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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance use residential treatment services provided. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Per the records, there was no evidence of suicidality or homicidality, and she was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  She was medically and psychiatrically stable to the extent that she did not need 24 hour per day, seven days per week services during the dates of service in dispute. Her medication management and anti-craving medications could have been provided in an ambulatory setting. The patient was motivated and appeared to be working the program. She was cooperative and participating in her treatment plan. She had an extensive period of sobriety with Alcoholics Anonymous involvement. Therefore, she was aware of steps necessary for recovery. Although she continued to struggle with her emotions and required further treatment to help develop coping skills and gain control over her emotional lability/anger, this did not require the structured environment of a residential setting.  This could have been accomplished at intensive outpatient program level of care.  All told, substance use residential treatment services provided were not medically necessary for the treatment of this patient.Final Result: The reviewers 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: Physician reviewer number two 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 authorization and coverage for laparoscopic hiatal hernia repair with LINX placement surgery.  Findings:  The physician reviewer found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures.  Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval.  Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. Thus, the requested laparoscopic hiatal hernia repair with LINX placement surgery is not likely to be of greater benefit than other treatment options.  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: 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 expert sin 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 residential treatment center services provided. Findings:  The physician reviewer found that residential treatment center services provided were not medically necessary for treatment of the patients behavioral health condition. According to the documentation submitted for review, the patient was experiencing mild post-acute withdrawals. The patient did not have emotional, behavioral, or cognitive factors to warrant residential treatment. He was medically and psychiatrically stable, and he did not require 24-hour monitoring. The documentation submitted does not demonstrate that treatment at a lower level of care would have led to decompensation or relapse. He was motivated, gaining insight, and engaged in treatment. He had sober supports. His continued recovery and treatment for his emotional issues could have occurred at a lower level of care. Thus, the services at issue were not medically necessary for treatment of the patients medical condition. 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 physician reviewer number is board certified in psychiatry with sub-specialty 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

Nature of Statutory Criteria/Case Summary:A 23-year-old male enrollee has requested authorization and coverage for gynecomastia surgery. Findings: The physician reviewer found that a review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested surgery. The patients bilateral masses and correctable causes have not been sufficiently evaluated. A report of relevant laboratory studies and endocrine work-up is not documented. In addition, the patients pain and discomfort does not show that it is due to distention and tightness from hypertrophied breast. Moreover, the photographs show gynecomastia grade of I or II, which is relatively mild to moderate. The records also do not mention a concern for possible malignancy based on examination detail and mammography results. Therefore, based on the documentation provided for review, the request for gynecomastia surgery has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewers determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer 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: An enrollee has requested authorization and coverage for Repatha SureClick. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested medication in this clinical setting. Based on the records provided, the patient has no current angina; mild creatine kinase (CK) elevation; and low density protein (LDL) cholesterol of 72 mg/dl on maximally tolerated rosuvastatin medication at 5 mg/day combined with ezetimibe 10 mg/day. The patients records indicate an LDL close to the recommended goal. Studies have shown that mild CK elevation is not a contraindication to continuing statin medication. Moreover, the patients medical records do not document his intolerance to the currently prescribed lipid medications. Both have been demonstrated to have outcome benefits. Since the patients medical records do not confirm a contraindication to the currently prescribed lipid medications, or intolerance to the currently prescribed lipid medications, the requested medication is not medically necessary. Also, the patient has experienced effective lipid lowering to a goal on current medications. Medical studies support the use of proprotein convertase subtilisin/kexin type 9 inhibitors for patients who are unable to take statin medications and/or need additional reduction in LDL cholesterol. In this patients case, his records do not document that he is unable to take statin medications or that he needs additional reduction in his LDL cholesterol. As such, Repatha SureClick is not medically necessary for the treatment of this patient. Final Results: 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 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 advanced lipoprotein testing CPT code 83698 and CPT codes 82172, 83695, 83701, and 83701-59 performed on a separate date of service. Findings:  The physician reviewers found that in this circumstance, prevention guidelines for the management of cardiac risk and dyslipidemia have been established. These guidelines are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. As such, CPT code 83698 performed and CPT codes 82172, 836695, 83701, and 83701-59 performed on separate date of service were not likely to be more effective than any available standard therapy in evaluating this patients medical condition. Final Result: 2 of 3 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 the AmniSure rupture of membranes (ROM) test. Findings:  The physician reviewers found that the diagnosis of ROM is made based on patient history and clinical exam including a speculum evaluation of the vagina and cervix. Typically, the patient history with a description of leakage of fluid, a sterile speculum exam to evaluate pooling and the pH of any secretions, and a microscopic examination for cervical ferning complete the exam. From a review of the chart, it appears that the patients cervix was noted to be long and closed. Both evaluation of pooling of fluid and amniotic ferning testing were negative. She was determined to have a bacterial vaginosis infection and was appropriately treated. At the initial time of the pelvic exam, a vaginal swab for AmniSure testing was also done. The patient was also noted to not be contracting, had a reassuring fetal status, and had no further leakage of fluid. Thus, a complete speculum exam would have been adequate to rule out ROM in this clinical presentation, especially given that no pooling or ferning was appreciated. If the work-up including the clinical history or elements of the traditional pelvic/speculum exam were ambiguous or conflicting, then further evaluation with testing my AmniSure may have been warranted. In this clinical setting, the AmniSure ROM test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Results: 2 of 3 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 number one and two are board certified in obstetrics and gynecology and are actively practicing. Physician reviewer number three is board certified in obstetrics and gynecology with sub-specialty certification in maternal and fetal medicine 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 phentermine. Findings:  The physician reviewer found that The request for phentermine has not been established as medically necessary for treatment of the patients medical condition. The decision to initiate drug therapy in overweight patients should be made only after a careful evaluation of risks and benefits. The first step is evaluation of the patient, which should include determination of the body mass index (BMI), the distribution of fat based upon the waist circumference, and investigations for comorbid conditions such as diabetes mellitus, dyslipidemia, hypertension, heart disease, sleep apnea, and symptomatic osteoarthritis. According to studies Anti-obesity drugs can be useful adjuncts to diet and exercise for adults with obesity and a BMI greater than 30 kg/m2, who have failed to achieve weight loss goals through diet and exercise alone. In this case, the patients BMI is 29.9 kg/m2 previously which was the last documentation of her weight provided for review. More recently, a telephone appointment reports that she tried phentermine in the past but has not been able to sustain weight loss and has requested another course. There is no documentation of current weight, BMI, blood pressure and cardiovascular exam provided. Phentermine is to be prescribed with careful evaluation of the patients obesity, comorbidities, cardiovascular risk and follow up visits. Evaluation for conditions contributing to obesity should be performed. The patient should be evaluated for obesity management where the goals of therapy, treatment options for long-term management are discussed and informed. In sum, phentermine 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 physician reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 ThyraMir gene test. Findings:  The physician reviewers found that the Bethesda System recommends a repeat thyroid biopsy. Moreover, the newest 2015 American Thyroid Association's guidelines state that for nodules with AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat fine needle aspiration (FNA) or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. The American Thyroid Association also recommends taking the patients history, ultrasound appearance and other clinical factors, including the institutions rate of malignancy, in consideration in order to make medical and surgical decisions. In this patients case, the provider after consideration of this patient's condition and in consultation with the patient, made the decision to repeat the biopsy and order genetic testing, specifically, the ThyraMir test. The gene test proved helpful in the management of this patient. A review noted that for thyroid lesions with indeterminate cytology, the detection of any mutation translated into a malignancy risk for AUS/FLUS, FN, and SMC of 88%, 87%, and 95% respectively, compared to 6%, 14%, and 28% in mutation-negative lesions. The guidelines recommend oncologic thyroidectomy based on this positive results, as opposed to observation or diagnostic lobectomy. All told, ThyraMir gene test performed was likely to have been superior over other methods of evaluating this patients medical condition. Final Result: 3 of 3 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: All three physician reviewers 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: Overturned Decision of Health Plan

Standard Review A transgender male enrollee has requested authorization and coverage for a hysterectomy. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees gender dysphoria. 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. Nature of Statutory Criteria/Case Summary: There is support in the literature for the requested procedure in this clinical setting. For patients with gender dysphoria, treatment options range, but can include hormonal therapy, gender conforming surgery and appropriate screenings based on assigned sex at birth. The medical literature indicates that gender reassignment surgery is considered essential for the wellbeing of transgender patients. This patient has well documented gender dysphoria.  He has been living in the gender role that conforms to his gender identity. The records also reflect that he has been placed on hormone therapy and has undergone a double mastectomy. This patient was evaluated by multiple specialists to prepare him for the next step towards his gender conforming surgery. While the records also indicate that this patient has been on opioid therapy for treatment of his chronic kidney stones and low back pain, his opioid therapy is not a contraindication to the requested surgery. An evaluation noted that this patient had no clear evidence of substance use disorder from the history provided by the patient, in addition to a partial review of the medical record. Moreover, the documentation provided did not indicate that a detoxification referral/recommendation was made for this patient. As such, this patients opioid therapy is not a contraindication to the requested gender conforming hysterectomy. Instead, this patients record reflects that he has met the requirements recommended by World Professional Association for Transgender Health. Therefore, the requested hysterectomy is medically necessary for the treatment of this patient's gender dysphoria.  Final Result: The reviewer determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the neck for evaluation of the enrollees neck pain. Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI. MRI of the cervical spine is not indicated unless the patient has undergone a documented six-week trial of physical therapy and anti-inflammatory medicine. There is no documentation showing that the patient has undergone physical therapy. In addition, AIM Specialty Health guidelines recommend a plain x-ray of the cervical spine prior to having a MRI. The medical records do not indicate that this has been performed. Thus, the patient does not meet criteria for a cervical spine MRI. Final Result: The reviewers 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.