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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program services from the date of service in question, forward. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Per the records, it appears that she has stabilized.  Her medical status is intact, and she appears psychiatrically stable.  She is at her ideal body weight.  She continues to have issues with extended mealtimes as well as requirements for prompting to finish meals.  The records do not demonstrate that she needs continued partial hospitalization program care.  Per the clinical notes, she could now be treated safely and effectively in an intensive outpatient program.  She had some minor laboratory abnormalities which were not serious in nature and could be addressed on an outpatient basis.  The literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for treatment of anorexia nervosa.  All told, partial hospitalization program services from the date of service in question, forward were not and are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 with sub-specialty certification in child and adolescent 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 hydrocodone-acetaminophen 10-325 tablets four times per day for treatment of his back pain. Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative setting. However, in this case the records do not demonstrate a thorough work-up for the patients back pain has been completed. In the documentation available for review, the MRI was not entirely normal and it is possible that further work-up will lead to a treatable solution. In addition, not all non-opioid treatment options have been utilized. There is no documentation of behavior therapy despite much research to support its use. Also, not all non-opioid medications classes and physical therapy have been optimized. Moreover, it is reasonable to consider alternatives to opioids. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An  enrollee has requested authorization and coverage for Harvoni 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 1 patients should be treated with Harvoni for 8-12 weeks or Zepatier for 12 weeks and patients with a viral load of less than 6,000,000 IU/mL can be treated for eight weeks. The medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The guidelines recommend either Harvoni or Zepatier as acceptable therapy. No medical contraindication to Zepatier is reported in this patients case. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is needed, but the requested treatment with Harvoni for eight weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection as Zepatier is available.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for minimally invasive surgery to treat L4-S1 spondylosis and stenosis and L4-L5 spondylolisthesis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  A study concluded that the current evidence does not support the routine use of minimally invasive surgery for cervical or lumbar discectomy. Well-designed trials are needed given the lack of high-quality evidence.  This patient presents with worsening low back pain radiating into the lower extremities with symptoms of neurogenic claudication.  He has been diagnosed with L4-S1 spondylosis and L4-L5 spondylolisthesis. He has failed to improve despite reasonable conservative treatment. The in-Plan providers have recommended L4-S1 laminectomy, posterior instrumented fusion, and L4-L5 transforaminal lumbar interbody fusion.  The patient has requested minimally invasive surgery, but a specific procedure has not been proposed.  There is limited evidence-based guideline and peer-reviewed literature evidence to support minimally invasive lumbar surgery over standard lumbar spine surgery for this patients medical condition. Therefore, the requested minimally invasive surgery to treat L4-S1 spondylosis and stenosis and L4-L5 spondylolisthesis is not medically indicated 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 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 authorization and coverage for deep brain stimulation. Findings:  The physician reviewer found that deep brain stimulation for OCD has generated some potentially promising studies. However, these studies are of small numbers and of short-term duration. Current data does not include any large, single series, randomized, prospective study that has shown the long-term safety and effectiveness of deep brain stimulation for OCD. Further,  a study concluded that more research is needed. Another study reported that deep brain stimulation for OCD is a promising treatment for therapy but the published experience is limited. Currently, the accepted indications for deep brain stimulation include Parkinsons disease, certain dystonias, and certain types of epilepsy . All told, the use of deep brain stimulation for treatment of this patients OCD 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 procedure is 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 reviewer number one is board certified in neurological 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.Physician reviewer number two  and three are board certified in psychiatry and  are actively practicing. The reviewer 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 reimbursement for monitored anesthesia care provided. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient reported that she was intolerant of opiates.  The use of monitored anesthesia care and propofol for sedation during colonoscopy is a controversial topic.  There have been many reviews regarding the use of propofol in the United States which have resulted in differing opinions.  There is great regional variation in use.  In this case, the patient has a specific intolerance to opiates, which would be a major component of the usual sedation regimen of opiate and benzodiazepine.  Using benzodiazepine alone would not be very efficacious and much higher doses would be required.  Because of this intolerance, a propofol sedation approach was indicated.  All told, monitored anesthesia care provided on the date of dispute was medically indicated for the 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 anesthesiology 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 digital breast tomosynthesis performed.  Findings:  The physician reviewer found that the digital breast tomosynthesis performed on the date of dispute was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. A study found that the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. In addition, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis . Given the support above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in diagnostic radiology and are actively practicing. All 3 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 digital breast tomosynthesis performed on 11/18/16. The Health Plan has denied this request indicating that for evaluation of her risk for breast cancer. Findings:  The physician reviewer found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Final Result: The reviewers determined that the service 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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 gene test, Guardant 360 for evaluation of her lung cancer. Findings:  Two physician reviewers found that multiplexed genotype testing, such as Guardant 360, allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially.  This is the most tissue-efficient approach, particularly when dealing with small tumor samples.  In addition, multiplexed genotyping is the most time-efficient process for screening patients, thus facilitating prompt treatment or protocol inclusion.  Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for CPT code 15877 (suction lipectomy trunk) and CPT code 17999 (skin tissue procedure) for treatment of her abdominal and flank lipodystrophy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical records document significant weight loss following bariatric surgery.  The patient was noted to have mild to moderate soft tissue excess of the abdomen and flanks, for which she underwent abdominoplasty with liposuction of the upper abdomen and flanks. However, the submitted photograph shows evidence of only mild excess in the abdomen and flanks.  Further, the records do not document a functional deficit (e.g., disabling rashes, pain, physical limitation, back strain, etc.) that failed reasonable conservative management.  Therefore, CPT code 15877 (suction lipectomy trunk) and CPT code 17999 (skin tissue procedure) were not medically necessary for the treatment of this patient. With regard to whether the services at issue were reconstructive in nature, based on the records provided, the patients condition does not constitute an abnormal structure of the body.  The photograph shows evidence of only mild excess skin of the upper abdomen and flanks.  The patients appearance was consistent with a normal appearance of the upper abdomen and flanks.  In sum, the services at issue were not reconstructive in nature. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition and were not reconstructive in nature. Therefore, the Health Plans denial should be upheld. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet rich plasma (PRP) injection of the left lateral epicondyle. Findings:  The physician reviewer found that there is sufficient medical literature supporting the use of platelet rich plasma for chronic lateral epicondylitis resistant to other conservative treatment. Medical studies suggest platelet rich plasma to be a safe and effective therapy for tennis elbow. A study  evaluated to a total of 230 patients with chronic lateral epicondylar tendinopathy. All patients had failed conservative conventional therapy. At 24 weeks clinically meaningful improvements were found in patients treated with platelet rich plasma compared with an active control group. Similarly, another study performed a retrospective study of patients with chronic lateral epicondylitis treated by a  surgical technique (50 elbows) or platelet rich plasma (60 elbows). Outcome was evaluated with visual analog scores, Mayo elbow scores, and grip strength measurements. The platelet rich plasma group was reported to be better for short and midterm pain relief and functionality. The improvement was 83% in the platelet rich plasma group. In this case, the patient has chronic elbow tenderness over the lateral epicondyle and pain with resisted wrist extension with manifestations of lateral epicondylitis tendinopathy. Platelet rich plasma injection for chronic lateral epicondylitis upon failure of conservative treatment has been established as 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 procedure 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 reviewers 1, 2 & 3 are  board certified in orthopedic 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of her risk for breast cancer. Findings:  Three physician reviewers found that in the peer-reviewed medical literature, researchers 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. Final Result: The reviewers determined that the service 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: Reviewers 1, 2, and 3 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 authorization and coverage for cardiac rehabilitation for treatment of myocardial infarction. Findings:  The physician reviewer found that based on the records provided the patient had a myocardial infarction less than one year ago, atypical chest symptoms, and adverse emotional consequences. In this circumstance, criteria for cardiac rehabilitation are met since the patient had a myocardial infarction less than one year ago. Monitored cardiac rehabilitation has the potential benefits of assessing for exercise induced dysrhythmias, recurrent exercise induced ischemia, improving functional capacity, developing confidence with activity, and improving psychological status through education typically provided at a cardiac rehabilitation program. Current guidelines also support the benefits of cardiac rehabilitation in patients after myocardial infarction. 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 cardiovascular 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.