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 and prospective authorization and coverage for Cromolyn Sodium for treatment of the enrollees mast cell activation disorder. Findings:  The physician reviewer found that mast cell activation disorder is a form of mastocytosis which is caused by the presence of too many mast cells (mastocytes) and CD34+ mast cell precursors. Patients affected by mastocytosis are susceptible to itching, hives, and anaphylactic shock, caused by the release of histamine from mast cells. Cromolyn is a U.S. Food and Drug Administration (FDA) approved therapy for mastocytosis. Therefore, the patient is likely to benefit from the proposed medication. As such, Cromolyn Sodium oral concentrate provided was and is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon ostial dilation for treatment of the enrollee's nasal congestion and sinus pressure.Findings:  All three physician reviewers found that while sinus ostial dilation, even by balloon sinuplasty, is an appropriate therapeutic option for patients with chronic sinusitis, the criteria for this patient has not been met. The indication for balloon sinuplasty (balloon ostial dilation) is chronic sinusitis refractory to maximal medical treatment. The American Academy of Otolaryngology Head and Neck Surgery defines chronic rhinosinusitis (CRS) as a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12 weeks consecutive duration. CRS is characterized by two or more symptoms, one of which is nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip), with or without facial pain/pressure and reduction or loss of smell with endoscopic evidence of mucopurulence, edema, and/or polyps and/or CT presence of mucosal thickening or air fluid levels in the sinuses. Chronic rhinosinusitis was not documented in this patient. While there was a notation of recurrent sinus infections, there was no documentation of 12 weeks of consecutive disease. However, recurrent sinusitis is not an indication for balloon sinuplasty. There was no documentation of chronology of disease, symptoms or treatment. There was no documentation of findings on nasal endoscopy suggestive of sinus disease. For these reasons noted above, balloon ostial dilation is not likely more effective than the standard therapies available for treatment of this patients medical condition.  Final Result: Three physician reviewers determined that 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 physician reviewers are board certified in otolaryngology 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:  An enrollee has requested authorization and coverage for breast reduction mammoplasty for treatment of her back, neck and shoulder pain. Findings:  The physician reviewer found that the patient with evidence of possible symptomatic macromastia.  She has chronic neck and back pain that affects her posture negatively and activities of daily living.  She has undergone conservative management of her pain with physical therapy, stretching and medical management. She has suggestion of possible symptomatic macromastia. However, the planned amount of resection was not provided for this patient. The American Society of Plastic Surgeon has guidelines for the requested procedure. One of the guidelines recommend that Physicians should document the severity of the symptoms of breast hypertrophy and impact on health related quality of life as measured by a breast specific questionnaire which includes at least two of the following signs/symptoms: Chronic breast pain due to weight of the breasts; Intertrigo unresponsive to medical management; Upper back, neck, and shoulder pain Backache, unspecified; Thoracic kyphosis, acquired; Shoulder grooving from bra straps; Upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area  Headache; Congenital breast deformity. Hammond and Loffredo note the following, Also, the presence of common symptoms related to strain on the upper torso attributable to the weight of the breasts must be documented. These symptoms can include headaches, neck pain, back pain, submammary intertrigo (particularly during the warmer months), painful bra strap marks with grooving and possible associated ulnar paresthesias caused by pressure on the brachial plexus, breast pain, difficulty wearing clothing that fits proportionately, and emotional sequelae (particularly in younger girls). In this patients case, the submitted documentation does not meet the above criteria. A radiograph report of the cervical spine did not note an etiologic finding. While the photographs do confirm macromastia, the records did not provide the planned resection for each breast. For this patient, the diagnosis of macromastia was not adequately defined and supported by examination detail. For these reasons, breast reduction mammoplasty is not medically necessary for treatment of this patients medical condition based on the documentation provided.Final Result: The reviewer determined that the requested procedure 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (phosphatase and tensin homolog test).  Findings: Three physician reviewers found that the testing at issue was not likely to be more beneficial for evaluation of the enrollee's medical condition than any available standard therapy. In this case, the enrollee underwent PTEN testing as part of panel testing. However, taken individually, the criteria for testing for PTEN as part of PHTS has not met National Comprehensive Cancer Network (NCCN) guidelines. The enrollee does not have a personal history of cancer or any of the associated disorders in the criteria per guidelines. In addition, she does not have a family member with the disorder. The familial cancers are on both sides of the family and were not reportedly at young ages. Cervical cancer is not associated with genetic risk but with environmental factors. Given the enrollee's lack of criteria met to qualify for testing, the PTEN gene test was not likely to be more beneficial for evaluation of the enrollee's medical condition than any available standard therapy.Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a hybrid ablation endoscopic Maze (surgical Maze with catheter ablation) for treatment of the enrollees atrial fibrillation.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  In this patients case, the records document recurrent symptomatic atrial fibrillation despite cardioversion, two separate ablation procedures, and Class 3 antiarrhythmic therapy with both amiodarone and dronedarone.  In this circumstance, a combined hybrid surgical and endocardial ablation procedure is reasonable and appropriate. Current guidelines consider this hybrid approach reasonable and a Class IIb recommendation for patients with symptomatic atrial fibrillation refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication and who have failed attempts at catheter ablation.  This patient meets these criteria. All told, the requested hybrid ablation endoscopic Maze (surgical Maze with catheter ablation) is 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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet-rich plasma services for treatment of the enrollees knee pain. Findings:  2/3 of the physician reviewers found that the medical records fail to demonstrate the superior effectiveness of the services at issue.  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. This patient was treated with platelet-rich plasma for his left knee complaints, diagnosed as left medial meniscus pathology. There was no compelling rationale to support platelet-rich plasma treatment for this patients left knee pain over other conservative nonoperative treatment options. Therefore, platelet-rich plasma services provided were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: 2/3 of 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: An enrollee has requested authorization and coverage for Synvisc, one injection per knee for treatment of the enrollees bilateral knee pain. Findings:  The physician reviewer found that current evidence based medical guidelines and literature support repeated cycles of viscosupplementation treatment to delay time of total knee replacement in patients with knee osteoarthritis who have failed conservative treatment when prior injections have provided significant improvement in symptoms for six months or more.  In this patients case, she has been diagnosed with bilateral knee osteoarthritis with bone-on-bone findings. She has reportedly undergone multiple prior series of viscosupplementation series with positive results in terms of significant pain reduction and improved function, allowing for delay of knee replacement surgery. However, the most recent injections did not provide any significant or sustained symptom relief. Accordingly, additional viscosupplementation injections are not supported, at this time, due to failure of injections and bone-on-bone degeneration. Therefore, Synvisc, one injection per knee is not medically necessary for treatment of the 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 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: An enrollee has requested authorization and coverage for the treatment plan, including surgery recommended by MD for treatment of the enrollees recurrent hernia status post repair. Findings:  The physician reviewer found that the records indicate the patient presented with a variety of pain complaints which may or may not have been related to the inguinal hernia. An open mesh repair was performed with some relief of the pain with recurrence nine months later. Two providers found that therapy should include nerve blocks to identify potential causative nerves with possible neurectomy but did not recommend removal and replacement of the mesh as no recurrence was noted. MRI imaging with valsalva did not demonstrate a recurrence according to an interpretation by a radiologist. A hernia specialist found that the MRI did show recurrence and recommended mesh removal with repeat mesh repair. As noted in the medical literature, mesh repair of inguinal hernias can be complicated by a variety of regional pain issues. The causes may include entrapped or injury to various nerves including the ilioinguinal and ileogenitalfemoral, as well as hernia recurrence. For the former causes, regional nerve blocks may be used, or if a specific causative nerve is identified, neurectomy may be beneficial. However, the MRI interpreted by the radiologist does not demonstrate recurrence and therefore a repeat surgical procedure may actually worsen the patients outcome. Based on these observations, the requested treatment plan, including surgery recommended by MD is not supported as 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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine for evaluation of his of thoracic spine pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The only reason to obtain an imaging study is if it will alter the course or type of therapy.  In this patients case, the records do not specifically address symptoms in the neck or cervical spine.  Based on the clinical notes, there is not a direct indication to warrant a cervical spine MRI.  The American College of Radiology (ACR) has attempted to provide evidence-based guidelines to help guide choices for diagnostic procedures.  In this clinical setting, the American College of Radiology (ACR) has recommended plain x-rays as a first line study, and specifically states that MRI of the cervical spine is generally not appropriate.  Were the patient to have specific neurological signs or symptoms, then an MRI may be appropriate.  Additionally, findings on MRI do not necessarily correlate with symptoms.  It is well known that a patient may have incidental findings on an MRI that are not symptomatic, and, conversely, may have relatively unimpressive findings on MRI but may be experiencing significant symptoms. The current medical evidence does not support the requested services in this patients case.  All told, the requested MRI of the cervical spine is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for frovatriptan succinate 2.5 mg tablets for treatment of the enrollees chronic migraines. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The medical records indicate inadequate responses to the preferred agents of Zomig, Maxalt and Imitrex. Thus, there is documentation that three of the preferred medications have been tried. The current medical evidence supports frovatriptan succinate in this clinical setting. Therefore, the requested frovatriptan succinate 2.5 mg tablets are 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided indicating that she did not receive emergency services.Findings:  The physician reviewer found that the patient is a female who presented to the emergency department with reports of diarrhea, rash and vomiting. She had been evaluated the day prior at urgent care and prescribed a Medrol dose pack without relief. On the day of arrival to the emergency department, the patient reported continued rash with lip swelling and wheezing. The patient was admitted for observation, started on IV steroids, famotidine, and Benadryl. The patient was assessed with acute urticarial rash, possible viral gastroenteritis, leukocytosis and hypothyroidism. She was maintaining her airway and no uvular swelling was noted. Her lungs were clear without wheezing. She was discharged on the following day. The patient has requested reimbursement for emergency medical services provided.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 emergency 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.