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 Nutropin injection provided and prospective authorization and coverage for Nutropin injections. The Health Plan has denied this request indicating that the medication at issue was not and is not medically necessary for treatment of the enrollees idiopathic short stature. Findings: According to  the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations (SDs) below the mean for age or more than 2 SDs below the mid-parental height percentile; (2) growth velocity < 25th percentile for bone age; (3) bone age more than 2 SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets most of the above criteria. The records indicate that this patients height is more than three SDs below the mean for his age and gender. His bone age is delayed, and his adult height prediction is under 63 inches, which is more than two SDs below his genetic target height. Although he passed provocative GH testing, he meets U. S. Food and Drug Administration criteria, which is the criteria set by the Pediatric Endocrine Society for a trial of GH therapy to improve height potential. Therefore, the Nutropin injections provided and the request for prospective authorization and coverage for Nutropin injections were and are medically necessary.Final Result: The reviewer determined that that the medication at issue was and 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 pediatrics with a 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospital stay. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees chronic neck pain. Findings: The submitted documentation fails to demonstrate the medical necessity of services at issue. The patient has chronic neck pain with no dermatomal/myotomal symptoms or findings of a cervical radiculopathy. The submitted records do not indicate that he has symptoms or findings of a cervical myelopathy with hyperreflexia, pathologic reflexes like Hoffmans, Babinski, clonus, bowel-bladder incontinence, increased muscle tone, frequent falls, or spasticity. There is no documentation he has failed conservative management. Based on the records provided, this patient did not meet criteria for surgery on that day. Criteria for cervical radiculopathy was not met; cervical myelopathy was not met; imaging showing cord compression was not met; pseudarthrosis was not met; instability was not indicated; kyphosis was not met; adjacent segment disease with radiculopathy/myelopathy was not met; or infection was not indicated. The surgery was not in accordance with generally accepted standards of medical practice. The patient was deemed medically stable by the internal medicine provider by medical examination and his surgeon noted he had no active hospital problems.  Moreover, he did not require an invasive procedure that day. He had no metabolic nor cardiopulmonary needs. Thus, this patient did not meet the criteria for the surgery. Therefore, inpatient hospital stay was not medically necessary. Final Result: The reviewer determined that 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 neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Genomind Genecept assay. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.Findings:  There is a lack of support for genetic testing as a first line approach in this clinical setting.  The Genomind Genecept assay is a pharmacogenomic test, which looks at the relationship between genetic factors and how medications are metabolized. This may provide information about whether a particular medication is tolerated by an individual; however, it does not indicate whether the medication will be effective. A review of the medical literature revealed very few clinical studies demonstrating the clinical utility of this type of testing (Walden, et al; Spina and de Leon). A review by Singh and colleagues concluded that the current evidence for pharmacogenomic testing does not provide support for its routine use. A review by Carlson and colleagues noted that testing for specific drug metabolizing enzymes in patients, especially those with treatment resistant conditions or serious adverse side effects, may be helpful; however, more studies are needed. Rahman and colleagues, in their review noted that pharmacogenetic testing does not yet have sufficient data from randomized controlled trials to alter established evidence based treatment guidelines. Accordingly, based on current medical literature, the Genomind Genecept assay was not likely to have been more beneficial for evaluating this patients medical condition than any available standard therapy.   Final Result: All three reviewers have determined 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:  One reviewer is board certified in psychiatry with expertise in child and adolescent psychiatry and is actively practicing. Two reviewers are board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery evaluation and follow-up for treatment of the enrollees obesity.  Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested services. There is no published or scientifically supported standard to deny bariatric evaluation based on failure to complete a specified number of physician supervised weight loss months. The records document a body mass index of 45.10 kg/m2, and this patients comorbidities include hypertension and type 2 diabetes. The medical evidence supports the requested services in this clinical setting. Therefore, the requested bariatric surgery evaluation and follow-up are 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 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: An enrollee has requested authorization and coverage for Orthovisc injections. Researchers concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in a meta-analysis of 137 studies with 33,243 patients. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Researchers conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and reported that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Researchers found that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. In addition, current guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Guidelines stated that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high quality scientific evidence. This patient presents with severe recurrent right knee pain. Significant functional limitations are noted in walking tolerance and activities of daily living. Clinical examination findings have been consistent with reported right knee severe osteoarthritis. Reasonable conservative treatment, activity modification and corticosteroid injections, have failed to provide adequate symptom relief. He is unable to take NSAIDs due to acute and chronic renal failure. Records documented prior viscosupplementation had been performed on two occasions with six months of significant pain reduction and functional restoration. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given these findings, the requested Orthovisc injections are 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for Jakafi. Jakafi is approved for the treatment of intermediate or high-risk myelofibrosis, including primary myelofibrosis, post-polycythemia vera myelofibrosis and post-essential thrombocythemia myelofibrosis. Jakafi is the only JAK2 inhibitor approved for use in myelofibrosis and generally reserved for the treatment of symptomatic myeloproliferative disorder with our without splenomegaly. While treatment with Jakafi significantly improves both symptoms and the quality of life of patients with myeloproliferative disorder, it has not been demonstrated to reduce the risk of leukemic transformation, which can be achieved through the use of stem cell transplant. This patient is asymptomatic, lacks splenomegaly, and does not meet these criteria. All told, Jakafi is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that Jakafi is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication is 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:  One reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.According to researchers,  all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 2 patients should be treated with Mavyret. These recommendations apply regardless of fibrosis stage. Researchers trial showed a 99% cure rate with treatment. Data shows reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret to treat the patients hepatitis C is supported as medically necessary. 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensive outpatient program services for a minimum of eight weeks. In this particular case, the patients roles, perspectives, experiences and symptoms cause significant intrapsychic distress and impairment in functional domains. She has had difficulty maintaining relationships. She struggles with periodic suicidality. She has recurrent depression with anxious distress, which is a combination that is both difficult to treat and associated with poorer outcomes.  Per the records, she has neither championed the second individuation nor consolidated her identity. Service delivery in the outpatient setting was not sufficient. She did not successfully complete the initial episode of intensive outpatient program treatment. While in the program, the provider opined that another eight weeks of intensive outpatient program services would be expected. Based on the records, treatment cannot reasonably be conducted in a less restrictive setting, as less intensive treatment is likely to result in inadequate care. The intensive outpatient program setting is reasonably expected to both improve her condition and prevent a more serious episode of illness. Further, the intensive outpatient program setting represents a safe and appropriate placement consistent with good medical practice. Thus, intensive outpatient program services for a minimum of eight weeks are 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 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 thermography. The Health Plan has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees breast tissue.Findings:  Breast thermography is also known as infrared imaging of the breast and measures infrared emission from the breast tissue. The examination is based on the premise that abnormal tissue will have more blood flow, increased metabolic activity and therefore emit more infrared activity due to higher temperatures. However, researchers do not support the use of thermography as a screening tool in the detection of breast cancer or as a diagnostic examination. There is a lack of research that has shown the benefit with thermography alone or in addition to mammography. Annual screening mammography/digital breast tomosynthesis are recommended for breast cancer screening in women of average risk. Therefore, in this patients case, thermography is not likely to be of greater benefit in the evaluation of the patients condition than the available standard imaging for the evaluation of this patients breast tissue. Final Result: All three reviewers have determined the requested services are 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 diagnostic radiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for single photon emission tomography computed (SPECT) scan. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma.Findings:  Sentinel lymph node excision (SLNE) is considered the most sensitive and specific staging test for the detection of micro-metastatic melanoma in regional lymph nodes. Melanoma metastasizes early into regional lymph nodes. Thus, SLNE is an important diagnostic and potentially therapeutic procedure for patients with melanoma. The histological status of the sentinel lymph node (SLN) is the most relevant prognostic factor for overall survival in patients with melanoma, independent of primary tumor thickness. However, SLNE has a high false negative rate of up to 44%. The current gold standard for SLN detection and targeted extirpation is preoperative lymphoscintigraphy. As such, the SPECT technique could help overcome these difficulties by providing additional anatomical information to the provider. Therefore, the preoperative three dimensional SLN mapping by means of SPECT was beneficial in this patients case. In addition, the National Comprehensive Cancer Network (NCCN) guidelines noted that, In selected cases, especially the head and neck and pelvic regions, SPECT-CT imaging may be performed as an adjunct to planar imaging to better define the anatomic location of the sentinel node(s).  Based on recent recommendations in the guidelines as well as the medical data, SPECT scan was likely to have been more effective over other modalities for the evaluation of this patients medical condition. Final Result: All three reviewers have determined 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 reviewers are board certified in diagnostic radiology 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 reimbursement for platelet-rich plasma injections (CPT 0232T). Findings:  Two of the three physician reviewers found this patient presented with a history of chronic bilateral knee pain. There was imaging evidence of bilateral lateral meniscus tears. Prior hyaluronic acid injections had provided two years of good relief. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure was not submitted. The procedure report documented bilateral knee platelet-rich plasma injections were performed for the diagnoses of bilateral meniscal tears and knee pain. There is an absence of large well-designed clinical studies to support the safety and efficacy of platelet-rich plasma in knee meniscal and cartilage disorders. The use of platelet-rich plasma injections is not supported in this clinical setting. In this patients case, the evidence does not support the use of platelet-rich plasma injections over other conservative treatment options. In sum, platelet-rich plasma injections were not likely to have been more effective than other treatment modalities. 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 orthopedic surgery 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.