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 lumbar spinal fusion, related services and hospital stay. Decompression surgery for lumbar spinal stenosis is the most common spinal procedure in the elderly. In the presence of multilevel severe spinal stenosis with evidence of neural compression, as in this case, decompression is known to be of benefit. Per the records, the patients spinal stenosis was severe and involved multiple levels. There was clinical evidence of neurogenic claudication. Based on the severity of the pain and the severe spinal stenosis on the MRI scan, additional conservative treatment was not likely to have been beneficial. The weakness of the legs necessitated surgical decompression on an urgent basis. The medical evidence suggests that decompression plus fusion may be better than decompression alone in the treatment of multilevel advanced degenerative changes resulting in degenerative spondylolisthesis. Fusion has advantages of reduction of postoperative leg pain, with similar complication rate to decompression alone. All told, lumbar spinal fusion, related services and hospital stay 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Norditropin FlexPro. The records provided for review document that this patient has been receiving growth hormone (GH) therapy for diagnosed GH deficiency. The patients epiphyses remain open. In addition, the patients growth velocity is greater than two cm per year. Further, the patient has not yet reached their mid-parental target height. Thus, it is medically necessary to continue GH therapy at pediatric doses for treatment of GH deficiency.  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 pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. However, there is a lack of peer-reviewed published studies confirming the role of DecisionDx-Melanoma Gene Assay in this clinical setting. All told, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Gene Assay 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 DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in dermatology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Orthovisc injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The researchers reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. This patients records document consistent relief with hyaluronic acid injections. Thus, repeat hyaluronic acid injections were appropriate. Accordingly, the Orthovisc injections provided were medically necessary for treatment of this patients medical condition. 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 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: A 37-year-old male enrollee has requested reimbursement for the partial hospitalization program (PHP) services. The records provided for review document that the patient showed no withdrawal or post-acute withdrawal symptoms. He was not a danger to himself or others, nor was he aggressive or violent. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant PHP level of care. He was medically and psychiatrically stable. He was not psychotic or manic. He showed no signs of impulsivity or agitation. His medication management and Suboxone induction could have been performed in an ambulatory setting, which is where is it is commonly performed. He lived in a supportive environment. For these reasons, the patient could have been safely and adequately treated at the intensive outpatient program (IOP) level of care. Thus, the PHP services provided were not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. The National Comprehensive Cancer Network (NCCN) guidelines do not support the DecisionDx-Melanoma Gene Assay testing for use outside of the clinical trial setting. Moreover, there is a lack of peer-reviewed medical literature demonstrating that the results of the DecisionDx-Melanoma Gene Assay would change the recommended therapy or long-term outcomes. Given the lack of data demonstrating improved patient health outcomes, the DecisionDx-Melanoma Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Assay provided 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 DecisionDx-Melanoma Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the fistula plug. In this case, a fistula plug was recommended for the treatment of a fistula that has failed medical therapy and prior procedural closure attempts. The American College of Gastroenterology (ACG) guidelines for management of anorectal disorders recommends the use of a bioprosthetic anal fistula plug for treatment of complex anal fistula disease (case study). This recommendation is also made in the American Society for Colon and Rectal Surgery (ASCRS) guidelines for management of anal fistula (Steele, et al). The use of an acellular fistula plug has been demonstrated to be effective as first-line therapy for anorectal fistula (case study). Based on clinical literature and guidelines, the fistula plug was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the fistula plug was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the fistula plug was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in surgery with sub-specialty certification in colorectal surgery and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for modafinil. The submitted documentation fails to demonstrate the medical necessity of the requested medication. The records do not document that the patient has undergone diagnostic sleep testing in the form of polysomnography/multiple sleep latency test (MSLT) to confirm a diagnosis of narcolepsy. Current diagnostic standards for narcolepsy require objective findings on a MSLT to establish a diagnosis of narcolepsy. Furthermore, while it is also noted that modafinil is a non-formulary drug, the Health Plan does have other central nervous system stimulant agents which have otherwise been shown to be effective for the treatment of daytime sleepiness due to narcolepsy. There is not sufficient clinical information regarding the patients cardiovascular history to determine that the use of these other wake promoting agents on the formulary would otherwise be contraindicated for use in this patient. The current medical evidence does not support the requested medication in this clinical setting. Therefore, modafinil 100 is not medically necessary for the treatment of this patient. 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 neurology with sub-specialty certification in sleep 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 patient has requested authorization and coverage for cataract surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients cataracts. The submitted documentation does not support the medical necessity of the requested services. At issue in this case is whether cataract surgery is medically necessary to improve the patients vision and functioning. Although the patient exhibits cataract on examination, the records show that vision loss is primarily related to an uncorrected refractive error. The patients symptoms are likely correctable with glasses.  The provider prescribed glasses to improve the patients vision and functioning. However, it appears that the patient wishes better vision without glasses. There is not compelling evidence that the patients cataract is causing any of the patients symptoms. Therefore, the requested services are not medically necessary for the treatment 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 ophthalmology 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 enrollee has requested reimbursement for the OncotypeDx Breast Cancer Assay testing. The OncotypeDx Breast Cancer Assay recurrence score can be considered in select patients with one to three involved ipsilateral axillary lymph nodes to guide the addition of combination chemotherapy to standard hormone therapy. A retrospective analysis of a prospective randomized trial suggests that the test is predictive in this group similar to its performance in node-negative disease. Studies show that the use of OncotypeDx Breast Cancer Assay in well selected patients with one to three positive nodes. This patient is postmenopausal with involvement of one node and is ER and PR positive and HER2 negative. Thus, she meets the criteria for testing. For these reasons, the OncotypeDx Breast Cancer Assay was was medically necessary for evaluation of this patients breast cancer. Final Result: The reviewer determined that the testing at issue was medically necessary for evaluation 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 medical oncology 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 patient has requested authorization and coverage for Mavyret The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America  all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, patients should be treated with Mavyret Final Result: The reviewer determined that the requested  medication regimen 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: The parent enrollee has requested reimbursement for partial hospitalization program (PHP) services. Per the provided documentation, the patient remained symptomatic. On admission to the PHP, the patient was noted to have disheveled appearance, guarded behavior, depressed and irritable mood, psychomotor retardation, anhedonia, and poor insight and judgment.  The patient was frequently documented as having depressed and anxious mood. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment in this patient population. The CASII utilizes dimensions that are relevant to the patients clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services. Based on the patients clinical history provided and documentation available for review, the patient met CASII criteria for Level 4 intensive integrated services without 24-hour psychiatric monitoring. The patients clinical status, in addition to current medical literature, support that treatment at the PHP level of care was medically necessary for this patient . For these reasons, the PHP services provided were medically necessary for treatment of this patients behavioral health issues. 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 with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. However, there is a lack of peer-reviewed published studies confirming the role of DecisionDx-Melanoma assay in this clinical setting. Given the absence of evidence demonstrating that the service at issue was likely to impact decision-making or affect the patients clinical management, its use is not supported. All told, the DecisionDx-Melanoma assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma assay 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 DecisionDx-Melanoma assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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.