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 Nucynta 100 mg. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The patient has neuropathic pain. She has tried Lyrica, tramadol and Percocet. Additionally, she is allergic to morphine. Per the records, Nucynta has been beneficial for this patient in the past. The requested medication is medically reasonable in this patients case. Studies examined the role of tapentadol (Nucynta) in peripheral neuropathy and found it efficacious. Similarly, studies noted that tapentadol had some effectiveness in chronic regional pain syndrome. All told, Nucynta 100 mg is 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 anesthesiology with sub-specialty certification in pain 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for SmartPill wireless motility capsule. Findings:  Two of the three physician reviewers found this patient has considerable underlying disease which is likely affecting him. However, the information provided by the SmartPill study is likely to provide little benefit in the care of the patient. The patient is already on a modified diet for the management of gastroesophageal reflux disease. This diet overlaps the recommendations for gastroparesis, including the intake of low-fat, small frequent meals. Additionally, treatment of constipation, whether due to slow transit or another etiology, includes the use of laxatives and maintenance of hydration. In summary, the management of this patient is not likely to change based on the results of the SmartPill. In sum, SmartPill wireless motility capsule is not likely to be superior over other available methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: A male enrollee has requested reimbursement for laboratory testing, chromosomal microarray analysis and fragile X analysis (CPT 81229 and 81243). Findings:  The physician reviewer found that Chromosomal microarray is considered first-line testing for non-syndromic developmental delay or intellectual disability, autism spectrum disorder, or multiple congenital abnormalities without a specifically well delineated genetic syndrome. Fragile X testing is indicated for patients with intellectual disabilities, developmental delay, or autistic spectrum disorder. In this case, the patient has a documented developmental verbal learning disability. Based on the symptoms described, he appears to meet the criteria for the diagnosis of autism spectrum disorder. However, the constellation of symptoms provided is not consistent with fragile X syndrome. All told, the laboratory testing, chromosomal microarray analysis and fragile X analysis (CPT 81229 and 81243) performed was not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the testing at issue was 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 psychiatry with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 61-year-old female enrollee has requested authorization and coverage for Fisher Wallace Cranial Electrical Stimulator (transcutaneous electrical nerve stimulation (TENS) device). Findings:  The physician reviewer found that Fisher Wallace Cranial Electrical Stimulator may be appropriate for patients with intractable depression. However, this device is not intended for myofascial pain, chronic pain syndrome, or chronic insomnia. In this case, there is no evidence of refractory depression given the lack of documentation that the patient had been tried on, and failed, multiple antidepressants. In addition, the patient indicated that CBT was helpful for insomnia. All told, the requested Fisher Wallace Cranial Electrical Stimulator (transcutaneous electrical nerve stimulation (TENS) device) is not medically necessary for treatment of this patients medical 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Estrogel Gel 1.25 gm (0.06%). Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. There are many different formulations of hormone replacement therapies, each with a varying combination of estrogen and progestin. In this case, the patient presented with complaints of hot flashes. The patient has tried CombiPatch and Vagifem. The notes indicate that they have not tolerated these two therapies, with complaints of nausea, rashes and muscle cramps. Although the patient may be experiencing symptom relief with the requested medication, they have not exhausted the formulary alternatives. The patient was previously prescribed CombiPatch in 2014. This medication contains estradiol, which is the same ingredient as the Estrogel Gel she is currently tolerating, as well as progesterone. The other medication they did not tolerate was the Vagifem. This is an estrogen only vaginal estradiol product. It is used specifically for vaginal symptoms related to menopause, including vaginal dryness and discomfort with intercourse. Vagifem is not for systemic symptoms, such as hot flashes. One of the medications offered by the Health Plan is Premarin, which is a conjugated estrogen product that when used orally can help treat systemic vasomotor symptoms, such as hot flashes. In this patients case, it is medically appropriate for the patient to try other formulary products that are likely to help relieve her symptoms. Thus, Estrogel Gel 1.25 gm (0.06%) is not medically necessary 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 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 FoundationOne blood test. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of lung cancer.Findings:  Molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network guidelines, for non-small cell lung cancer, strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Therefore, FoundationOne blood test was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Two of the three 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement of psychiatric treatment services provided from 10/28/15 through 11/24/15. Review of the submitted documentation indicates that during the period at issue there was no evidence of suicidality, homicidality, or grave disability. The patient showed no self-harming urges or behaviors. She was cognitively intact, and was not manic or psychotic. There was no evidence of impulsivity and no bizarre behavior. On admission, other than the reported `hot, sweaty, and dry mouth,` no withdrawal symptoms were reported.  There was no Clinical Opiate Withdrawal Scale (COWS) score documented upon admission. Vital signs were stable. Labs were within normal limits. The patient had no acute medical or psychiatric conditions necessitating the admission. At no time, either on admission or throughout her stay, was she in any life-threatening condition or situation.  The admitting physician made no indication that the patients situation was emergent in nature. Other than the admitting history and physical, no physician progress notes were provided. Suboxone tapers are commonly performed on an outpatient basis, and the nutritional supplements and microcurrent therapy prescribed did not require this type of structured setting. All told, the patient did not receive emergency medical services from 10/28/15 through 11/24/15. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for OxyContin. OxyContin is an opioid analgesic recommended after a trial of a first-line oral analgesic has failed. Guidelines provide specific requirements for the ongoing use of opiate pain medication to treat chronic pain. Recommendations state the lowest possible dose be used as well as ongoing review and documentation of pain relief, functional status, appropriate medication use and its side effects. In addition, providers of opiate medication should document the patients response to pain medication including the duration of symptomatic relief, functional improvements, and the level of pain relief with the medications. This patients documentation does not demonstrate that the use of the prescribed opioid medication decreased the patients level of pain from one visit to the next. In addition, there is no noted functional improvement or improved pain noted during the duration of the prescription for OxyContin. For these reasons, OxyContin is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic surgical cholecystectomy. There is sufficient support for the requested services in this patients case. Cholecystectomy can be effective for the management of biliary colic associated with gallbladder disease, regardless of the presence of gallstones.  It can result in resolution of biliary colic, even when the gallbladder ejection fraction is normal on hepatobiliary scan.  In this case, the patient has symptoms consistent with biliary colic or gallbladder-associated pain, and there is a possibility that cholecystectomy may result in resolution of her abdominal pain. Therefore, the requested laparoscopic surgical cholecystectomy 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100-40 mg, three tablets daily for eight weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg, three tablets daily for eight weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tissue graft (CPT 20926). Findings:  The physician reviewer found that this patient sustained panfacial fractures as a result of an ATV accident.  Fat grafting has been proposed to help treat an external depressed scar causing chin asymmetry. No functional impairment has been adequately detailed associated with the external scar. Thus, the medical necessity of the requested services has not been established. However, the patients condition constitutes an abnormal structure of the body. A scar of the chin is considered to be an abnormal structure of the body. This abnormal structure of the body was caused by traumatic injury from the ATV accident. The records do not establish that the requested surgery will be performed to improve function. Rather, the requested services will be performed to create a normal appearance to the extent possible. The records demonstrate that the surgery will provide more than a minimal improvement in the appearance of the patient. Therefore, the requested services are reconstructive in nature. All told, the requested tissue graft (CPT 20926) is reconstructive in nature. Final Result: The reviewer determined that the requested services are reconstructive in nature. Therefore, the Health Plans denial should be overturned. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast magnetic resonance imaging (MRI). The records provided for review document that this patients breast tissue on mammography was described as heterogeneously dense, not extremely dense. The patient was evaluated with targeted ultrasound and diagnostic mammogram which included coned compression spot films and were interpreted as negative. In addition, there are no increased risk factors for breast cancer delineated such as a strong family history or BRCA1 genetic mutation in the patients medical records. While small masses can be obscured by heterogeneously dense tissue, the same limitations of mammography that are present in extremely dense tissue are not present in heterogeneously dense breasts. Given the patients lack of genetic predisposition to breast cancer, heterogeneously dense tissue on mammography, and the negative targeted ultrasound and diagnostic mammogram, the requested breast 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous positive airway pressure (CPAP) machine and supplies. The records indicate that this patient has a diagnosis of OSA based on polysomnogram findings and requires use of CPAP based on snoring documented during polysomnogram, daytime symptoms, and hypertension. There is adequate evidence in the records documenting compliance with CPAP, and CPAP titration studies that support the patients diagnosis of OSA, with associated symptoms to meet CPAP criteria. All told, the requested CPAP machine and supplies are supported as medically necessary for treatment of this patients OSA. Final Result: The reviewer determined that the requested equipment 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 certifications in pulmonary 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: A female enrollee has requested reimbursement for genetic testing. Findings:  Three physician reviewers found the current medical evidence does not support the services at issue in this clinical setting. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques, such as gene expression profiling, routine prognostic genetic testing of primary cutaneous melanoma before or after sentinel node biopsy is not recommended outside of a clinical trial. There is a lack of support for the use of DecisionDx-Melanoma testing or other such prognostic genetic testing in this patients case. There is a lack of evidence indicating that DecisionDx-Melanoma testing is more beneficial than standard of care. Therefore, genetic testing was not likely to have been more efficacious 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.