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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for speech therapy treatment of his autism and expressive and receptive language delay. Findings:  The physician reviewer found that recent data suggests that older children diagnosed with ASD can benefit from access to speech therapy. In a recent article, it was shown that direct one-on-one intervention with a speech and language therapist can be effective for all areas of language for older children with developmental language disorder, regardless of their gender, receptive language or ASD status, or age. While these results are encouraging, in this case, the patient has received direct one-on-one speech therapy for many years, and has failed to demonstrate progress necessary to support the medical necessity for continued therapy. Final Result: The reviewer determined that the requested service 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 revision of gastric bypass surgery for treatment of her obesity. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Although this patient remains morbidly obese, revisional bariatric is not medically necessary.  This patient was unable to document the necessary behavioral, dietary and lifestyle changes that were felt to be necessary by the multidisciplinary team to warrant success from a second or different bariatric procedure.  The current medical evidence does not support the requested services in this clinical setting.  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 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 representative of an enrollee has requested reimbursement for residential treatment center services for treatment of his medical condition. Findings:  The physician reviewer found that Based on the documentation submitted for review, residential treatment center services were not medically necessary for treatment of the patients medical condition. Residential treatment is utilized for acute stabilization and is not supported for long-term type treatment. The evidence based literature indicates that psychiatric symptoms must be severe and present to the degree for residential treatment level of care is needed. In this case, the records do not indicate severe psychiatric symptoms were present prior to his admission or during his stay. Per the American Academy of Child and Adolescent Psychiatry Child and Adolescent Level of Care Utilization System (CALOCUS), the patients symptoms and environment correlates with a treatment intensity level of three which correlates with intensive outpatient services. The patient had some risk of harm due to episodic outbursts, however he was not having active suicidal ideation. His function status was moderate as he had minimal school disruption and able to complete his activities of daily living in an age appropriate manner. He had no active serious medical problems and has a stable housing situation. His family is actively involved in treatment and attend family therapy sessions on a regular basis. Moreover, the patient participates actively in therapy, but has poor insight. Based on the records submitted for review, the patient had stabilized sufficiently to allow transition to a less restrictive setting during the dates in dispute. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa and ribavirin for a duration of 24 weeks for treatment of his hepatitis C. 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, no data is available for retreatment of Sovaldi and Daklinza failures in genotype 3 patients.  Epclusa/ribavirin for 24 weeks may be considered for those who require immediate retreatment, although no support for immediate retreatment, such as cirrhosis, is provided in this case. The guidelines state that the only available data is in patients who have failed Epclusa.  The guidelines otherwise recommend deferral of therapy in anticipation of future regimens, stating Given the limited data and marginal efficacy, genotype 3 patients who have failed an NS5A inhibitor and do not require urgent retreatment should have their retreatment deferred in anticipation of future regimens with improved activity in genotype 3 and against resistant variants.  Final Result: The reviewer determined that the requested medication regimen 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 gene testing provided Findings:  The physician reviewer found that Guradant360 is a type of liquid biopsy that offers molecular profiling on tumor types. As human epidermal growth factor receptor 2 (HER2) testing was not able to be obtained on the patients pelvic washings, the testing at issue was performed to help guide therapy. However, molecular profiling of breast cancer is not supported by the National Comprehensive Cancer Network (NCCN) guidelines. For patients with clinical courses consistent with hormone receptor (HR) positive breast cancer, or with prior positive HR results, the panel has noted that a course of endocrine therapy is reasonable, regardless of whether the receptor assay is repeated or the result of the most recent HR assay. Further, it is possible to perform testing for HER2 on liquid specimens. Therefore, molecular profiling performed was not likely to be more beneficial than standard HER2 testing or using prior biopsy molecular markers to guide therapy. For the reasons provided, Guardant360 gene testing provided on the date of dispute 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 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: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are all 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of a breast screening mammogram. Findings:  The physician reviewer found that the report noted fatty tissue but no evidence of cancer. The Health Plan has denied reimbursement for digital breast tomosynthesis.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two dimensional imaging alone.  Thus, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely of greater benefit to the patient than had her examination been performed using two dimensional imaging alone. Final Result: The reviewers determined that the service at issue was 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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 gene test, OncotypeDX prostate for evaluation of his prostate cancer. Findings:  Two physician reviewers found that the OncotypeDX Prostate Cancer Assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS). This test may be utilized to counsel men regarding the best course of therapy (active surveillance vs. treatment) in newly diagnosed low or low-intermediate prostate cancer. Two recent studies have suggested that OncotypeDX can predict adverse pathology and unfavorable outcomes after radical prostatectomy. These studies are recently published and need continued validation from a widespread clinical use. In addition, it is difficult to ascribe clinical utility of OncotypeDX Prostate in patients planning to undergo active surveillance within six months of diagnostic biopsy. Moreover, the validity of using different degrees of tumor pathology as markers to extrapolate the risk of progression of a tumor in vivo is unclear. In addition, current guidelines for prostate cancer suggest that additional evidence regarding the clinical utility of these tests are needed prior to making recommendations as to their routine application. 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: Reviewers 1, 2, and 3 are board certified in urology and is actively practicing. The reviewers 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 reimbursement for reconstructive bilateral breast surgery for treatment of the enrollees acquired breast deformity. Findings:  The physician reviewer found that based on the documentation provided, the patient has undergone typical treatment of complications following aesthetic breast surgery. There is a lack of sufficient documentation that the initial placement was for reconstructive reasons. Thus, the procedure performed in July 2014 was aesthetic with respect to a mastopexy and implant removal. This surgery was complicated by a hematoma, redundant skin and scarring which are known complications in breast surgery/mastopexy. The patient is not documented to have a well-defined functional deficit relative to her condition prior to the procedures in question. Photographs submitted for review are consistent with a poor aesthetic result following previous explanation and mastopexy. This is expected given her previous complication and nature of remaining soft tissue following implant removal. There is no documentation to support that the patient had an original congenital breast deformity. The medical records support that the mastopexy and fat grafting was done for appearance concerns and not functional concerns. There is insufficient documentation that her preoperative condition was significantly abnormal given her previous complicated explanation and mastopexy surgery. Final Result: The reviewer determined that the surgery at issue was 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 plastic 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 for partial hospitalization program level of care services. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The progress notes indicate that the patient was cooperative in recent treatment. He was noted to be providing good cooperation while in therapy at the acute inpatient level of care, as well as during his short time in the partial hospitalization program.  He did not display any dangerous behaviors while in the partial hospitalization program or in the acute hospital setting.  The patient has no significant history of behavioral health treatment.  He has not tried or failed any psychotropic medications, and the most recent documentation indicates that he was not on medication.  Due to the patients minimal behavioral health treatment history, he could have been safely treated in a less restrictive setting.  The supplied documentation does not indicate that he is having severe mood swings, or other severe psychiatric symptoms.  It appears that his recent episode of wrapping a cord around his neck has been his only self-harm behavior.  Outpatient treatment and least restrictive options are considered first lines of care.  The records do not document that the patient failed outpatient treatment.  All told, partial hospitalization program level of care services provided and resumption of partial hospitalization program level of care services for a minimum of 30 days were not and are 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (Afirma gene expression classifier). Findings:  Three physician reviewers found that the Afirma testing performed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There are multiple peer-reviewed scientific articles supporting the benefits of the genetic testing in thyroid nodules. In this case, cytopathology of the 2 cm thyroid nodule was consistent with a follicular lesion/Hurthle cell lesion of undetermined significance. The risk of malignancy is 15-30% in follicular neoplasm nodules. The American Thyroid Associations guidelines state that for follicular neoplasm nodules, molecular testing may be used to supplement malignancy risk assessment data in lieu of proceeding directly with surgery. Informed patient preference and feasibility should be considered in clinical decision-making. If the genetic test is suspicious, the risk of malignancy increases to 40%. In this case, the result of the gene expression classifier was suspicious for malignancy. In addition, the MTC and BRAF gene mutation analysis were negative. This information was important to determine the extent of surgery. A benign Afirma test result could have prevented an unnecessary surgery and observation can be safely continued. Accordingly, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing at issue was 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 endocrinology, diabetes and metabolism 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: parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin 20 mg. Findings:  The physician reviewer found that there is a lack of data to comment on whether there is any component of genetic short stature.  The patients bone age is not delayed.  In growth hormone deficiency, a bone age is characteristically delayed.  Of note, the bone age study was obtained approximately one year before growth hormone therapy was recommended.  Although the growth hormone stimulation test is low, there are no insulin-like growth factor 1 (IGF-1) data to confirm this.  Growth hormone stimulation tests are known to have a high rate of false positivity and low sensitivity.  Accordingly, this may represent a false positive.  There is a lack of data on height velocity, which is also an important component of the rationale for supporting a diagnosis of growth hormone deficiency.  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 pediatrics with sub-specialty certification 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for sclerotherapy. Findings:  The physician reviewer found that indications for intervention in varicose veins are based on the persistence of symptoms after a trial of conservative therapy including compression stockings, diet, exercise, elevation and use of nonsteroidal anti-inflammatory drugs. This is not documented in this patients case.  The records do not document that the patient has failed a trial of compression stockings.  Based on the duplex, there is no indication for primary treatment of varicose veins.  Final Result: The reviewers determined that the requested services are 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: the physician reviewers are board certified in vascular surgery 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An  enrollee has requested reimbursement for the pneumatic compression cooling/heating device provided .Findings:  The physician reviewer found that according to the systematic review by a study The evidence base to support the common practice of superficial heat and cold for low back pain is limited, and there is a need for future higher-quality randomized controlled trials. There is a lack of high-grade evidence-based literature to support the need for this type of iceless cold compression device after spinal stenosis surgery when superficial ice applications could have sufficed. No marginally significant benefits in analgesia, health or function would have been reasonably expected with the use of this device over independent ice application. For the reasons provided, the pneumatic compression cooling/heating device provided during the dates of dispute 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 device at issue was 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 & 3 are board certified in physical medicine and rehabilitation and pain medicine and are actively practicing. The reviewers are all 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.