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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 10 sessions of individual acupuncture services. The submitted documentation does not support that the requested services are medically necessary. The Official Disability Guidelines (ODG) state that an initial trial of 3-4 acupuncture treatments over 2 weeks is appropriate to determine treatment efficacy. With evidence of objective functional improvement, a total of up to 8-12 visits over 4-6 weeks may be recommended. These guidelines state that the evidence is inconclusive for repeating this procedure beyond an initial short course of therapy. The reviewed medical records, including the clinical chart notes from the acupuncture provider, fails to identify measurable objective improvement with the initial trial of acupuncture. The submitted acupuncture records, and medical records following acupuncture, failed to identify any objective evidence of functional gains or lasting benefit on a subjective basis that would support the need for an additional 10 sessions of individual acupuncture services. The absence of measurable objective or subjective improvement does not support the present request. Accordingly, the requested 10 sessions of individual acupuncture services are not medically necessary for the enrollees medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in oriental 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 spinal distraction device procedure. Interspinous process decompression offers an intermediate step in the continuum of care for patients with neurogenic intermittent claudication associated with lumbar spinal stenosis. The Coflex device is a titanium alloy interlaminar device designed to fit between two adjacent spinous processes in the lumbar spine. The U.S. Food and Drug Administration (FDA) approved indications for Coflex is one- or two-level lumbar stenosis from L1 to L5 producing at least moderate impairment in skeletally mature patients. The FDA specified that patients should have failed at least six months of non-operative treatment. One randomized controlled trial conducted in patients with grade I or lower spondylolisthesis showed that stabilization of a decompression with a Coflex implant was non-inferior to decompression with spinal fusion. However, the health benefit of fusion in this patient population remains unconfirmed. Until the results of higher quality trials become available, the use of a Coflex implant cannot be recommended over laminectomy, which is considered the gold standard for lumbar spinal stenosis. All told, the requested spinal distraction device procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested spinal distraction device procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services. The patient presented to urgent care for ankle pain. The patient described her pain as sharp, aching and constant for 2 days. There was no history of trauma. On exam, the patients vital signs were normal. The patient noted pain in the medial ankle, however, the exam was normal. Specifically, there was no tenderness to palpation, swelling, erythema or instability. There was normal range of motion and normal strength documented. X-rays were ordered and were normal. The patient was treated with an ACE wrap, and she was instructed to take over-the-counter Motrin, and to elevate and ice her ankle.The services at issue were not necessary for treatment of an emergency medical condition. An emergency medical condition is defined as a condition that manifests by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment of bodily function, or serious dysfunction of any body organ or part. In this case, non-traumatic ankle pain that has persisted for two days does not constitute circumstances under which the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment of bodily function, or serious dysfunction of any body organ or part. Non-traumatic ankle pain that has persisted for two days does not represent an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue.Final Result: The reviewer determined the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (fetal sex and fetal chromosome microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in the maternal blood). Findings:  The physician reviewer found that Fetal aneuploidy testing including trisomy 13, 18, and 21, is consistent with the current guidelines from the American College of Obstetricians and Gynecologists (ACOG). However, the ACOG and Society of Maternal Fetal Medicine caution that testing for microdeletions have not been clinically validated. Furthermore, expanded carrier screening panels do not replace previous risk-based screening recommendations. The availability of expanded carrier screening does not preclude the appropriateness of ethnic based screening or screening based on family history. For these reasons, the fetal aneuploidy testing for trisomy 13, 18, and 21 portion of the gene test (fetal sex and fetal chromosome microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in the maternal blood) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the fetal aneuploidy testing for trisomy 13, 18, and 21 portion of the gene test (fetal sex and fetal chromosome microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in the maternal blood) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the fetal aneuploidy testing for trisomy 21, 18, and 13 portion of the gene test (fetal sex and fetal chromosome microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in the maternal blood) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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 laser removal of facial hair. Findings:  The physician reviewer found that per World Professional Association for Transgender Health (WPATH) Position Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A., in addition to hormonal balancing, medically necessary gender affirming/confirming surgical procedures include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary; genital reconstruction by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, scrotoplasty, and penile and testicular prostheses, as necessary; facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient.In this patients case, review of medical records support that gender dysphoria was persistent, severe, and related to, facial hair. Based upon the self-identified relationship of masculine facial hair and her gender dysphoria, the requested services are medically appropriate. Therefore, the requested laser removal of facial hair 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 endocrinology, diabetes and metabolism and expertise in transgender care 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 photodynamic therapy. Findings:  Three physician reviewers found that actinic keratoses are premalignant lesions of the skin which have the potential to develop into squamous cell carcinoma if left untreated. The use of photodynamic therapy is a well-established and effective treatment option for actinic keratoses. The medical evidence supports photodynamic therapy for actinic keratoses of the head and neck. Thus, photodynamic therapy was likely to have been more efficacious than other treatment options. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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 the gene expression analysis and protein biomarker, with CPT code 81479. As noted by researchers, there is interest in analysis of certain biomarkers as novel tools to improve prostate cancer risk assessments. The authors reported that although several of these novel biomarkers have an improved predictive accuracy that is better than classical parameters, there is still a need for further well-designed, large, multicenter, prospective trials to avoid common bias and clinical validation. Similarly, other researchers concluded that with the development of genetic expression panels careful study and validation of these tests and integration into clinical practice will be critical to realizing the potential of these tools. Given the lack of data supporting equivalent or superior patient health outcomes with use of genetic testing in this circumstance, the gene expression analysis and protein biomarker, with CPT code 81479, was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the gene expression analysis and protein biomarker, with CPT code 81479, was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the gene expression analysis and protein biomarker, with CPT code 81479, was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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 authorization and coverage for heart surgery to insert a catheter closure of a patent foramen ovale. Findings:  The physician reviewer found that this procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the records provided, the patient had an embolic colonic ischemic event while on antiplatelet therapy. The patient has an associated atrial septal aneurysm and a patent foramen ovale (PFO), and no other clear source of embolism. In this circumstance of probable paradoxical embolization through a PFO, while already on antiplatelet therapy, there is mounting evidence from long term follow up studies suggesting that PFO device closure is more effective than medical therapy alone for patients who are under 60 years of age. Moreover, the patients who are most likely to benefit from PFO device closure are those with higher volume right-to-left interatrial shunting and atrial septal aneurysm, such as this patient has. These circumstances are associated with an increased risk for paradoxical embolism. Current ACC/AHA guidelines are also consistent with this approach. Therefore, the requested heart surgery to insert a catheter closure of a patent foramen ovale is reasonable, appropriate, and likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: Three of the reviewers determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine, with subspecialty certification in cardiovascular disease and interventional cardiology, and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine, with subspecialty certification in cardiovascular disease, and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for iron transfusion therapy. On 07/25/18, the patient did not have symptoms of anemia, such as excessive fatigue or shortness of breath. The patient also did not have laboratory indices of frank anemia. It is notable that the patient had normal iron stores (total iron) and ferritin, which indicate that the patient was not anemic at that time. There is no history provided of trial and failure of oral iron preparations.Chen and colleagues explain that in similar patients with gastric bypass, iron deficiency can manifest as anemia, which occurs in 650% of patients who undergo gastric bypass surgery. Chen and colleagues also stated that oral iron malabsorption may be the primary reason behind the iron deficiency but many patients (up to 50%) may still absorb oral iron normally. Oral iron absorption is not always hindered and patients with borderline iron stores, as this patients, may be adequately supplemented with oral iron. Iron infusion therapy is indicated only for patients with anemia who cannot get the iron they need through oral supplementation. In this case, there is a lack of documentation showing that the patient has tried and/or failed oral iron supplementation. Lab results also do not show that the patient is anemic.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 hematology 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: The parent of an enrollee has requested reimbursement for services. Group A streptococcus (GAS) is a very common cause of pharyngitis in school-aged children. It classically presents with rapid onset of sore throat and fever. The tonsils are frequently red and swollen, with a gray or white exudate. There may be associated anterior cervical lymphadenopathy, headache, abdominal pain, nausea, and vomiting. When rash is present, it is given the name scarlatina, occurring as a result of toxin production one to two days after onset of illness. Scarlet fever combines upper respiratory tract infections symptoms with a characteristic rash produced by infection with pyrogenic exotoxin-producing GAS. The rash typically appears one to two days after onset of symptoms, and is described as diffuse, finely popular, and erythematous, producing a bright red discoloration that blanches with pressure. After about four days, it fades and the skin desquamates. The tongue also has a characteristic appearance with white coating and swollen erythematous papillae. Cough, conjunctivitis, and diarrhea are more suggestive of a viral etiology. Rapid strep testing is very specific, but not very sensitive. Throat culture is the gold standard. Therapy includes symptomatic treatment as well as antibiotic therapy if GAS is highly suspected. Complications of GAS pharyngitis include parapharyngeal abscess, acute post-streptococcal glomerulonephritis, post-streptococcal reactive arthritis, and possibly several neuropsychiatric disorders. In this patients case, she was taken to urgent care with fever, sore throat, and cough. She was not clinically dehydrated. She was hemodynamically stable, and she was in no respiratory distress. Her examination was significant for erythematous and swollen tonsils and associated anterior cervical lymphadenopathy. Her situation was not an emergency, and the care that she received was comparable to care provided in a primary care office. Therefore, the services at issue were not emergency medical services. 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 date of service at issue.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 pediatrics with sub-specialty certification in pediatric critical care 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 reimbursement for blood test. Findings:  Three physician reviewers found In this case, Anser IFX was ordered to determine Remicade level, and whether antibodies to Remicade were present. Loss of response to Remicade (infliximab) can occur for many reasons. The presence of antibodies alone does not necessarily result in loss of response to infliximab or infusion reactions, nor have threshold levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. The current medical literature lacks high-quality controlled studies to define drug level or antibody level thresholds requiring action, compare clinical strategies (such as dose increase or change in medication) based on those thresholds, and then definitively establish that use of Anser IFX improves outcome when used in those treatment pathways. The literature that is available is not sufficient to establish improvement in health outcomes, and studies are contradictory. Thus, the blood test was not likely to have been more effective 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 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.