Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for psychiatric emergency medical services. The American Academy of Child and Adolescent Psychiatry (AACAP) defines a psychiatry emergency as a dangerous or life-threatening situation in which a child needs immediate attention. Wheat and colleagues state, Psychiatric emergencies are acute disturbances in thought, behavior, mood, or social relationship that require immediate intervention as defined by the patient, family, or social unit to save the patient and/or others from imminent danger. In this case, the patient did not obtain treatment immediately following an initial crisis, waiting instead for two weeks, at which time the crisis had resolved. The records noted that the patient endorsed passive suicidal ideation but was not deemed to be at imminent risk or in need of emergency care and was seen again one week later. In this clinical setting, the patient did not meet the definitions of psychiatric emergency. Therefore, the psychiatric emergency medical services that the patient received were not emergency medical services. Final Result: The reviewer determined that the services at issue were not emergency medical services. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly acupuncture for two to three months. On review of the available documentation, this patient presents with interstitial cystitis. The patient has undergone treatment with physical therapy, medications, as well as modifications in her diet without adequate relief of her symptoms. The patients provider has recommended treatment with acupuncture. The current peer-reviewed medical literature supports a trial of acupuncture to address this patients interstitial cystitis. Medical literatures reported that, Therapies with the potential for benefit in patients with bladder pain syndrome are dietary management, acupuncture and physical therapy. The authors noted that complementary alternative medicines for patients with interstitial cystitis can include acupuncture. Researchers found that the results of their study support that acupuncture is an effective, useful, non-invasive method in patients with interstitial cystitis. In reviewing the available documentation, the records do not indicate that the patient has undergone an acupuncture trial. Given the patients pain levels despite prior treatment modalities, an acupuncture trial for pain management and function improvement is appropriate. Overall, the medical literature supports treatment with acupuncture for 12 once weekly sessions given this patients diagnosis of interstitial cystitis. For these reasons, the requested once weekly acupuncture for three months is medically necessary for 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 a licensed L.Ac., board certified in oriental medicine and acupuncture, 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 surgical repair to the left knee to include subchondroplasty. There is a lack of evidence in the current medical literature to support the safety and efficacy of the requested service in this clinical setting of a young individual without knee arthrosis. Reports in the current medical literature on calcium phosphate injections into symptomatic bone marrow lesions are almost exclusively in the setting of bone marrow edema associated with osteoarthritis of the knee. In this case, the patient is a 28-year-old female with normal x-rays and magnetic resonance imaging (MRI)  that did not suggest articular abnormality, but rather mild medial tibial plateau edema. Given that the patients symptoms are attributed to subchondral insufficiency/stress fracture, which is not an articular problem, there is no role for arthroscopic surgery, partial meniscectomy, or synovectomy. Therefore, surgical repair to the left knee to include subchondroplasty is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested surgical repair to the left knee to include subchondroplasty is 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 requested service 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: 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility services. Functional impairments due to a cerebral stroke can be severe to profound. Researchers found that while functional recovery may be amenable to natural recovery processes and rehabilitative measures, the extent of the initial injury is a major factor influencing post-stroke motor recovery with implications for neurotherapy after brain injury. Additional medical literature shows that rehabilitation is an important aspect of the continuum of care in strokes, and that successful rehabilitation involves understanding the natural history of stroke recovery and a multidisciplinary approach to identify and treat common poststroke sequelae. A researcher found that patients may improve spontaneously within the first three months and then more slowly in the coming year. While there is general consensus in current medical literature that initiating intensive rehabilitative measures earlier in the post-stroke course enhances outcomes, the data guiding optimal practices regarding dose, manner, and venue of stroke rehabilitation in the more subacute and chronic stages are poor. In this case, the patient sustained a stroke. The patient underwent extensive therapy but remained at a low level of function, requiring maximum to total assistance for basic self-care and mobility. The patients cognitive deficits contributed to their poor recovery. The patient was transferred for hospitalization for acute cholecystitis. They were subsequently discharged back to the skilled nursing facility, functioning at an even lower level. The records noted that the patient remained dependent for all care and mobility. In this case, the  given that the patients overall needs can be met at a custodial level of care, provided in a long-term care setting without rehabilitation or in the community by laypersons with minimal to no training at all, the services at issue were not and are not medically necessary for the treatment of this patient. Therefore, skilled nursing facility services were not and are not medically necessary 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 overturned.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone with acetaminophen tablets 5-325 mg and/or tramadol 50 mg. The Centers for Disease Control and Prevention (CDC) guidelines state that, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Further, the CDC noted that, If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The Federation of State Medical Boards indicated that, opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. The American Society of Interventional Pain Physicians (ASIPP) guidelines indicate that providers should Consider up to 40 morphine milligram equivalent (MME) as low dose, 41 to 90 MME as a moderate dose, and greater than 91 MME as high dose. The records document that this patient has chronic pain due to polyarthralgia and lumbar radiculopathy. The patient has been treated with a combination of low dose Tramadol and Percocet, which has yielded adequate pain relief and allowed for improved functioning and performance of activities of daily living including work. The patients treatment plan includes updated imaging and possible pain injections. In addition, there is no report of inappropriate urine drug screen or CURES reports. Overall, the patients total daily morphine equivalent is below 40 MME, which places them in an acceptable low-dose range. Based on the available medical records for review and current guidelines, the requested oxycodone with acetaminophen tablets 5-325 mg and tramadol 50 mg are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medications 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 anesthesiology with subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The enrollee has requested reimbursement for advanced lipoprotein testing. The records reviewed document that this patient presented with a history of coronary atherosclerosis and hyperlipidemia. The patient underwent coronary artery calcium scoring revealed a score in the 70th percentile, with evidence of moderate overall calcified plaque distributed as scattered calcification in the proximal to mid right coronary artery, in the proximal and mid left anterior descending artery, and scattered calcification of the circumflex artery. The patients treatment regimen includes rosuvastatin with Zetia and aspirin. The patient underwent advanced lipoprotein testing during an annual follow-up visit. However, the current American Heart Association (AHA) and American College of Cardiology (ACC) guidelines do not recommend use of advanced lipoprotein testing in this patients clinical setting (Grundy, et al.). Per current AHA/ACC guidelines, while some of the lipoprotein particles may be associated with increased risk for atherosclerotic cardiovascular disease, the target of lipid lowering therapy is low density lipoprotein (LDL) cholesterol. Multiple randomized trials have shown that lowering of LDL, generally with statins, lowers risk for atherosclerotic cardiovascular disease. This patient was already started on treatment with rosuvastatin prior to undergoing the advanced lipoprotein testing. All told, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the advanced lipoprotein testing 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested reimbursement for DecisionDx-Melanoma genomic testing (CPT 81529).Findings:  Three physician reviewers found that commercially available gene expression profiling (GEP) testing, such as the DecisionDx-Melanoma test, has been marketed as being able to classify cutaneous melanoma into separate categories used on risk of metastasis. However, it remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, micro satellites, and sentinel lymph node biopsy (SLNB) status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies (as have been performed in breast cancer) are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, SLNB, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models (i.e., the AJCC 8th edition melanoma risk calculator/prognostic tool in development). Accordingly, the DecisionDx-Melanoma genomic testing at issue was not likely to have been more beneficial than any other available standard therapy for the patient's condition.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any other available standard therapy for the patients condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for gallbladder and scar tissue removal. Duncan and Riall explain that gallbladder disease is common, and that cholecystectomy is effective in the management of complications such as biliary colic, acute cholecystitis, common bile duct stones, and gallstone pancreatitis. Eckenrode and colleagues found post-cholecystectomy resolution of symptoms in 66% of patients with a positive HIDA scan and 77% of those with a negative HIDA scan, concluding that a HIDA scan with ejection fraction was not useful in patients with typical symptoms of biliary colic and negative ultrasounds, and should not be used to make a decision for cholecystectomy. Tabibian and colleagues report that laparoscopic lysis of abdominal adhesions is associated with improvement in pain, with even partial lysis noted as effective. The authors further note that chronic symptoms related to intra-abdominal adhesions are not uncommon, yet accurate diagnosis can be elusive despite extensive testing, and that laparoscopic lysis of adhesions can provide short and long term therapeutic benefits, confirm or modify the diagnosis, and change management and outcome. In this case, the patient has symptoms potentially consistent with biliary colic or gallbladder-associated pain, and prior laparoscopic findings of possible chronic cholecystitis. In this case, current medical literature supports the possibility that cholecystectomy may result in resolution of the patients abdominal pain while alternatives such as observation or medical therapy would not.  The records document the presence of extensive adhesions, including in the bowel, requiring multiple lysis surgeries in the past, a finding of sigmoid colon adherent to the pelvic wall, and incomplete colonoscopy due to tortuous colon. The patient has undergone an extensive workup for other causes of abdominal pain. In this clinical setting, cholecystectomy and lysis of adhesions are medically indicated to treat the patients left lower quadrant abdominal pain. Therefore, gallbladder and scar tissue removal 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 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: The patient has requested authorization and coverage for (1) Nurtec ODT 75 mg or (2) Ubrelvy 50 mg tablet. The American Headache Society (AHS) notes that in individual pharmacological therapies for acute migraine treatment, non-steroidal anti-inflammatory drugs (NSAIDs) and triptans are effective for the treatment of acute migraine attacks. The U.S. Food and Drug Administration (FDA) describes Nurtec ODT as a calcitonin gene-related peptide (CGRP) receptor antagonist indicated for the acute treatment of migraine with or without aura in adults. In a randomized, double-blind, placebo-controlled trial, Croop and colleagues reported that that the percentage of patients achieving headache pain freedom two hours after a single dose was statistically significantly greater in patients who received Nurtec ODT compared to those who received placebo. The authors further reported that there were no serious adverse events or safety concerns. While the AHS guidelines have not yet been updated to include recommendations on CGRP therapies, Pringsheim and colleagues note that when the initial treatment for an acute migraine does not provide meaningful and sustained benefits, a treatment from a different medication class is typically chosen. In this case, the patient has a history of migraines that have not responded to multiple oral abortive therapies including triptans such as rizatriptan and sumatriptan. Given that Nurtec ODT is an alternative treatment and a different medication class approved by the FDA for the treatment of acute migraines in adults, the requested medication is medically indicated. Therefore, (1) Nurtec ODT 75 mg 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orencia IV infusions. According to the American College of Rheumatology (ACR) guidelines, addition of a biologic disease-modifying anti-rheumatic drug (DMARD) or targeted synthetic DMARD is recommended for patients taking methotrexate who have not achieved rheumatoid arthritis disease control (Frankel, et al.). Furthermore, the ACR guideline indicates that switching to a biologic DMARD or targeted synthetic DMARD of a different class is recommended over a DMARD belonging to the same class for patients who have not been able to achieve disease control. In this case, the patient has a history of moderate-to-severe rheumatoid arthritis, which is evidenced by the large scale joint destruction she has experienced requiring bilateral ankle, hip, and knee surgery. In addition, the patients documented hand and foot joint deformities are consistent with aggressive rheumatoid arthritis. The patient reports 7/10 joint pain with more frequent rheumatoid disease flares. Prior treatment with typical conventional DMARDS including methotrexate, leflunomide, and Plaquenil, has failed to control the patients symptoms. Subsequently, the patient was placed on Enbrel. The patients provider has recommended treatment with Orencia, which is a biologic DMARD of a different class and different mechanism of action than Enbrel. Applying the ACR guideline recommendations, treatment with Orencia is supported as appropriate to manage this patients moderate-to-severe rheumatoid arthritis. All told, the requested Orencia IV infusions are medically necessary for 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 subspecialty certification in rheumatology 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.