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

An enrollee has requested reimbursement for DecisionDx-Melanoma test. This patients tumor was pT1a, which by American Joint Committee on Cancer (AJCC) staging is the lowest risk category. Class 1 result does not provide any more information than was already known about the patients tumor. Specifically, based on routine risk analysis, the patients prognosis is exceptionally good. Overall, there is a paucity of evidence from a randomized controlled clinical trials demonstrating that the information garnered from the DecisionDx-Melanoma can improve patient outcomes. All told, the DecisionDx-Melanoma test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for 5 days a week of Intensive Outpatient (IOP) level of services. Studies have demonstrated higher rates off depression with patients who have chronic health problems including diabetes. Coexisting depression in people with diabetes is associated with decreased adherence to treatment, poor blood sugar control, higher complication rates, decreased quality of life, increased healthcare use and cost, increased disability and lost productivity, and increased risk of death. Depression increases risk of health problems and poor treatment adherence, and there is a bi-directional relationship between diabetes and depression. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining the necessary level of care for adults. The enrollees composite score indicates that the patient qualifies for a High Intensity Community Based Services level of care. High Intensity Community Based Services serve treatment needs that require contact several times per week. The patient has many risk factors as well as worsening diabetic control in the setting of her binge eating and co-morbid mood instability. If the patient does not continue in the structure of an intensive outpatient setting, she is likely to continue to gain weight, have poor medication adherence, and be at risk of further health complications. A High Intensity Community Based Services level of care is consistent with the requested 5 days a week of Intensive Outpatient (IOP) level of services. Therefore, 5 days a week of Intensive Outpatient (IOP) level of services is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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: Upheld Decision of Health Plan

The patient's parent is requesting Nutropin AQ Nuspin (a growth hormone) for idiopathic (unknown cause) short stature ISS. The patient is below the percentile for age and height prediction of 5% and there is a family history of short stature with mid-parental height. The patient has normal growth and maturity factors and no known underlying disease. His growth factor (IGF-1) is normal. Growth hormone in the treatment of ISS is supported by randomized controlled trials and consensus guidelines. Federal Drug Administration approval for this indication is for non-growth hormone-deficient short stature, defined by height less than or equal to -2.25 standard deviations, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. The patients pretreatment height is not less than or equal to -2.25 standard deviations. The IGF-1 is normal.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 pediatric endocrinology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for a positron emission tomography with computed tomography attenuation (PET/CT) scan for the full body (CPT code 78816) and if that was not approved then she requested coverage for a PET/CT scan from skull to mid-thigh (CPT code 78815). The enrollee has recurrent right infiltrating ductal breast cancer. She has undergone a double mastectomy, a hysterectomy, and received hormonal therapy. She found another small mass approximately 4 years after treatment. The provider recommended PET scan with CT attenuation to check for the spread of the disease (metastases) and for re-staging of her disease. The literature shows a PET/CT is more sensitive and specific than bone scan for detection of the presence of bone metastases and will also show the presence of soft-tissue metastases. Done as a single study, it is more efficient than having the patient undergo multiple studies, such as a bone scan and CT scan. The PET/CT is a study indicated for this enrollee and is more sensitive and specific in detecting disease than bone scan, leading to earlier detection and earlier treatment of any metastatic disease detected for the enrollee. The use of a PET scan to restage advanced or recurrent breast cancer and monitor response to therapy is accepted and widespread. There is lymph node involvement with this enrollee so it is important to assess if there is further involvement of cancer throughout the body because there is increased risk of further spread that could be missed if not scanned.     Final Result: Two of three reviewers determined that the requested service of full body PET/CT scan is likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in medical oncology and one is board certified in radiation oncology. All three reviewers are 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for a consultation with a pain management specialist. In this case, the patient has persistent low back pain which has been managed with Norco three times a day. The patients last two urine drug screens have been inconsistent, due to the absence of prescribed Norco and the presence of marijuana and alcohol. Records indicate that there was an additional concern of possible tampering with urine samples. Records reflect that the provider made a plan to taper Norco and to offer Suboxone, which was declined. The provider also made a referral to a pain management specialist, which is appropriate given that the patient would be exploring non-opioid and non-pharmocologic treatments, consistent with CDC guidelines. Accordingly, the requested consultation with a pain management specialist is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical, thoracic and lumbar spine without contrast and magnetic resonance imaging (MRI) of the lumbar spine without contrast.The submitted documentation does not support that the requested services are medically necessary. In this case, the patient reports that she is in a great deal of discomfort, which she relates to her neck and back. Recent magnetic resonance imaging (MRI) studies demonstrated multilevel degenerative changes, with no acute abnormalities, and no evidence of a spinal stenosis. While recent MRI studies noted that axial lumbar sequences were not obtained, there were no disclaimers in the final Impression for the MRI. In common practice, if the lack of a part of a study impacts the final diagnosis or impression, specific note of that would be made in the Impression portion of the report. The final stated Impressions in the MRI studies, however, were clear and did not equivocate. There is no reason to repeat any part of the MRI at this time, especially after so short an interval. Therefore, magnetic resonance imaging (MRI) of the cervical, thoracic and lumbar spine without contrast is not medically necessary to treat the patients medical condition. In addition, magnetic resonance imaging (MRI) of the lumbar spine without contrast is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested authorization and coverage for speech therapy services provided in the Armenian language without the use of a translator twice a week. Bilingual or multilingual children have critical periods of brain development that allow them to learn language in a different fashion than adults. In addition, bilingual children that have primary problems with speech fluency, the most effective remediation of these problems is active, ongoing speech and language therapy. In this patients case, his primary speech therapist has documented an ongoing need for services and his progress with this intervention. Speech therapy in the Armenian language is appropriate since the patient lives in a bilingual household and needs to communicate in both languages to perform his activities of daily living. All told, speech therapy services provided in the Armenian language without the use of a translator twice a week 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for surgical laparoscopic implantation of a gastric electrical stimulator. Medical literature states that in refractory cases, especially when there is weight loss, invasive therapeutics such as insertion of feeding tubes, intrapyloric injection of botulinum toxin, implantable gastric electrical stimulation, or surgical (partial) gastrectomy are occasionally considered, but there is little evidence of efficacy, and these are not devoid of potentially major complications. The American College of Gastroenterology further noted that, gastric electrical stimulationdoes not adequately address clinical need. This patient has a history of nausea and heartburn possibly secondary to gastroparesis and GERD. The current peer-reviewed medical literature has not established the long-term safety and efficacy of a gastric electrical stimulator for use in this clinical setting. Therefore, the surgical laparoscopic implantation of a gastric electrical stimulator was 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 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty 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

The patient has requested authorization and coverage for rhytidectomy and lip augmentation, along with the already authorized facial feminization surgery. The World Professional Association for Transgender Health (WPATH) acknowledges that, for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATH further states that although facial feminization procedures are labeled purely aesthetic, these procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. However, the records suggest that a rhytidectomy and lip augmentation would be performed to counter the effects of aging, not to address the patients gender dysphoria. All told, the requested rhytidectomy and lip augmentation, along with the already authorized facial feminization surgery, 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 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for a colonoscopy. The most recent joint guidelines issued by the American College of Gastroenterology (ACG), American Gastroenterological Association Institute (AGA), and American Society for Gastrointestinal Endoscopy (ASGE) for surveillance after a screening colonoscopy state that the interval for repeat screening colonoscopy depends on the findings at the baseline colonoscopy and subsequent colonoscopies. The guidelines state that individuals with 5 to 10 adenomas, an adenoma that is 10 mm or greater in size, or an adenoma with villous component or high-grade dysplasia, should undergo surveillance three years after the prior colonoscopy, which would warrant colonoscopy in this case approximately one year from now. In this case, the patient has a 10 mm adenoma to meet the recommendation for a repeat colonoscopy in three years. Only patients with more than 10 adenomas, or piecemeal resection of an adenoma or sessile serrated polyp, are recommended to have a repeat colonoscopy at one year or less. Under these circumstances, the requested colonoscopy is not medically necessary at this time. Accordingly, the requested colonoscopy 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 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for a Positron Emission Tomography (PET) scan.The submitted documentation does not support that the requested services are medically necessary. Small cervical lymph nodes are commonly detected on CT scans. In addition, surgical oncologists and radiologists should be aware of reactive lymphadenitis in interpreting postoperative restaging FDG PET/CT scan when FDG avid lymphadenopathy is only seen in the lymphatic draining location from surgical site. In this case, the patient presented with a common complaint. She was appropriately evaluated with a CT scan which did not demonstrate substantial adenopathy. The palpable nodule corresponded in location to a tiny lymph node which was subsequently biopsied with a benign result. The patients history notes that she had a prior biopsy of what was apparently a benign thyroid nodule. Under these circumstances, a PET scan is not warranted, as there is no history of a prior malignancy, and there were no signs of diffuse adenopathy detected on physical examination. Accordingly, the requested Positron Emission Tomography (PET) scan is not medically necessary to treat the patients medical condition.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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested authorization and coverage for nasal/sinus endoscopy surgery with balloon ostial dilation. The enrollee has diagnoses of obstructive sleep apnea, chronic sinusitis, nasal congestion, and a deviated nasal septum. After nasal endoscopy, she was treated with naso-topical therapy, including steroids, nasal saline, and humidification to her continuous positive airway pressure device. After months of treatment, the provider noted the enrollee remains symptomatic and that naso-topical therapy has failed. The provider recommended endoscopic sinus surgery for short and long term relief of her condition. This enrollee is not a good candidate for the nasal/sinus endoscopy surgery with balloon ostial because there is no postoperative computed tomography scan of the sinuses, documentation of specific medical therapy, or clinical complaints and findings in the medical records that would validate the need for the requested procedures. Medical records are insufficient to support the need for this procedure.Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in otolaryngology and are 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.