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 the residential treatment center (RTC) level of care services for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that the patients post-acute withdrawal symptoms were not severe in nature given that the same symptoms were reported during the entire course of his residential stay. He was not a danger to himself or others, nor was he aggressive or violent. He was cognitively intact and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the RTC level of care. He was medically and psychiatrically stable, and he was not on any medications when stepped down to RTC. He was engaged in the program and motivated towards sobriety. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would have interfered with his care. He was cooperative and participated in his treatment plan. These findings indicate that the patient could have continued to work on his sobriety, coping skills, and relapse prevention in an ambulatory setting. For these reasons, the RTC level of care services provided 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a stress echocardiogram. Based on the submitted records, this patient presents with increased coronary risk in addition to symptoms of palpitations and exertional dyspnea concerning for an anginal equivalent and/or left ventricular dysfunction. In this circumstance, further evaluation to assess for left ventricular dysfunction and coronary ischemia is medically appropriate.  An imaging stress test is appropriate to evaluate for both left ventricular dysfunction and coronary ischemia in the same procedure. Stress echocardiography is indicated based on the patients symptoms, regardless of upcoming low risk non-cardiac hysterectomy surgery. Current guidelines endorsed by several national organizations consider stress echocardiography appropriate in this setting. Therefore, the requested stress echocardiogram is medically necessary for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are 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 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: The parent of an enrollee has requested authorization and coverage for oral immunotherapy. Findings:  Anaphylaxis is a life-threatening hypersensitivity reaction to something in the environment. Onset is sudden and typically dramatic, with respiratory, skin, and gastrointestinal manifestations. There are multiple triggers, including foods, insect stings, and medications. Foods are the most common triggers in the pediatric population. Because anaphylaxis is a medical emergency, treatment must be rapid. Current guidelines agree that epinephrine is the first medication of choice. Second-line treatments include antihistamines (H1 and H2) and glucocorticoids. Oral immunotherapy is a promising therapy for people with allergies. However, it is still under investigation in both children and adults. It is also not without risk because of the potential for causing allergic reactions. Studies are currently underway investigating its utility in children with peanut anaphylaxis. At this time, the superior efficacy of the requested services has not been established. This treatment modality is still in the research phase, not yet ready for clinical use. Therefore, the requested oral immunotherapy is not likely to be of greater benefit than other treatment options. Final Result: Two of the three physician 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 and 2 are board certified in pediatrics and are actively practicing. Physician reviewer 3 is board certified in allergy and immunology and pediatrics 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

A male enrollee has requested authorization and coverage for 4Kscore blood test. The 4Kscore test is a blood test that incorporates four prostate-specific kallikrein assay results and clinical information into a proprietary algorithm to calculate an individual patients percent risk for aggressive prostate cancer on prostate biopsy. The 4Kscore blood test is intended to be used in a patient with an abnormal PSA who is being considered for initial or repeat prostate biopsy to identify the risk of high-grade prostate cancer. The test result provides percent risk for detecting high-grade prostate cancer on subsequent biopsy. However, the use of 4Kscore is not considered clinically appropriate and generally accepted standard of care in routine screening for prostate cancer in men. In addition, this patient has a rising PSA and was recommended to undergo a prostate biopsy, which is considered the standard of care for management of patients with rising PSA. For these reasons, the requested 4Kscore blood test is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested testing 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 urology 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: The parent of a 12-year-old female enrollee has requested authorization and coverage for Nutropin AQ NuSpin. Based on the records provided for review, this patients height is not more than two standard deviations below the mean for age and gender, bone age is not delayed more than two standard deviations from chronological age, and there are no known morphological abnormalities of the pituitary gland. While the patient experienced slow deceleration in height over a period of six years, both the height and weight decelerated simultaneously. This pattern is not typical of GH deficiency. Furthermore, the patient experienced growth fall off as well as chronic abdominal pain and transition to a gluten-free diet. Thus, the cause of the growth fall-off is not likely to be GH deficiency. Provocative GH testing has poor sensitivity and specificity for the diagnosis of GH deficiency, and the fact that the patient had a suboptimal response to provocative GH testing does not indicate that she is GH-deficient, as there is a high false positive rate of such tests during the peripubertal time period in children. All told, the requested Nutropin AQ NuSpin is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara 90 mg/mL every eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Crohns ileitis with intestinal obstruction.A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed (Sandborn, et al). Another study showed a 73% response in patients with anti-TNF resistant Crohns disease, and 80% of responders maintained remission for one year (Kopylov, et al). A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of immunosuppressants and anti-TNF medications, both of which the patient has failed (Tuskey, et al). Alternatives such as Enbrel and Tysabri are not recommended for the treatment of Crohns disease, while Stelara is U.S. Food and Drug administration approved and recommended by guidelines for the treatment of Crohns disease (Lichtenstein, et al). For these reasons, the request for Stelara 90 mg/mL syringe every eight weeks is supported as medically necessary for the treatment of this patients Crohns disease.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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 63-year-old male has requested reimbursement for intensive care unit (ICU) services provided on the basis the services were emergent in nature. The patients post-operative MRI showed resection of a large mass, but with mild brain edema and slight shift of brain structures from right to left. This suggested that he was still at risk for seizures or other neurologic sequelae and therefore frequent neurological checks were indicated. However, the patient was not experiencing an emergency medical condition as defined above. He was two days post-op and not at risk of immediate harm. The need for ICU care was at the discretion of the operating neurosurgeon as a precautionary measure to monitor the patients neurological status but the ICU services he received were not needed for treatment of an emergency medical condition.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.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 represented minor male has requested authorization and coverage for three speech therapy sessions. Findings:  The physician reviewer found that based on the available documentation, the requested speech therapy is medically necessary to address this patients significant pragmatic language disorder due to his autism spectrum disorder. The patient continues to have difficulty engaging in and sustaining conversations. Notes suggest that the resulting difficulties include inappropriate interactions with peers, the stereotyped use of language, and the employment of nonverbal communication. Studies emphasized the importance and benefit of a multimodal therapy approach to children on the autism spectrum who have impaired pragmatic language. The studies reported that speech therapy, social skills groups, and peer engagement were beneficial. All told, the requested three speech therapy sessions are 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 pediatrics and neurology with special qualification in child 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly individual therapy (psychotherapy) sessions. Findings:  The physician reviewer found that the records provided for review indicate that this patients symptoms do not reflect the triad of PTSD of hyperarousal, withdrawal, and hardened re-experiencing. Overall, she does not have a constellation of depressive symptoms suggestive of the need for ongoing individual therapy. There is no documented significant impairment of routine functioning. Moreover, the patient is not manifesting as a danger to herself or others, self-injurious behavior, or acute mental health symptoms such as psychosis, mania, severe depression or severe anxiety, uncontrolled eating disorder behavior, volatility, or major degradation of interpersonal relationships. Given these findings, the requested services are not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX prostate cancer assay. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer.Findings:  National Comprehensive Cancer Network (NCCN) guidelines recommend testing with Oncotype DX post-biopsy for NCCN very-low- and low-risk prostate cancer in patients with at least 10 years life expectancy who have not received treatment for prostate cancer and are candidates for active surveillance or definitive therapy. Men with clinically localized disease may consider the use of tumor based molecular assays. Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of NCCN risk groups. These include, but are not limited to, likelihood of death with conservative management, likelihood of biochemical progression after radical prostatectomy or external beam therapy, or the likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy.  Accordingly, this assay is considered a standard of care in guiding treatment decision making. Therefore, Oncotype DX prostate cancer assay was likely to have been more beneficial than any available standard therapy for the evaluation of this patients medical condition. Final Result: Two of the three reviewers have 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: The enrollee has requested reimbursement for the FoundationOne blood test.  Molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) guidelines strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective therapies may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Molecular profiling such as with FoundationOne is likely to be more beneficial than any available standard therapy. For these reasons, the FoundationOne blood test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that FoundationOne blood test provide was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 six weeks of residential treatment center services. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records do not indicate that the patient has severe physical health concerns at this time. She does not have substance use issues. The supplied documentation does not indicate suicidal or homicidal ideation. Based on the records, the patient could receive effective treatment on an intensive outpatient basis due to her lack of self-harm behaviors and lack of active suicidal or homicidal ideation. The literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for the treatment of eating disorders. The literature supports therapy on a consistent basis along with medication for eating disorder treatment. Based on the records, it is not clear that she has failed less restrictive treatment options. The records indicate that the patient can be safely and effectively treated in a less restrictive setting. Therefore, residential treatment center services are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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.