least 30 times and was already treated as an inpatient in 2019. The patient was obstructive with treatment (score 3) as she has been non-adherent with treatment. This gives the patient a composite score of 24, which is consistent with medically monitored residence-based services, such as RTC. Based on a LOCUS score of 5 for functional status, the patient met the criteria for medically managed residence based services, such as inpatient behavioral health level of care. However, 11 days after admission, the patient showed improvement with mild functional impairment (score 2) as she was able to attend to her ADLs and constructive participation (score 2) in treatment. This gives the patient a composite score of 22, which is consistent with medically monitored community-based services. The provider noted that the patient was stable for discharge to a RTC. Given these findings, the inpatient behavioral health treatment level of care provided was medically necessary for treatment of this patient.Final Result: The reviewer determined that a portion of the services at issue was 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

The patient has requested reimbursement for intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS guideline, this patient met the criteria for IOP services. This gives the patient a composite score which is consistent with high intensity community based services, such as IOP. Accordingly, the IOP services 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet 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. The patients Clinical Institute Withdrawal Assessment (CIWA) score was a 6 on admission. She appeared to have adequate ability to tolerate and cope with withdrawal discomfort. The patient has Ehlers-Danlos syndrome and thyroid disease. These conditions were stable and there was no concern that symptoms would interfere with her recovery treatment. The patient has an eating disorder, anxiety, depression, post-traumatic stress disorder (PTSD), and attention-deficit/hyperactivity disorder (ADHD). She has not been suicidal or homicidal. There is no psychosis. She was able to perform activities of daily living and participate in groups. She has been intermittently compliant with medications in the past. The patient was willingly engaged in treatment as a proactive participant. She was aware of her addiction problem and expressed that she is committed to changing her substance use and adhering with psychiatric medications. The patient has undergone repeated treatment episodes with little positive effect on her level of functioning. She experienced cravings that were managed with naltrexone. The patient lives alone and she indicated that she removed alcohol from her home. She demonstrated motivation and willingness to obtain a positive social support system. Her family is supportive, but does not live nearby. Given these findings, the patient did not meet the criteria for biomedical conditions and recovery environment. Therefore, the RTC services were not medically necessary for treatment of this patient.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 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.