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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services. The submitted documentation supports the medical necessity of the services at issue. This patients polysubstance use was complicated by co-occurring depression and anxiety. His substance use and psychiatric symptoms were impairing his daily routine and negatively impacting his occupational and interpersonal domains. He had only fair motivation. Finally, he had been treated at various levels of care, but had been unable to maintain sobriety. During the disputed timeframe, the patient was engaged in active treatment. However, he remained symptomatic. He endorsed daily craving and no motivation. He was still craving substances. He worried about relapsing. His sleep was disrupted by nightmares. His antidepressant was changed, and his anti-craving medication was increased. Considering the severity of this patients illness burden and his past treatment failures, the partial hospital program level of care was safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Additionally, the services provided were reasonably expected to improve his condition and prevent a more serious episode of illness. All told, partial hospitalization program 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laser assisted cataract surgery and intraoperative aberrometry in both eyes.Findings:  Three physician reviewers found the use of femtosecond laser at the time of cataract surgery is well-described. However, at this time, there is a lack of conclusive evidence that this technology is indicated for uncomplicated cataract cases. In this case, there is no evidence in the records provided to indicate why the use of femtosecond laser and aberrometry were indicated for cataract extraction. The presence of glaucoma and insertion of iStent is not an indication for the use of the femtosecond laser. Thus, laser assisted cataract surgery and intraoperative aberrometry in both eyes was not likely to have been of greater benefit than other available treatment options.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 ophthalmology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar fusion and lumbar total disc arthroplasty for treatment of the enrollee, who has been diagnosed with degenerative disc disease of the lumbar spine. Findings:  The physician reviewer found that The current medical evidence fails to demonstrate the medical necessity of the requested services. Resnick and colleagues documented that low level evidence did not demonstrate an added benefit of fusion for patients with degenerative disc disease and stenosis without spondylolisthesis. The authors concluded that in the absence of deformity or instability, the inclusion of a fusion was not recommended. Lackey and colleagues conducted a systematic review and meta-analysis of outcomes in hybrid constructs for multilevel lumbar degenerative disc disease. The authors stated that it could not be concluded that a hybrid construct is superior to multilevel lumbar fusion or total disc arthroplasty based on this meta-analysis. The results highlighted the need for further prospective studies to delineate best practice in the management of degenerative disc disease of the lumbar spine. This patient presents with progressively worsening low back pain radiating into the right lower extremity. He is status post two prior discectomy surgeries, one at L4-L5 and one at L5-S1. Clinical examination findings documented motor deficit consistent with degenerative disc disease at the L5-S1 level. He had been diagnosed with L4-S1 spondylosis. The current medical evidence does not support single-level artificial disc replacement in the setting of multilevel lumbar degenerative disc disease. In addition, the proposed disc replacement adjacent to a fused spinal segment would represent a hybrid-type complex/construct, of which there is a lack of significant long-term large volume medical literature studies at large. There is a lack of compelling rationale presented to support the medical necessity of the requested hybrid procedure for this patient. Therefore, the requested lumbar fusion and lumbar total disc arthroplasty is 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for soft tissue mobilization, phonophoresis with dexamethasone cream, ultrasound, iontophoresis, electric stimulation, traction and therapeutic massage. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees hip impingement and mild scoliosis.Findings: The submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting. The proposed interventions do not address the patients underlying condition. Femoroacetabular impingement is a poorly understood condition, overall, with limited high grade evidence in the extant literature to inform optimal management outside of surgery to address pathological anatomy. (Amanatullah et al; Freke et al; and Mansell et al). Accordingly, soft tissue mobilization, phonophoresis with dexamethasone cream, ultrasound, iontophoresis, electric stimulation, traction and therapeutic massage are not expected to positively affect the patients clinical course or functional outcomes in a significant manner for her hip dysplasia/femoroacetabular impingement or other conditions. There is a lack of support in the medical literature to indicate that these services would provide a marginally significant improvement in terms of symptom management over an independent exercise program and independently applied palliative measures. As such, sustained or objective benefit of the proposed measures would not be reasonably be expected in this clinical setting. Therefore, soft tissue mobilization, phonophoresis with dexamethasone cream, ultrasound, iontophoresis, electric stimulation, traction and therapeutic massage are not medically necessary for the treatment of this 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for a computed tomography (CT) of the head/brain with and without dye. The records provided for review document that this patient presents with a history of chronic headache condition of at least five months. The patient reports that her headaches resolve with a change in position. There is no evidence of thunderclap headaches or a history of malignancy, trauma, symptoms of meningitis, or sinus infection. In addition, the patients neurological examination has been normal. Applying the American College of Radiology (ACR) appropriateness criteria, the requested CT of the head/brain with and without dye (CPT code 70470 is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is 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 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

Nature of Statutory Criteria/Case Summary: A 54-year-old female enrollee has requested authorization and coverage for acupuncture two times per week for treatment of the enrollees low back pain and lumbago with sciatica.  Findings:  The physician reviewer found that the records provided for review document that this patient presents with chronic pain that has been unresponsive to prior medication and injection therapies. Three acupuncture sessions were provided with approximately two to three weeks between visits, with some symptomatic relief. The current peer-reviewed medical literature reveals that acupuncture is more effective than placebo. As this patient continues to complain of chronic lower back pain, six consecutive weekly acupuncture sessions are supported as medically necessary. Further care, beyond the trial, will be based on the patients symptoms, functional benefits obtained with these treatment sessions and the residual functional-sensory-motor deficits that need to be addressed. Accordingly, six acupuncture sessions are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in oriental 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 methadone HCL 10 mg, one tablet every four hours. The step-wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. There is no documentation of the completion of behavior therapy despite significant research to support its use. Furthermore, no objective treatment goals for pain and function are noted for the requested medications. The Centers for Disease Control and Prevention (CDC) also state that when opioids are started, providers should prescribe the lowest effective dosage. Finally, not all non-opioid and non-narcotic medications classes have been optimized or tried. For these reasons, the requested methadone HCL 10 mg, one tablet every four hours, is not medically necessary for treatment of the patients medical condition.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 Repatha SureClick. Findings: The physician reviewer found that the patient presents with documented obstructive coronary disease, intolerance to multiple statin medications, and LDL that is significantly above a goal of less than 70 mg/dL while on Zetia medication. Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria and statin intolerance is well documented. In this clinical setting, the addition of a PCSK9 inhibitor such as Repatha has been shown to be safe and effective at lowering cholesterol and has been associated with improved cardiovascular outcomes. Therefore, Repatha SureClick is medically necessary for the 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 sub-specialty certification in cardiovascular 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Botox injection.As noted in the medical literature, intrapyloric injection of Botox is not recommended for patients with gastroparesis. Although observational studies suggest that injection of Botox into the pylorus can improve both gastric emptying and symptoms by inhibiting pylorospasm, randomized trials have failed to demonstrate an improvement in symptoms as compared with placebo. All told, the Botox injection rendered was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the Botox injection provided 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 Botox injection provided was not likely to be more beneficial for treatment 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial laser hair removal. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria and are not reconstructive in nature. Findings: The requested services are medically necessary in this clinical setting. Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. The record notes that hormone therapy has not been effective in treating this patients excessive facial hair. The patient has reported anxiety over being misgendered despite hormone therapy. Therefore, facial laser hair removal is medically necessary for treatment of this patients gender dysphoria.With regards to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is considered an abnormal body structure. It would be abnormal for a female to have terminal hair on the face. The patients abnormal appearance is the result of gender dysphoria, a disease classified in the Diagnostic and Statistical Manual of Mental Disorders. Facial laser hair removal can provide substantial improvement in the appearance of terminal hair and create a normal appearance to the best extent possible. Additionally, facial laser hair removal would also provide more than a minimal improvement in the appearance of this patient as well as improve the patients emotional function. For these reasons, facial laser hair removal is reconstructive in nature. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma test. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma.Findings:  There is a lack of evidence based medical literature to support the superior efficacy of the services at issue in this patients case. DecisionDx-Melanoma assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class I consistent with a low risk of metastasis or Class II suggestive of a high risk of metastasis. A study found there was a statistically significant association of a Class 1 signature by DecisionDx-Melanoma assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently Class II. The researchers concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. While DecisionDx-Melanoma signature may be an independent predictor of metastasis risk, more studies are needed to show its efficacy when compared to standard methods used to guide therapy or predict the risk of cancer. All told, DecisionDx-Melanoma gene assay was not likely to have been more effective for the evaluation of this patients medical condition than any available standard therapy. Final Result: All three reviewers determined that 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:  All three reviewers are board certified in dermatology 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested enrollee has requested reimbursement for DecisionDx-Melanoma test. Findings:  The physician reviewer found that there is lack of evidence in the medical literature as to the superior efficacy of the services at issue over standard techniques in the evaluation of this patients medical condition. As such, the services at issue are not considered standard of care in this clinical setting and its usage is not expected to affect the management of the patients melanoma. The results from the testing would not change treatment recommendations. Accordingly, the DecisionDx-Melanoma test was not likely to have been of greater benefit in the management of this patient than the available standard techniques. Final Result: All three reviewers determined that 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: All three reviewers are board certified in dermatology 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.