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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage esophagogastroduodenoscopy (EGD).Pediatric gastrointestinal guidelines state that both an esophagogastroduodenoscopy (EGD) and a colonoscopy are indicated in the setting of suspected inflammatory bowel disease (IBD), as seen in the ESPGHAN Porto criteria. In contrast with adults, IBD can lead to inflammation in the upper GI tract in over 60% of children with that disease. Moreover, in roughly 10% of cases of pediatric Crohns disease, inflammation of the upper tract leads to a diagnosis which would be missed or delayed if investigation were limited to colonoscopy (without EGD). Researchers found in a prospective study that among 176 children with Crohns disease, 44 had non-granulomatous inflammation on colonoscopy (non-diagnostic for Crohns disease). However, 16 of these children could be diagnosed with Crohns disease with the use of information acquired during EGD. The authors concluded that EGD has a 9% diagnostic yield in the diagnosis of Crohns disease in children. In this case, IBD is suspected based on the patients symptoms and the results of CT imaging, and EGD is indicated along with colonoscopy for the purpose of accurate diagnosis. Accordingly, the requested esophagogastroduodenoscopy (EGD) 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 pediatrics, with subspecialty certification in pediatric 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

The patient has requested reimbursement for residential treatment center (RTC) 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 framework, the patient did not meet the criteria for the RTC services. The patient has a composite score which is consistent with high intensity community-based services, such as intensive outpatient program (IOP) level of care. Given these findings, the psychiatric RTC level of care 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 subspecialty certification 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

An enrollee has requested authorization and coverage for anorectal manometry. The submitted documentation does not support that the requested services are medically necessary. Typical indications for anorectal manometry testing include fecal incontinence, constipation and to guide biofeedback therapy. In this case, the patient has a body odor that is felt to be originating from the anorectal area. At this time, there are no well-designed, established, randomized control trials that have proven the safety and efficacy of anorectal manometry for the requested indication. Evaluation for body odor that is felt to be related to the anorectal area is not an indication for anorectal manometry in the current, peer reviewed medical literature. Accordingly, the requested anorectal manometry 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 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: Overturned Decision of Health Plan

The patients caregiver has requested reimbursement for intensive outpatient program (IOP) level of care services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, 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) developmental, medical, substance use 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. The patients composite score is consistent with community-based services, the minimum being intensive outpatient therapy. Given these findings, 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 subspecialty 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: Upheld Decision of Health Plan

The patients parent has requested reimbursement for neuropsychological testing. The American Academy of Pediatrics (AAP) report that the diagnosis of attention-deficit/hyperactivity disorder (ADHD) is made based on clinical history and interviews with patients and their caregivers, as well as collateral information obtained from teachers. Researchers found that neuropsychological testing has not been found to improve diagnostic accuracy in most cases, although it may have benefit in clarifying the child or adolescents learning strengths and weaknesses. In this case, the patient underwent neuropsychological testing at the recommendation of his school psychologist. The provider who performed the testing expressed concern that patients inattention, impulsivity, and anxiety might have affected the testing results. The records do not include documentation of a prior clinical assessment or treatment of the patients ADHD symptoms by a psychiatrist, psychologist, or pediatrician. Overall, the records do not support an indication for a full neuropsychological assessment, rather than a clinical assessment for ADHD. All told, the neuropsychological testing was not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 psychiatry with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acute rehabilitation services including speech therapy and occupational therapy through telehealth conferencing, four hours per day, five days per week. Functional impairments due to acquired brain insults such as stroke can range from mild to profound. While natural recovery evolves with time, many impairments are addressable by compensatory measures and directed rehabilitation efforts. Most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke and gains are slower in the subsequent stages. The records provided for review document that this patient was admitted to the hospital with acute left thalamic and left posterior parietal embolic infarcts. The patient is independent with all of his activities of daily living and with mobility and required supervision for bathing. While the patient has some coordination deficits and weakness, he is independent to supervision for basic self-care and household mobility. Additional rehabilitation services on an intermittent basis in the community are appropriate. Furthermore, the records do not demonstrate that the patient requires rehabilitation services for four hours per day or that this intensity of services is likely to provide a substantial benefit over standard rehabilitative care. All told, the requested acute rehabilitation services including speech therapy and occupational therapy through telehealth conferencing, four hours per day, five days per week 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for irreversible electroporation (IRE). Epithelioid hemangioendothelioma is a soft-tissue sarcoma with histologic markers that suggest an endothelial origin. There is no well-defined treatment strategy for hepatic epithelioid hemangioendotheliom. Epithelioid hemangioendothelioma is poorly responsive to chemotherapy, immunotherapy, and radiotherapy, as well as several other treatment modalities. In addition, surgical resection and transplantation are highly invasive and complicated by rejection issues. IRE is a non-thermal focal ablation method which kills cells non-thermally but spares structures such as extracellular matrix, blood vessels, and bile ducts; it has shown safety and efficacy even in tumors which were ineligible for or refractory to conventional therapies. IRE has been demonstrated to be safe and effective for the treatment of epithelioid hemangioendothelioma and is less invasive than surgery or transplant. In this case, the patient has epithelioid hemangioendothelioma with no well-defined treatment strategy. IRE is a viable treatment option with demonstrated safety and efficacy, compared with alternatives, which are associated with significant adverse effects or invasiveness. For these reasons, the requested IRE 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Abemaciclib (Verzenio) 100 mg twice per day. Based on the records provided for review, this patient with metastatic breast cancer was initially on a combination with Ibrance with good tumor response. However, she developed side effects, which resolved with discontinuation of Ibrance, but precluded continuation of her treatment regimen. Her provider recommended changing from fulvestrant to Arimidex and from Ibrance to Verzenio. A major advance in the treatment of ER positive HER2 negative metastatic breast cancer has been the addition of CDK4/6 inhibitors, such as Ibrance or Verzenio, to standard hormonal therapy. Randomized studies evaluating these combinations have shown a significant increase in progression-free survival, as well as overall survival (Finn, et al.). The National Comprehensive Cancer Network (NCCN) supports treatment with any of the three available CDK4/6 inhibitors in combination with either fulvestrant or Arimidex in this patients clinical setting. Given the patients initial positive response, but inability to tolerate Ibrance, it is reasonable to offer a new combination, using a similar medication. Therefore, the requested Verzenio 100 mg twice per day is medically necessary for treatment of this patient. 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 subspecialty certification in medical 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Synvisc-One in right knee. The American Medical Society for Sports Medicine (AMSSM) supports hyaluronic acid injections in the knees for patients who have failed to respond to conservative treatment and to potentially delay total knee replacement in patients with severe osteoarthritis and pain that interferes with functional activity. This patient presents with complaints of severe right knee pain with functional limitations. The patients right knee clinical examination findings are consistent with radiographic evidence of tricompartmental osteoarthritis, described as bone-one-bone. The records document that the patient experienced tachycardia with a recent cortisone injection. She is reportedly not a candidate for surgery. Given this patients functional limitations, and failure of conservative treatment, as well as contraindication to cortisone injections, the use of hyaluronic acid injections is appropriate. Thus, the requested Synvisc-One injection for the right 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

An enrollee has requested reimbursement for Guardant360 testing. Molecular diagnostic studies are considered within the current standard of care for patients with non-small cell lung cancer (NSCLC). Numerous gene alterations have been identified that impact therapy selection. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. The National Comprehensive Cancer Network (NCCN) guidelines strongly recommends broader molecular profiling, with the goal of identifying rare driver mutations for which effective therapies are available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. This patient was diagnosed with NSCLC. The provider noted that on the initial biopsy, the only molecular marker evaluated was epidermal growth factor receptor (EGFR), and there was insufficient tissue for additional testing. In this clinical setting, the use of Guardant360 analysis avoided a repeat biopsy and yielded the necessary data to guide this patients treatment. All told, the Guardant360 testing 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 reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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

:  The enrollee is requesting authorization and coverage for a power wheelchair. The enrollee has a history of traumatic brain injury and bilateral leg pain. The enrollee has co-morbidities of delusional disorder, post-traumatic seizures, and bilateral hearing loss. Medical records note it has been determined that the enrollee is not able to operate a power wheelchair in a safe manner. He has been evaluated by physical therapy and found to be an unsafe wheelchair operator. This enrollee poses a significant safety risk to himself and others if provided a power wheelchair. Literature discussion on the role of powered wheel chairs notes the type of device used depends not only on the physical, but also, importantly, on the cognitive function of the individual. A recent study notes intelligent power wheelchair development is at an early stage and requires further study.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 physical medicine, rehabilitation and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for a power scooter. The submitted documentation does not support that the requested power scooter is medically necessary. The submitted records do not reveal that the patients mobility limitations cause him to be unable to perform activities of daily living in the home or outside of the home. A functional mobility assessment of the patient indicates that the appropriate device for the patient would be a heavy-duty four wheeled walker with a seat for his endurance deficits. The documentation does not reveal significant neurological deficits or gait abnormalities, but rather poor endurance due to obesity and COPD. In addition, records indicate that the requested power scooter would not fit inside the patients home. The patient was noted to be independent with shopping and occasionally needs help for heavy work. He has low endurance and uses oxygen at night. The records noted a gait normal distance of 50 feet, best distance of 100 feet, and worst distance of 25 feet. The documentation does not support that the patient requires a power scooter for outside the home. The patients needs could be adequately met with a heavy-duty four-wheeled walker with a seat as recommended by his provider if he experiences fatigue on longer distances. Records reflect that the patients physician is encouraging exercise, and medical literature supports physical activity, as sedentary behavior is linked to adverse health outcomes. Under these circumstances, the requested power scooter is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested durable medical equipment is 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 physical medicine and rehabilitation, with subspecialty certification in neuromuscular 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.