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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgery to remove an ovarian cyst. This patient has a prior history of ovarian cancer and she now presents with an enlarging, complex left ovarian cyst that is greater than 10 cm. The size and complexity of the mass meet commonly accepted guidelines for surgical removal of the cyst. The fact that the patient has a normal CA125 is reassuring, but not a replacement for moving toward surgery. The patients hemoglobin A1C is not a reason to delay surgery. Based on the American College of Obstetricians and Gynecologists (ACOG) guideline, the removal of this patients symptomatic ovarian cyst is appropriate. Accordingly, the requested surgery to remove an ovarian cyst is medically necessary for 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for the medication, bexarotene, 75mg, 8 capsules PO daily. The patient has multiple skin lesions of the scalp, torso, and arms. A scalp biopsy showed T-cell lymphoma. The plan is for treatment with bexarotene. Three specialists believe methotrexate use is not in the patients best interest, due to the side effects, black box warning, and potential for liver damage. Studies show bexarotene can also cause liver damage. Studies also show methotrexate, combined with other medications, works better than bexarotene. Literature shows standard treatments work well for treating this disease.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for procedure to repair spinal hardware. Medical literature indicates that failed solid bony fusion, or pseudoarthrosis, is a well-known complication of lumbar arthrodesis. The authors concluded that treatment of lumbar pseudoarthrosis includes a variety of surgical options such as replacing loose instrumentation and interbody fusion techniques. Researchers reported that the results of recent studies suggest that a patients pretreatment psychological state is a major independent variable that affects the ability to detect change in functional outcome. This patient presents with a six-month history of severe low back pain following a low speed rear-end motor vehicle accident. She has a history of T10-pelvis instrumented fusion. Imaging studies have shown fractures of the posterior rods bilaterally at L5-S1 and displacement of the left-sided rod from the left S1 screw bracket, which are reportedly unchanged. There are areas of disruption of the bone graft at the area of the left-sided hardware disruption, but a lack of evidence of pseudoarthrosis. The records provided for review do not include lumbosacral flexion and extension films. Moreover, there is no report of a recent psychological evaluation as recommended in the medical literature. Given these findings, the requested procedure to repair spinal hardware is not medically necessary for 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 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:  The enrollee requested reimbursement for genetic cancer screening. The enrollee has a family history of cancer. Her physician ordered a genetic screening test because of her family history. The provider believes the results will help guide treatment recommendations. Individuals with a personal or family history of cancer may carry a mutation that increases the risk for other types of cancer. These individuals are appropriate candidates for genetics counseling and testing. There is no evidence submitted that this enrollee had any assessment or any genetic counseling prior to undergoing genetic testing. This enrollee is at increased risk for breast cancer, but she is not at high risk for the types of cancer that are included in the panel for cancer screening.Final Result: Two of the three reviewers determined that the requested service was not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in clinical cytogenetics and clinical genetics and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for mastectomy simple complete (CPT 19303 x 2) and nipple/areola reconstruction (CPT 19350 x 2) surgeries. The American Psychiatric Association (APA) including non-binary patients in the diagnosis of gender dysphoria. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that, For certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATH supports medical and surgical treatments for gender dysphoria in the presence of persistent, well-documented gender dysphoria (Coleman, et al.). This patient has persistent, well-documented gender dysphoria, and meets the WPATH criteria for chest surgery. Given these findings, the mastectomy simple complete (CPT 19303 x 2) and nipple/areola reconstruction (CPT 19350 x 2) surgeries were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for home health nursing services of 88 units per month of home health aide services and 48 units/month of home licensed vocational nursing services. The enrollee has type 2 diabetes mellitus, pain in the right knee, paralysis of one side as a result of a stroke, moderate chronic kidney disease, and chronic pain syndrome. The enrollee receives skilled nursing services for medication management and teaching. Per records, a certified home health aide is needed for bathing assistance one to times per week. Literature shows the process for determining the necessity of home health services includes an evaluation of the persons need for services. Medical records do not support the need for such services for this enrollee. Medical records show this enrollee has weakness, but no inability to perform activities of daily living. The medical records did not show the enrollee continues to have a medical problem that needs special care which can only be provided by skilled individuals. The enrollee is noted to need assistance with bathing and in the community. These services can be provided by an unskilled individual and do not require a nurse or home health aide.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurology 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for massage therapy. The enrollee has chronic, midline low back pain and right-sided sciatica. The enrollee has tried physical therapy without improvement. He would like to avoid medications, if possible. The enrollee was referred to chiropractic care for massage therapy and acupuncture treatment. Studies are limited regarding the effectiveness of massage for treating lower back pain. The few studies available show that massage is as effective as placebo, and not as effective as electrical stimulation for treating chronic low back pain. Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified chiropractors and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested reimbursement for genetic testing. The patient has a history of speech delays, attention-deficit/hyperactivity disorder, and learning disabilities. She had a brain illness fifteen months before the office examination described in the medical record. After her recovery, she displayed more memory and learning problems. She was diagnosed with mild autism spectrum disorder. She is tolerating a low dosage of methylphenidate and has improved significantly. She underwent genetic testing. The testing shows she has a lower risk of serious reactions when taking medications for her mood. This patient requires medications to help with her attention problems and her anxiety. The testing can improve her medication use and improve her quality of life by helping to resolve her symptoms more quickly. This test helps pick the medications most likely to help in treating attention-deficit/hyperactivity disorder. This will cut down on the amount of time needed to find a good medication.Final Result: Two of the three reviewers determined that the requested service was likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in child and adolescent psychiatry and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hypoglossal nerve stimulator (CPT 64568 and CPT 0466T). The U.S. Food and Drug Administration (FDA) has approved hypoglossal nerve stimulation for the treatment of moderate to severe obstructive sleep apnea (OSA) refractory to continuous positive airway pressure (CPAP). However, research comparing its effectiveness to existing alternatives, such as airway surgery or oral appliances, is lacking. Researchers conducted a systematic review comparing oral appliances and CPAP in adult patients with mild to severe OSA. The authors found that although CPAP improved apnea/hypopnea index (AHI) scores more than oral appliances, CPAP users also showed significantly worse compliance with their devices. Moreover, the American Academy of Sleep Medicine guidelines recommend oral appliances for adults with OSA refractory to CPAP. This patients records do not include documentation of trial and failure of an oral appliance to manage his OSA. Overall, there is insufficient peer-reviewed medical literature to support the use of hypoglossal nerve stimulation over other available therapies, including oral appliances. In summary, the requested hypoglossal nerve stimulator (CPT 64568 and CPT 0466T) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested hypoglossal nerve stimulator (CPT 64568 and CPT 0466T) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in otolaryngology 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 an inCourage vest airway clearance therapy system. This patient has bronchiectasis with symptoms that include chronic cough and expectoration, which have persisted despite multiple bronchodilator, anti-inflammatory, and antibiotic medications. In addition, the records document that the patients shortness of breath prevents use of other techniques to mobilize bronchial secretions such as the Flutter valve, Acapella or Aerobika. Based on these findings, the patient is likely to benefit from the use of high frequency chest wall oscillation (HFCWO). This patients bronchiectasis has failed to respond to multiple standard therapies and her shortness of breath further limits her treatment options. All told, the inCourage vest airway clearance therapy system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Findings:  Two of the three physician reviewers found the inCourage vest airway clearance therapy system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Final Result: The reviewers determined that the requested equipment is 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 reviewer 1 is board certified in internal medicine with subspecialty certification in pulmonary disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Oasis Wound Matrix. This patient has a diabetic foot ulcer. He has experienced poor progress in the healing of his wound with standard therapy including serial debridement, wound care, and off-loading. According to the medical records provided, there has been evidence of progress in the healing of his wound with the use of the Oasis Wound Matrix. The literature supports the use of wound matrices for the healing of poorly healing diabetic foot ulcers. Oasis is a product that has been demonstrated to show a benefit in the healing of wounds in this clinical setting. Therefore, the Oasis Wound Matrix was likely to have been more beneficial than any other available standard treatments for the patients medical condition.Findings:  Two of the three physician reviewers found the Oasis Wound Matrix was likely to have been more beneficial than any other available standard treatments for the patients medical condition.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 plastic surgery 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: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Applying the ASAM guidelines, this patient meets the criteria for RTC level of care services. The patient has demonstrated mild to moderate withdrawal symptoms per Clinical Opiate Withdrawal Scale (COWS) scoring. The patient also has biomedical conditions including hepatitis C and prior myocardial infarction. The patients behavioral issues include depression, anxiety and post-traumatic stress disorder (PTSD). The patient has shown a willingness to change, but he continues to report cravings and demonstrates impulsive behaviors. The patient remains at high risk for relapse as he demonstrates impulsivity and reports being unable to control his behaviors. The patients recovery environment is not stable and his peers continue to use substances. The patient requires a safe and stable living environment in order to develop his recovery skills. He thus qualifies for ASAM Level III treatment, similar to what the patient has received at the current RTC facility. Given the severity of the patients illness, the RTC level of care services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 with expertise 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: The patient has requested authorization and coverage for skilled nursing facility (SNF) services, physical therapy and gait training services prior to discharge, and a new pair of diabetic shoes and inserts. This patient does not require SNF services with the specialized skill, knowledge and judgment of a skilled professional nurse for safe and effective treatment. The patient does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. Her medical conditions are chronic and stable. Similarly, the patients functional level does not require physical therapy services with the specialized skill, knowledge and judgment of a specialist. The patient has undergone prior gait training and has been able to ambulate with restorative nursing. A right foot x-ray ruled-out a definite acute bony fracture. For these reasons, SNF services including physical therapy and gait training services are not medically necessary for treatment of this patient. With regard to the requested diabetics shoes and inserts, the records document that the patient was provided a new pair of shoes. The records do not include documentation of a follow-up evaluation to determine whether she needs new shoes and/or inserts as the patient states she still has foot pain. The records do not state that the provider performed this fitting. Prior documentation from the Hangar Clinic do not reveal that the patient required new shoes, but rather recommended a gradual wearing period to break in her new shoes. Without evidence of a new evaluation and fitting, another pair of new shoes and new inserts are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services and equipment 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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.