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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for neurofeedback. Findings:  The physician reviewer found that Neurofeedback is a specific form of biofeedback that involves electroencephalogram (EEG) and is utilized to improve brainwave activity in patients with anxiety disorder. Reiner and colleagues have found that biofeedback was more helpful than other relaxation techniques such as meditation, yoga, and unassisted breathing techniques. Moradi and colleagues have also found that neurofeedback is an effective treatment for anxiety disorder. Yan and colleagues conducted a randomized controlled trial and found that changes in mean abnormal anxiety were significantly higher in the neurofeedback group than in the control group. In this case, treatment with neurofeedback is appropriate to treat the patients condition, consistent with standards of good medical practice, and has been shown to be more beneficial for treatment of this patients medical condition than any available standard therapy, and is thus medically necessary.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients condition. Therefore, the Health Plans denial should be overturned.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Mohs micrographic surgery for treatment of the patients medical condition. Findings:  The physician reviewer found that As noted in the medical literature, squamous cell carcinoma of the lower extremity can be excised with simple excision. However, this patients case is an exception based on the location and resistance to previous treatment. Current data supports an indication for Mohs surgery in this clinical setting. Nouri noted that Mohs micrographic surgery can be effective despite the variability in time interval between the initial biopsy and surgery. Given these findings, Mohs micrographic surgery is medically necessary to assure a complete excision of this patients lower extremity squamous cell carcinoma.Final Result: The reviewer determined that the requested service 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 dermatology 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 genetic testing.Findings:  Two of the three physician reviewers found that the American College of Obstetricians and Gynecologists recommends genetic screening for common recessive diseases in all populations. The genetic testing performed in this patients case has been validated. The genetic testing ordered included the diseases recommended by American College of Obstetricians and Gynecologists for screening. This screening is considered the standard of care for all pregnant patients. The testing allows for patients to make important medical decisions. In sum, genetic testing was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers 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: Physician reviewer 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in clinical genetics and genomics 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 a specialty office visit with a surgical oncologist. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees melanocytic neoplasm of skin.According to MCG 22nd edition of Guideline R-0124 Malignant Melanoma and Pigmented Skin Lesions-Referral and Management, a surgical oncology appointment is not necessary for the patient's medical condition. He had congenital giant hairy nevus at the bathing trunk distribution with atypical melanocytic proliferation that was excised in part and also had sentinel node biopsy; none of the removed tissue incorporated malignant cells. Therefore, the requested service is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 dermatology 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.Findings:  Three physician reviewers found that this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. In sum, DecisionDx-Melanoma testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency neurolysis (CPT codes 64636 and 64635) of the right side and prospective authorization and coverage for radiofrequency neurolysis of the left side.Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this patients case. A study reviewed the efficacy of radiofrequency ablation of lateral sacral branches and found the evidence was insufficient to determine the indications and effectiveness of sacral lateral branch thermal radiofrequency neurotomy. The authors noted the need for additional research. Therefore, radiofrequency neurolysis (CPT codes 64636 and 64635) of the right side was not likely to have been superior over other treatment options. Additionally, radiofrequency neurolysis of the left side is not likely to be more efficacious than other treatment options. Final Result: The reviewers determined that the services at issue were not and 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 anesthesiology with sub-specialty certification in pain medicine 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 facial feminization surgeries. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health condition. At issue in this case is whether any or all of the requested facial feminization surgeries are medically necessary for the treatment of this patient. Facial feminization surgery (FFS) would provide reconstructive surgical services for an abnormality as a result of the disorder of gender dysphoria. The outcome of reconstructive surgery would be enhancement of psychological and social functioning. The patient has a documented history of gender dysphoria and has been on cross gender hormone therapy. The guidelines for the medical necessity of FFS exist in two reviews from World Professional Association for Transgender Health (WPATH) and the Transgender Law Center. Based on the documented history of gender dysphoria and evidence of extreme mental distress due to her current gender incongruence, the medical necessity of FFS is supported. Therefore, the requested facial feminization surgeries are medically necessary.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 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: The parent of an enrollee has requested reimbursement for laboratory testing for allergies (immunoglobulin G (IgG) food sensitivity testing). Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this patients case. Food-specific IgG testing does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods. Per the medical evidence, food-specific IgG testing should not be used as a tool to diagnose food allergy, and the positive food should not be eliminated from the diet based upon results of these tests. The standard evaluation of food allergy consists of blood immunoglobulin E (IgE) level for foods and skin testing. IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum. These tests are widely available. Immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. Therefore, laboratory testing for allergies (IgG food sensitivity testing) was not likely to have been superior over other methods of evaluating this patient.Final Result: The reviewers determined that the services 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: Physician reviewer 1 is board certified in allergy and immunology and is actively practicing. Physician reviewers 2 and 3 are board certified in pediatrics and allergy and immunology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the platelet rich plasma injections. Review of the available literature on platelet rich plasma for the treatment of knee osteoarthritis fails to demonstrate that the requested treatment significantly changes outcomes or results in better or more durable pain relief than other standard therapies. Currently, there is a paucity of randomized controlled clinical trials demonstrating the safety and effectiveness of platelet rich plasma injections. In addition, side effects, such as post-injection swelling and pain, short duration nausea and dizziness, have been reported in up to 20% of patients. Further, the American Society of Orthopaedic Surgeons (AAOS) clinical practice guidelines for treatment of osteoarthritis of the knee do not support platelet rich plasma injections given the lack of compelling evidence showing improved health outcomes. All told, the platelet rich plasma injections were not likely to be more beneficial for the treatment of the patients medical condition than any other available standard therapy.One reviewer found that the platelet rich plasma injections were likely to be more beneficial for the treatment of the patients medical condition than any other available standard therapy.Final Result: Two of the three 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: One reviewer is board certified in orthopedic surgery and is actively practicing. One reviewer is board certified in orthopedic surgery and is actively practicing.  One reviewer is board certified in orthopedic 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a gait trainer. The records indicate that the patient has significant to profound cognitive and physical impairments. She is unable to follow commands; has visual impairment and limited limb mobility, with contractures. There is no documentation in the available records of a completed, pertinent, recent physical examination or functional mobility evaluation; establishing that the patient is able to safely and effectively use a gait trainer even for therapeutic ambulation for exercise, let alone purposeful mobility. In any case, it is not being used for functional mobility. The gait trainer in question is also not necessary for a medical purpose, as there is insufficient evidence to establish that this type of device improves health outcomes. Therefore, the gait trainer is not medically necessary for the patients condition.Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation for possible surgery to remove two implant devices, which were reportedly placed in the enrollees left hand and groin/vaginal area. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees diabetes; peripheral neuropathy; chronic pain; hyperlipidemia; and coronary artery disease of the native artery. A review of the record indicates that the enrollee has been diagnosed with diabetes, peripheral neuropathy, chronic pain, hyperlipidemia, and coronary artery disease of the native artery. In a report dated, the provider noted the enrollee had persistent delusions that a chip had been implanted in her body. The provider reported no chip had been placed. The provider recommended treatment with psychiatry. The enrollees provider has not recommended consultation for possible surgery to remove two implant devices, which were reportedly placed in the enrollees left hand and groin/vaginal area.At issue in this case is whether the requested consultation for possible surgery; to remove two implant devices which were reportedly placed in the enrollees left hand and groin/vaginal area; is medically necessary for treatment of the enrollees medical condition. Colleagues noted that since no modality is perfect at identifying foreign bodies. A combination of high clinical suspicion a thorough physical examination and appropriate selection of the correct imaging modality will provide the best outcomes. In this case, the x-ray of the left forearm, showed a small nonspecific cyst, but no foreign bodies were identified. The physical examination, did not detect a mass in the left forearm or groin. The CT scan of the abdomen and pelvis did not note any foreign bodies. The radiographic studies and physical examination do not support findings of foreign bodies. Therefore, a surgical consultation for possible removal of foreign bodies is not medically necessary.Final Result: The reviewer determined that the requested service 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 general 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 an implantable heart monitor. Based on the records provided for review, the patient had symptomatic atrial flutter treated with an ablation without recurrent heart racing symptoms. In this circumstance, if evaluation for dysrhythmias is thought to be indicated, then Holter monitoring for frequent symptoms or offline self-activated event monitoring for less frequent symptoms should be sufficient in recording cardiac rhythm during palpitations. In addition, offline auto-triggered event recorders should be effective in identifying asymptomatic paroxysmal dysrhythmias. There is no documentation to indicate the patient is not able to effectively manage these types of devices or that these devices have already been tried and failed. Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and/or patient activated or auto-triggered event recorders appropriate initial tests and standard of care for evaluation of dysrhythmias. An implantable loop recorder was not appropriate in this clinical setting since offline analysis of a patient activated or auto-triggered event recorder would have been sufficient for the identification of dysrhythmias. Identification of recurrent atrial flutter with an implantable loop recorder has not been shown to improve health outcomes compared to standard monitoring techniques, especially in patients with symptomatic arrhythmias. Thus, the implantable heart monitor was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the implantable heart monitor was 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 device 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:  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty 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.