Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary. An enrollee has requested reimbursement for DecisionDX-UM rendered for evaluation of the enrollee, who was diagnosed with a rare form of cancer of the eye. Findings: Three physician reviewers found that the patient with right eye pain had visual acuity measured no light perception and intraocular pressure was 47.  The patients diagnosis was glaucoma. The pain to the eye was due to choroidal melanoma and previous radiation treatment. The provider recommended enucleation.  The patient underwent enucleation of the right eye.  The tissue sample was sent for pathologic evaluation including melanoma tissue for cytogenetic evaluation. The patient has requested reimbursement for DecisionDX-UM rendered. The Health Plan denied reimbursement of the cytogenetic testing. Per the Health Plan, the services at issue were investigational for evaluation of this patient.There is support in the evidence-based studies for the services at issue. The provider requested DecisionDX-UM to determine monitoring regimen for this patient. Cytogenetic testing of choroidal melanoma is an established method of laboratory testing for evaluation of melanomas.  The medical literature supports the routine use of this test and others like it for patients diagnosed with choroidal melanoma.  The standard of care is to adjust a patients monitoring and surveillance of the disease progression based on the genetic profile of the tumor.  Also, the counseling and eligibility for clinical treatment trials are based heavily on tumor genetic profile. As such, genetic testing is an important component of a patients treatment plan. For these reasons, the DecisionDX-UM rendered was likely to be more effective than other methods of evaluation of this patient.Final Result: 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 Physician reviewers are board certified in ophthalmology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings: Two physician reviewers found that the submitted documentation demonstrates the medical necessity of a portion of the services at issue.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient as part of her screening examination than had the examination been done with two-dimensional imaging alone.  However, once the abnormal area in the right breast had been identified, conventional mammographic imaging including spot compression films followed by targeted ultrasound would have yielded the same diagnostic information without repeating tomosynthesis. Thus, repeat unilateral (right breast) digital breast tomosynthesis was not likely to have been superior over other methods of evaluating this patient.Final Result: Two reviewers determined that a portion of the services 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 partially overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing for evaluation of the enrollees eye cancer. Findings:  Two physician reviewers found that the patient was diagnosed as having choroidal melanoma based on a fine needle aspirate. The specimen was submitted to pathology and for genetic testing to determine the risk of metastasis. The patient requested reimbursement for gene testing but the Health Plan has denied the patients request for reimbursement. Per the Health Plan, the services at issue were investigational for the evaluation of this of this patient. There is sufficient scientific evidence that genetic testing of the uveal melanoma tumor can stratify the tumors into high and low risk for systemic metastasis. Gene tests provide reliable information for providers as they determine a treatment course for their patients. Gene tests have been used to identify disease progression for several years. Moreover, the medical literature shows gene test has become part of the standard of care in patients who are diagnosed with uveal melanoma. The studies have shown that providers who treat patients diagnosed with uveal melanoma routinely use and offer gene test to their patients. These genetic tests assist providers in their monitoring and screening of these patients for metastasis. Furthermore, there may be a small window of time, in cases of uveal melanoma, to retrieve a sample tissue because the primary tumor may no longer be available to biopsy should the patient elect to undergo radiation plaque therapy. As such, gene testing provides critical prognostic information that would not be available otherwise. Therefore, the genetic testing performed was likely to be more efficacious to other treatment options for evaluation of this patients medical condition. Final Result: The 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 physician reviewers are board certified in ophthalmology 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 upper and lower jaw surgery for treatment of the enrollees facial pain, temporomandibular joint (TMJ) pain and shoulder and neck pain.  Findings: The physician reviewer found that the records provided for review document that this patient has been diagnosed with a maxillofacial skeletal deformity. Based on current medical literature, the proposed procedure will result in improved musculoskeletal and dento-osseous relationships. Moreover, the procedure should improve the patients mastication and associated temporomandibular joint as well as associated muscular disorders and symptoms. The proposed surgery is appropriate for the diagnosis of the patients condition, and is within generally accepted standards of medical care in the community. For these reasons, the requested upper and lower jaw surgery is supported as medically necessary for treatment of this patients maxillofacial skeletal deformity.Final Result: The reviewer determined that the requested surgery 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 oral and maxillofacial 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 magnetic resonance imaging (MRI) and second opinion consultation for evaluation of the enrollees right knee pain. Findings: The physician reviewer found that this patients records document careful and thorough medical care referencing a condition of polyarthralgia, right knee chronic pain and swelling, exogenous obesity with an elevated BMI, history of anxiety, development of ventricular premature beats and cardiac work-up. The medical history documents an anterior cruciate ligament tear of the right knee in 1978 followed in 1980 and 1990 with arthroscopic debridements of the right knee and finally followed by a hamstring anterior cruciate ligament reconstruction in 2000. Current examinations specifically state no malalignment varus or valgus and no instability at the knee. He has undergone evaluation with a full series of x-ray examinations including standing films. He has had conservative management including recommendations for physical therapies, patellar orthotics and steroid local injections into the right knee. Given these evaluations and interventions, the requested MRI of the right knee is not medically necessary. There is nothing to be gained through the added information obtained through MRI examination. Further, the American Academy of Orthopaedic Surgeons (AAOS) does not recommend arthroscopic debridement for degenerative changes within the knee joint and these changes have been documented with the x-rays obtained. There are no symptoms to suggest an isolated meniscal remnant tear and the history suggests that there would be little benefit from further arthroscopic surgery. Thus, the requested MRI and second opinion consultation as part of evaluation of the patients right knee pain is not medically necessary.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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested for breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Two physician reviewers found that there is a lack of peer-reviewed medical literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques, especially in a patient without an increased risk of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in well-designed randomized clinical trials. Thus, in this clinical setting, the use of the digital breast tomosynthesis was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of three reviewers determined that the diagnostic procedure 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 diagnostic radiology and are actively practicing. The reviewers are an experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested for breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure 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: All three physician reviewers are board certified in diagnostic radiology 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 colchicine tablet for treatment of the enrollee, who has a history of gout. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The guidelines recommends that patients use nonsteroidal anti-inflammatory drugs, rather than colchicine or glucocorticoids, as first-line therapy for most gout attacks if there is no contraindications to their use.  Typically, a potent nonsteroidal anti-inflammatory drug, such as naproxen 500 mg twice daily or indomethacin 50 mg three times daily, for reduction of acute gouty inflammation is recommended.  In patients with intolerance or contraindication to nonsteroidal anti-inflammatory drugs, the use of oral colchicine is recommended.  In this case, the patient does not have any documented contraindications to the use of nonsteroidal anti-inflammatory drugs.  There is no documentation of a diagnosis of hypertension, active peptic ulcer disease, chronic kidney disease, or heart problems.  All told, the requested colchicine tablet 0.6 mg is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings: Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has dense breasts. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Given the support cited above, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure 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: All three physician reviewers are board certified in diagnostic radiology 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 computed tomography or magnetic resonance imaging for the evaluation of the enrollees localized swelling on her left leg. Findings: The physician reviewer found that there is support for the requested MRI of the knee but not a CT scan, in this clinical setting. An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment. Patients with persistent or recurrent unexplained pain after three to six weeks of conservative treatment may require MRI for further evaluation. The standard practice is generally to obtain baseline plain x-rays such as was performed in this case. However, plain x-rays are of only limited value as the menisci and ligaments are not visible on plain x-rays. In this particular patient, her referring provider did not recommend that an MRI or CT scan was indicated. Her physical examination did not support a meniscal tear or a ligamentous injury or tear, and her provider was not recommending an intervention. However, it was reported that this patient may also have been diagnosed with pes anserinus bursitis. MRI will generally demonstrate fluid in the bursa, and generally, there is very little fluid in a normal bursa.  To that end, MRI would be helpful and could conceivably avert an arthroscopic procedure. Therefore, the requested MRI is medically necessary for evaluation of this patient but a CT scan is not medically indicated.Final Result: The reviewer determined that a portion of the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested group therapy for treatment of the enrollees gender dysphoria. The patient has a recent history of psychiatric instability, and there is a lack of evidence demonstrating that the patients psychiatric status has yet been stabilized. The Health Plan indicates the patient can return to transgender group therapy once the more acute issues of suicidality and behavioral dysregulation have been stabilized. Until it is established that the patient is psychiatrically stable, she is not a candidate for transgender group therapy services as her ability to appropriately participate in the therapy will be limited. Although ongoing comprehensive psychiatric care is indicated for this patient, the requested group therapy sessions are not medically necessary for treatment of this patient at this time.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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical services on an emergent basis. Findings:  The physician reviewer found that The surgical services were not necessary for treatment of an emergency medical condition. The patient had a diagnosis of a weak nickel allergy after placement of Essure implants. Allergic contact dermatitis from nickel hypersensitivity is a type IV reaction, also known as delayed-type hypersensitivity, which results in cell-mediated T-cell activity. Common manifestations of contact allergic reactions are contact hypersensitivity, such as eczema, generalized dermatitis, and urticaria. In this case, the patient underwent laparoscopic removal of the Essure implants. There is a lack of evidence in the medical record demonstrating that the patient was in acute distress prior to the laparoscopic procedure. In addition, there is a lack of evidence showing that medical screening, examination, and evaluation was required to determine if an emergency medical condition existed and that surgery was necessary to eliminate 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 obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and infertility 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 partial hospitalization program services for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that the requested services are not medically necessary in this clinical setting. The documentation provided does not support this patients elevation to PHP level of care. From the notes received, the patients expressed depression and anxiety, as well as anger and aggression during IOP level of care, which are within the range of problems that can be contained within the IOP level of care program.  Initial IOP group notes show that the patient denied suicidal or homicidal ideation. All told, the request for partial hospitalization program 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.