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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for sclerotherapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients varicose veins. The submitted documentation does not support the medical necessity of the requested services. The patient has a history of deep vein thrombosis that does not seem relevant to the patients 1 to 2 mm varicosities. In addition, there is no clarity regarding the patients reflux. The presence or absence of reflux in this case is not relevant as to whether the sclerotherapy should be covered in any case. Treatment of branches is covered for veins typically greater than 3 mm. Based upon the documentation provided, the patient does not meet this criteria. Therefore, the requested sclerotherapy is not medically necessary for the treatment of the 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 vascular 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: A enrollee has requested authorization and coverage for enoxaparin sodium (Lovenox) twice daily. Findings:  The physician reviewer found that this patients records support the medical necessity of the requested Lovenox twice daily. The magnetic resonance imaging (MRI) findings, positive serology, and presence of cutaneous vasculitis demonstrate an indication for this medication. Moreover, Lovenox is considered the standard of care in this clinical setting. All told, the requested Lovenox twice daily is medically necessary for treatment of this patients medical condition. 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 nephrology 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

A patient has requested reimbursement, and prospective authorization and coverage for aqua physical therapy three times a week. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the patients lumbar radiculopathy. The submitted documentation does not support the medical necessity of the services at issue. Recent reviews demonstrate that exercise has generally been shown to be an appropriate intervention in the setting of chronic low back pain and various other musculoskeletal conditions. Exercise in a pool setting is one of several options for lower intensity exercise that can also provide symptom relief. However, there is a lack of evidence indicating that formal aquatherapy programs for low back pain result in marginally superior pain, health or functional outcomes over water-based exercises that are pursued independently or performed in informal group exercise settings, or in appropriate low-impact, land-based programs. There are various general water-based exercise programs not requiring formal therapy that have been reported to be effective for low back pain. Formal aquatic therapy, (as opposed to generalized water-based exercise) is medically necessary only for individuals in specific circumstances, for example, for patients who require therapy in a partially body weight unloaded who are unable to perform the applicable exercises without formal therapist guidance, instruction and supervision. The records do not establish that the patient has impairments that would preclude an appropriate water-based or low-impact land-based exercise program. There are no documented objective indications that the patient could not exercise in a pool unassisted (such as, basic pool walking, stretching, strengthening and/or swimming), in a group exercise setting, or with an exercise coach if the patient elected to do so. There are no indications that the patient could not pursue palliative interventions such as balneotherapy or topical thermal modalities. The records do not establish that a formal aquatic therapy program is medically necessary for this patient. Therefore, the aqua physical therapy three times a week was not and is not medically necessary for the treatment of the patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an x-ray of the lungs. This patient has a history of chronic back pain. He does not have a history of tobacco use.  The diagnostic imaging modality of a chest x-ray is indicated when there is a concern for underlying lung or heart disease. A patient may need a chest x-ray for acute complaints, such as shortness of breath, chest pain or cough. With regards to a chest x-ray in an asymptomatic patient, screening for lung cancer by chest radiograph is not recommended. In this case, the documentation does not support that the patient has symptoms that would necessitate further diagnostic work-up with a chest x-ray or has a significant history of tobacco use that would require lung cancer screening. Therefore, the requested x-ray of the lungs is not medically necessary for the evaluation of this patient. 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 internal 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: Anenrollee has requested authorization and coverage for acyclovir 400 mg, oral tablet, once per day. This patient was diagnosed with herpes simplex infection. Oral acyclovir is effective treatment for herpes simplex infection. Specifically, oral acyclovir has been shown to decrease the duration of illness and symptoms severity (a study). In addition, prophylaxis is effective and indicated in this clinical setting. All told, the requested acyclovir 400 mg, oral tablet, once per day is supported as medically necessary for treatment of this patients medical condition. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent an enrollee has requested authorization and coverage for speech therapy twice per week for 60 minutes per session. The requested speech therapy at an intensity of 60 minutes twice a week is medically necessary for this patient. The patient has severe expressive language delay, and is unable to engage in interactive communication. Studies investigating the intensity of speech therapy and outcomes of treatment in children with autism spectrum disorder and delayed speech and language are limited. Researchers studied 1433 children and adolescents with autism spectrum disorder with respect to intensity of speech and behavioral therapy. The authors found that the majority of patients demonstrated improvement. Given this support, the requested speech therapy twice per week for 60 minutes per session is supported as medically necessary for treatment of this patients medical condition. 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 pediatrics and 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 parent of an enrollee has requested authorization and coverage for Accutane. The provider reports that this patient has tried and failed conservative combination therapy. Accutane is U.S. Food and Drug Administration (FDA) approved for the treatment of moderate to severe acne. Accutane often provides long lasting clearance of severe, scarring acne which has been resistant to other therapies. The use of Accutane can prevent chronic, long-term scarring that can result from persistent nodulocystic acne. Thus, the requested Accutane is supported as medically necessary for treatment of this patients medical condition. 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for substance use residential treatment center (RTC) services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation does support the medical necessity of the services at issue. In this case, the patients alcohol use contributed to health, legal, occupational and interpersonal issues. The patient drank to self-medicate feelings of anxiety and overly harsh self-criticality. The patients overconsumption of alcohol placed self and possibly others at risk, as evidenced by the patients high-risk behaviors. Although poorly documented, there was concern for anxiety and depression. Anxiety-ridden mood disorders, without the complication of addictive illness, are difficult to treat and in general have poorer outcomes. Notwithstanding, the patient had failed treatment in a less restrictive setting and was referred to a residential treatment facility.  It is common practice to advance the level of care when less restrictive settings are inadequate. In sum, the services and setting were safe, appropriate and consistent with good practice in the United States, while the duration of treatment aligned with community standards. Additionally, the services provided at the time were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  Considering the clinical presentation and perusal of the relevant peer-reviewed literature, substance use residential treatment center (RTC) services were medically necessary for the 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 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: A female enrollee has requested reimbursement for fertility preservation services. Egg retrieval and egg and/or embryo freezing (cryopreservation) is a recognized option for women who have been diagnosed with cancer and who are undergoing treatment that can render them infertile. The medical evidence has shown that cancer treatment is toxic to ovaries/eggs. This option allows patients undergoing treatment to have children in the future. The goal of the procedure is to protect their gametes from the effect of the chemotherapy. This procedure is a treatment that is appropriate to offer to such patients. As noted in the medical literature, administration of gonadotoxic chemotherapy or radiation therapy often leads to infertility. Fertility preservation services, along with planning and intervention, have been proven to be an effective technique for preserving reproductive capacity. This treatment is supported by the American Society of Reproductive Medicine. In this patients case, when chemotherapy is anticipated to damage or destroy the womans eggs, such treatment is medically necessary. The American College of Obstetricians and Gynecologists also support fertility preservation treatment, noting, Based on the current state of evidence, modern procedures to cryopreserve oocytes should no longer be considered experimental.... Oocyte cryopreservation, with appropriate counseling, is recommended for patients facing infertility due to chemotherapy or other gonadotoxic therapies. For these reasons, the services rendered to this patient were medically necessary and a part of her cancer care. Accordingly, the preservation services were medically necessary for the treatment of this patients medical condition.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 obstetrics and gynecology 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 reimbursement for the Afirma Gene Expression Classifier (GEC) genetic testing. When FNA cytopathology is indeterminate, repeat FNA and or thyroid surgery are the standard options to obtain a definitive pathological diagnosis. In this patients case, the initial FNA cytology was as indeterminate. Thus, FNA could have been repeated, and if cytology was still indeterminate, surgical resection should have been considered. Thus, the Afirma GEC molecular test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the Afirma GEC molecular test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was 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:  One reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for circumcision. Final Result: The reviewer determined that the submitted documentation fails to demonstrate the medical necessity of the requested services. Based on the available documentation, the patient does not have medical problems or conditions for which a circumcision would be indicated. He did not report voiding complaints or a history of recurrent balanitis or urinary tract infections. Physical examination did not reveal penile abnormalities. Performing a circumcision for redundant foreskin for abnormal odor is not considered a clinically appropriate and generally acceptable standard of care. As such, the requested circumcision is not medically necessary for the treatment of this patient. Credentials/Qualifications: The reviewer 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bone density testing. Osteoporosis is an increasingly widespread condition, affecting 55% of Americans aged 50 and above. Of these, approximately 80% are women. Fractures are the most dangerous aspect of osteoporosis. Osteopenia, a condition in which bone mineral density is lower than normal, is considered by many physicians to be a precursor to osteoporosis. Given this patients postmenopausal status and her comorbidities, the bone density testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the bone density 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 bone density testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 Norco. The submitted documentation fails to demonstrate the medical necessity of the requested medication. In this case, objective treatment goals for pain and function were not documented. Clinicians should use caution when prescribing opioids at any dosage. Dose escalation is not a long-term plan, but a short-term plan for the treatment of tolerance. It is reasonable to consider alternatives to opioids and to wean the patient off opioids. In this patients case, not all non-opioid medications classes have been optimized or tried. For these reasons, Norco is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is 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 anesthesiology with sub-specialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injection in the right knee. The submitted documentation supports the medical necessity of the requested services. This patient presents with significantly symptomatic right knee osteoarthritis. Functional limitations are documented in walking. Clinical examination findings are consistent with weight-bearing x-ray findings of moderate tricompartmental osteoarthritis, worse in the medial compartment. The patient has failed to adequately respond to activity modification, oral and topical medications, and corticosteroid injections. A trial of viscosupplementation is recommended to potentially delay total knee replacement surgery. The evidence-based literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and has been demonstrated to be more effective than corticosteroid injections. Therefore, the requested Synvisc One injection in the right knee is 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.