Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for sleep studies. As noted in the medical literature, OSA is a condition caused by anatomical changes leading to obstruction of the upper airway during sleep. This patient underwent a three day sleep study. However, the testing was not performed in accordance with the standards established. Notably, the home sleep testing device used in this case was a Type IV HST unit which only measured one channel of respiration. The home sleep test unit in this case did not involve a respiratory effort sensor. This is below the minimum standards recently reaffirmed for the use of home sleep testing units. Furthermore, the current standard of practice indicates that one night of home sleep testing is sufficient to establish a diagnosis of OSA. All told, the sleep studies rendered on were not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 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: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). The records provided for review document that this patient has a negative neurological examination and there is no history of trauma or malignancy. The patient has not reportedly undergone a supervised six week trial of physical therapy. Moreover, there are no signs or symptoms to support an indication for MRI. All told, the requested MRI is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) scan. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees leiomyosarcoma.Findings:  There is support in the medical literature and in the guidelines for using PET for initial staging. The National Comprehensive Cancer Network guidelines state that PET scan maybe useful in tumors larger than 3 cm. This patients mass measured 3.5 x 2.8 cm. In addition, research has shown that PET can be useful in assessing grade and prognosis. Before giving this patient treatment options, it was critical to decide stage of the tumor, as the treatment for localized disease is different than that for stage 4 or metastatic disease.  The use of PET for leiomyosarcoma can provide information as to tumor grade and can be used to help assess treatment response in the future. The American College of Radiology guidelines state that PET could potentially avoid 20% of futile surgeries performed.  There is also literature that indicates that the results from PET may allow a small change in the management of patients using PET for initial staging of a sarcoma. In summary, the literature shows that PET can add information in terms of tumor aggressiveness as well as information as to the extent of metastasis. This information is helpful to assess the standardized uptake values on subsequent examinations. Accordingly, the PET scan performed was likely to have been more beneficial for the evaluation of this patients medication condition than the standard methods available.Final Result: Two of the three reviewers 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B.Findings: There is support in the medical literature for the requested medication in this clinical setting. Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B, In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for treatment of hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. As such, the request to switch the patient to Vemlidy to reduce the risk of tenofovir-related nephrotoxicity and loss of bone density is medically reasonable and appropriate. For these reasons, Vemlidy is medically necessary for the treatment of this patients hepatitis B. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter valve repair. Based on the records provided, this patient presents with symptomatic severe mitral regurgitation and high surgical risk due to comorbid conditions and inability to safely discontinue Plavix medication in the setting of a recent left main coronary stent placement. In this circumstance, percutaneous valve repair has shown to be a safe and effective alternative compared to open surgical repair for reducing mitral regurgitation in a relative large randomized trial. There is sufficient clinical data to support percutaneous repair with MitraClip for patients with prohibitively high risk for open surgical repair and suitable valve morphology. For these reasons, percutaneous mitral valve repair using MitraClip is appropriate in this patients circumstance. Accordingly, the requested transcatheter valve repair is likely to be more beneficial for the patients condition than any available standard therapy.  One reviewer found that the requested transcatheter valve repair is not likely to be more beneficial for the patients condition than any available standard therapy.  Final Result: Two of the three reviewers determined that the requested service is 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 cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for out of network fertility services on the basis that she was experiencing an emergency medical condition. Unfortunately, there are few interventions proven to improve early pregnancy loss or recurrent pregnancy loss. While intralipid therapy infusions may be a promising therapy, it is not considered an emergency service. The infusion of intralipid was not a treatment for an emergency condition. There is no evidence the patient presented with acute signs and symptoms of an emergency medical condition or received services necessary to relieve or eliminate an emergency medical condition. Based upon the available evidence, intralipid therapy infusion is an unproven treatment for possible prevention of pregnancy loss. In sum, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 the breast Botox injections performed. In the peer-reviewed medical literature, it was reported that patients who were injected with Botox in the pectoral muscles in the time between mastectomy and tissue expander placement reported less postoperative pain and used fewer narcotics in the first 24 hours after surgery and in the final expansion period than patients who did not receive the agent. Botox is an appropriate treatment for post-mastectomy breast reconstruction in this clinical setting. All told, the breast Botox injections performed were likely to be more beneficial for treatment of the patients condition than any available standard therapy.One reviewer found that the breast Botox injections performed were not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service 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 plastic surgery and is actively practicing. One Reviewer is board certified in plastic surgery and is actively practicing.  One Reviewer is board certified in plastic surgery 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transoral incisionless fundoplication utilizing the EsophyX device.  The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who presents with a history of gastroesophageal reflux disease (GERD).Findings:  The efficacy of transoral incisionless fundoplication (TIF) using EsophyX has been studied in randomized controlled trials. However, the conclusions are inconsistent: one large randomized trial including 60 patients found no improvement in esophageal acid exposure compared with baseline at 12 months; normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of PPIs in 61%. The study concluded that no long-term objective reflux control was achieved. The 2013 American College of Gastroenterology guidelines for treatment of GERD report that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy (moderate level of evidence). In 2013, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) reported that numerous published series have reported significant adverse events and that there is a lack of sham-controlled trials comparing TIF using EsophyX with anti-reflux surgery. SAGES concluded that further studies are required to define optimal techniques and most appropriate patient selection criteria, and to further evaluate device and technique safety. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) do not recommend endoscopic procedures for GERD in patients with complicated GERD (which the guideline defines as dysphagia or Barretts esophagus), both of which this patient has, and report that the long-term follow-up data for TIF with EsophyX is limited (ASGE Standards of Practice Committee). These conclusions are bolstered by recent reports of severe adverse events during the procedure and the need for surgery to revise ineffective TIF that had been performed using EsophyX device. For these reasons, TIF utilizing the EsophyX device is not likely to be more effective than the available standard methods of treating this patients medical condition.Final Result: All three reviewers determined 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for urgent care services on the basis that the services at issue were emergent. Based upon the submitted documentation, the patient presented on two separate occasions to urgent care facilities. The first episode was for evaluation of a finger injury. The patient had suffered a distal phalanx fracture and was wearing a splint when he caught an object thrown at him. His finger `snapped back` and his finger splint was dislodged. The patient's digit was noted to be tender. An x-ray was ordered to assess for acute fracture and for mal-alignment of the previous fracture. Following this, a new finger splint was applied to stabilize the known fracture. A patient experiencing a new injury to a finger with a known fracture that results in displacement of a splint meets criteria for an emergency medical condition. As such, the services were necessary for treatment of an emergency medical condition. With regard to the second urgent care services received, the patient was evaluated for allergy symptoms. There was no sudden or acute deterioration. The patient was not short of breath. He had already been evaluated for his symptoms and was receiving medications. His symptoms were not unanticipated. Treatment of allergy symptoms does not meet criteria for an emergency medical condition. In conclusion, the services performed during the first episode were necessary for treatment of an emergency medical condition; however, the services received during the second episode were not necessary for treatment of an emergency medical condition. Final Result: The reviewer determined that the patient received emergency medical services during the first episode, but not during the second episode. Therefore, the Health Plans denial should be partially overturned.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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for suction lipectomy tuck procedure. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition and are not reconstructive in nature. Findings: There is a lack of support in the documentation provided for the medical necessity of the requested services in this clinical setting. The patient previously underwent abdominoplasty following significant weight loss as a result of bariatric surgery. Based on the clinical documentation, there is no evidence of a functional impairment associated with a minimal to mild lower abdominal protuberance and asymmetric appearing abdomen. The photographs support that there is evidence of a relatively normal appearance given her previous weight loss and surgery. There is insufficient documentation from the medical record to support that the patient has a significant functional impairment associated with her lower abdominal findings. Therefore, suction lipectomy tuck procedure is not medically necessary for the treatment of this patient. In this patients case, the documentation provided does not show a functional impairment.  As such, the mild lower abdominal protuberance and excess skin is not an abnormal structure of the body. Based on the documentation provided, the protuberance is slight and relatively normal given the patients body habitus, previous weight loss, and surgery. Her condition should be considered as part of a treatment for obesity, which is considered a disease. However, there is insufficient documentation that a functional impairment exists. Since the appearance is relatively normal, the requested surgical revision would not likely provide more than a minimal improvement in the patients appearance. Accordingly, suction lipectomy tuck procedure does not meet the criteria for reconstructive surgery. Final Result: The reviewer determined the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. 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 authorization and coverage for interferon alfa-2B recombinant 1 M U injections, (30 units, three times per week). The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees extra skeletal Ewing sarcoma/peripheral primitive neuroectodermal tumor.Findings:  The current medical literature does not consider interferon alfa-2B a standard of care for patients with skeletal Ewing sarcoma/peripheral primitive neuroectodermal tumor. It is not supported by off label use by major drug compendia or the National Comprehensive Cancer Network guidelines. The abstract provided for review is from 1999 and in discussed patients with osteosarcoma. In addition, there are other standard therapies available to this patient as well as clinical trials that involve newer drugs that are less toxic and more promising according to medical literature. Accordingly, interferon alfa-2B recombinant 1 M U injections, (30 units, three times per week) is not likely to be more beneficial than any available standard therapy for treating this patients medical condition.Final Result: Two of the three reviewers determined that the 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 authorization and coverage for proton beam radiation therapy. Findings:  Three physician reviewers found that currently, there is insufficient clinical data to discern whether treatment with proton beam radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. In the comparison between IMRT (intensity modulated radiation therapy) and proton therapy, IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between IMRT and proton therapy. The National Comprehensive Cancer Network guidelines indicate that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and IMRT technique. Therefore, proton beam radiation therapy is not likely to be more effective than other treatment options. Final Result: The 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, 2 and 3 are board certified in radiation 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.