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 cervical/thoracic interlaminar epidural steroid injection for treatment of the enrollees neck pain. Findings:  The physician reviewer found that the request for cervical/thoracic interlaminar epidural steroid injection is not medically necessary for treatment of the patients medical condition. Researchers conducted a multicenter, randomized, comparative-effectiveness study comparing epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain. For the primary outcome measure, no significant differences were found between treatments, although combination therapy provided better improvement than stand-alone treatment on some measures. Whereas these results suggest an interdisciplinary approach to neck pain may improve outcomes, confirmatory studies are needed. In this case, the patient presented with neck pain and stiffness. There is no documentation of radicular pain in a dermatomal distribution, numbness or tingling. Functional difficulty is documented in activities of daily living. Clinical examination findings do not demonstrate radiculopathy or nerve root compression, correlated to imaging findings of C4-C7 degenerative disc disease. Prior physical therapy has been reported in prior year without lasting benefit. Prior epidural steroid injection in early this year provided two months of significant relief. There is no rationale presented to support the medical necessity of cervical epidural steroid injection for neck pain in the absence of signs/symptoms and clinical findings of radiculopathy. 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 180 cans of Ensure every 30 days for treatment of the enrollee who has a history of substantial gum loss. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity of the requested liquid diet. There is no medical documentation to support that this patient is having a problem maintaining his weight or that he is malnourished. In general, treatment of an underweight or malnourished patient should be directed at the underlying cause as well as dietary modification. The initial step in improving nutrition is to add high calorie foods to the diet and lift any dietary restrictions.  Nutritional supplements are recommended if the patient does not regain or maintain his or her weight despite adjustments in meal preparation and diet. There is no recent documentation to support that the patient is malnourished. The documented BMI does not suggest that the patient is underweight. There is no documentation that he would be unable to tolerate a standard liquid or soft diet instead of three cans of Ensure daily. Therefore, 180 cans of Ensure every 30 days is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested liquid diet is not medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the services at issue were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient showed no withdrawal symptoms, and was not a danger to self or others. The patients highest CIWA was 8. The patient was cognitively intact and was not gravely disabled. There were no emotional, behavioral, or cognitive symptoms requiring monitoring and supervision in the residential setting. The patient was not psychotic or manic. The patient was medically and psychiatrically stable. The patients elevated liver function tests (LFTs) were not of the severity to require 24-hour monitoring. There were no dosage changes to her Lexapro and Lamictal, the only medication changes were a dose of Toradol and the addition of Vistaril. The patients eating disorder was mild as only the patient had some urges but did not demonstrate behaviors. The patient was learning and solidifying coping skills. The patient was motivated, cooperative, and participating in all aspects of treatment plan. Thus, residential treatment center level of care was not medically necessary, and the patient could have been safely treated on an ambulatory basis.  Final Result: The reviewer determined that the services at issue were 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 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: An enrollee has requested reimbursement for acupuncture services for treatment of the enrollee who has a history of migraine headache. Findings:  The physician reviewer found that the submitted medical records as well as the medical literature do not demonstrate the medical necessity for the services at issue. While a study of acupuncture therapy for management of migraines was promising, there was considerable potential for bias since the study was non-blinded and the patients were allowed to self select treatments. Additionally, in this patients case, the reviewed medical records reflect the patient has a 20-year history of migraine headache that are not addressed as related to any spinal impairments or following a specific trauma to the head, spine or upper extremities. The progress report from a provider outlined the patients migraine management along with management of stress in the neck and shoulders. However, there were no submitted clinical record that this patients migraine onset, for the dates of services in question, were related to the patients prior medical history of migraine management. As such, the reviewed medical records do not identify a medical condition that would support acupuncture management. Final Result: The reviewer determined that the services at issue were 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) or positron emission tomography (PET) scan of her throat for evaluation of the enrollee, who has a history of globus sensation of her throat. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has been evaluated by multiple providers, including oral maxillofacial surgery, otolaryngology, family practice, and neurology, all of whom had evaluated the patient but were unable to determine any source of abnormal lesion that required further examination or biopsy. Multiple oropharyngeal nasal endoscopies and laryngeal examinations were documented in the clinical records, demonstrating that there was no evidence of any lesions of concern that warranted consideration of further biopsy.  The prior biopsy of the tongue also demonstrated no evidence of inflammation, infection or malignancy. Further imaging is not medically necessary in this patients case. All told, the requested MRI or PET scan of the throat are not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 referral with a bariatric surgeon for treatment of the enrollees morbid obesity. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. The records document morbid obesity. The patient has BMI of 39.51 kg/m2, hypertension and sleep apnea. Per the records, she has failed consecutive months of supervised weight loss efforts for greater than one year, without success. A referral to a bariatric surgeon is medically indicated to determine if the patient will be an appropriate candidate for surgery. The current medical evidence supports the requested referral in this patients case. All told, the requested referral with a bariatric surgeon 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injectionFindings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. A study conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Synvisc One injection is supported as medically necessary for treatment of this patients knee osteoarthritis. Final Result: The reviewer determined that the requested service 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 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 reimbursement for genetic testing for evaluation of the enrollees elevated prostate specific antigen (PSA). Findings:  Two physician reviewers found that there is a lack of support in the medical literature for the superior efficacy of the services at issue in this patients case. Several biomarkers have been developed to aid in the screening and diagnosis of prostate cancer. Such tests are often indicated in men with moderately elevated PSA or history of a prior negative biopsy. Their use facilitates reduction of unnecessary biopsies without sacrificing the early diagnosis of clinically significant prostate cancer. However, the utilization of this genetic testing for prostate cancer screening remains unclear. Further studies are needed before a recommendation can be made for its routine application in evaluating and identifying treatment options in patients diagnosed with prostate cancer. 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: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene testing for evaluation of the enrollees left thyroid nodule.  Findings:  Two physician reviewers found that the gene testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the documentation submitted for review, cytopathology of the first biopsy was consistent with FLUS. The risk of malignancy is 5-15% in FLUS. The Bethesda System recommends a repeat biopsy for this type of nodule. The American Thyroid Association (ATA) guidelines state that for nodules with FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat  [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. In this case, the biopsy revealed FLUS. As per guidelines, the biopsy was repeated which resulted in benign cytology results. The result of the Afirma GEC from the same specimen was also benign. A repeat biopsy performed three months after the initial biopsy as recommended by ATA was medically appropriate. However, Afirma GEC testing with a benign cytology result was not clinically indicated as the results provided no additional information or change in management. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers 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 reimbursement for residential treatment care for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patients post-acute withdrawals were mild in nature. She was not a danger to self or others. There were no emotional, behavioral, cognitive, or impulsive symptoms, and she was not manic or psychotic. She was motivated and was working on relapse prevention. The patient had demonstrated the ability to maintain extended periods of sobriety. She was medically and psychiatrically stable. Other than adding Naltrexone, her medications were unchanged, and medication management did not require 24-hour per day monitoring. No new problems had developed, and she was returning to a safe and supportive environment. The medical evidence does not support residential treatment in this clinical setting. Final Result: The reviewer determined that the services at issue were 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 lipectomy, head and neck and rhytidectomy for treatment of the enrollee, who is status post weight loss surgery, and are not reconstructive in nature.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested lipectomy, head and neck. The records do not support that a functional impairment is present related to her redundant skin. In addition, the photographs show mild to moderate findings. In this patients case, the requested lipectomy, head and neck is not reconstructive in nature. This patients condition does not constitute an abnormal structure of the body. The fat distribution of the neck, which would be treated in a lipectomy, appears normal in the photographs. The records do not indicate that the requested services will improve function, as there is a lack of documentation of a functional deficit. Additionally, the requested lipectomy, head and neck is not likely to provide more than a minimal improvement in the appearance of the patient. The requested rhytidectomy is not medically necessary for the treatment of this patient. There has not been adequate documentation of any functional impairment, and the photographs do not support an abnormal appearance. This patients condition does not constitute an abnormal structure of the body. The photographs show that she has some mild to moderate redundancy, but this is not considered an abnormal structure. The requested services will not improve function, as there is a lack of evidence of a functional deficit. Additionally, the requested rhytidectomy is not likely to provide more than a minimal improvement in the appearance of the patient. In sum, the requested lipectomy, head and neck and rhytidectomy are not medically necessary and are not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision Dx-Melanoma test for evaluation of the enrollees malignant melanoma. Findings:  Three physician reviewers found that DecisionDx-Melanoma is a 31-gene expression profile used to determine the risk of recurrence of melanomas. The National Comprehensive Cancer Network guidelines state that while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low-risk versus high-risk of metastasis, routine (baseline) prognostic genetic testing of primary cutaneous melanoma is not recommended outside of a clinical study. Per the National Comprehensive Cancer Network guidelines, there is no confirmation that the results of such genetic profiles have an independent prognostic value. 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: 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.