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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the tissue graft, to repair a forehead scar for treatment of the enrollees scar tissue and depression of right upper forehead.Findings:  The physician reviewer found that the patient presented with evidence of significant forehead depression as a result of instrumentation from a previous hospitalization due to an automobile accident. Photographs and medical documentation support a significantly abnormal condition. There is no evidence of a functional deficit. However, the patients appearance is significantly abnormal and the surgery is an attempt to create a normal appearance. In addition, fat grafting would offer more than a minimal improvement in the appearance of the patient. Final Result: The reviewer determined that the services at issue were medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injection for the right knee for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The current peer-reviewed literature generally supports repeat hyaluronic acid injections, such as Orthovisc, for the treatment of osteoarthritis of the knee if there is documented significant improvement for six months or more, but do not support the use of these injections in patellofemoral osteoarthritis. A review of the treating providers report does not evidence six months of significant improvement following the prior Orthovisc injections, as a corticosteroid injection was performed within four months. Additionally, there is no evidence of significant osteoarthritis outside of the patellofemoral compartment. There is a lack of support for the requested services in this clinical setting. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An female enrollee has requested authorization and coverage for E2300 power seat elevation system, E2301 power standing and K0108 power elevating leg rest for treatment of the enrollees nemaline rod myopathy. Findings:  The physician reviewer found that nemaline rod myopathy is an extremely rare muscle disorder with profound weakness of all muscle groups including the limbs, face and neck muscles. In general, the symptoms do not improve as the child ages, but they may plateau in weakness, and tend to regress with increasing weakness and failure of the heart muscle.  According to the documentation submitted for review, the patient is scheduled to start kindergarten. The record demonstrates that the patient has the capability to electrically propel the wheelchair. The upright position in school, will be very useful in elevating the patient to tables, platforms and preventing continuous sitting. There is a significant literature concerning the value of the standing position in children and adults who are unable to walk. In addition, the patient is likely to have a psychological boost of being eye level with her peers. In addition, there is evidence that the standing position aids in increasing bone density and improves cardiac function. Also, given that progressive heart disease is an ongoing problem in patients with nemaline myopathy, the standing position will aid in reducing the risk of heart disease. As such, the request for E2300 power seat elevation system, E2301 power standing and K0108 power elevating leg rest has been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology with special qualification in child 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 64-year-old male enrollee has requested authorization and coverage for acupuncture services A 64-year-old male enrollee has requested authorization and coverage for acupuncture services. Findings:  The physician reviewer found that The documentation provided do not support the medical necessity of the requested services in this clinical setting. For patients with low back pain, providers should consider the use of medications with proven benefits in conjunction with back care information and self-care. The medical literature in this clinical setting encourages assessment as to the severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long term efficacy and safety data before initiating therapy. For most patients, first line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. For patients who do not improve with self-care options, providers should consider the addition of nonpharmacological therapies. For patients with acute low back pain, the literature recommends spinal manipulations. For chronic or subacute low back pain, the literature supports intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive behavioral therapy, or progressive relaxation. In patients with acute, subacute, mixed, or unknown duration of pain, other studies show that it is difficult to draw definitive conclusions regarding benefits and harms of complementary and alternative medicine (CAM) therapies in this patient population. The benefit of CAM treatments was mostly evident immediately or shortly after the end of the treatment and then faded with time. With this patient, there is no sufficient demonstration of a patient workup or that he tried and failed treatments to justify the need for acupuncture. The provider has not documented any physical or orthopedic examinations of the low back, pain scales, functional deficits or failed conventional treatments. Therefore, with the lack of documentation of sufficient workup and prior treatments as well as the questionable long term effects of acupuncture, acupuncture services are not medically necessary for treatment of this patients 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Praluent for the treatment of the enrollees hypercholesterolemia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has genetically proven familial hyperlipidemia and elevated LDL level to 164 mg/dl while on Juxtapid. Juxtapid is an oral inhibitor of the microsomal triglyceride transport protein (MTP), and this medication has not been studied in combination with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors such as Praluent. This patient meets usual accepted criteria for the use of Praluent as monotherapy or in combination with a statin or ezetimibe since studies have demonstrated safety and efficacy in this regard. However, the medical necessity of Praluent in conjunction with Juxtapid has not been established since PCSK9 inhibitors have not been studied in conjunction with this medication. All told, Praluent is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the MitraClip procedure for treatment of the enrollee, who has a history of mitral regurgitation. Findings:  The physician reviewer found that in this patients case, the records document severe mitral regurgitation due to flail A1 segment with chordal rupture as a result of prior endocarditis in 2013. The medical records do not support a contraindication to open surgical repair. Moreover, the regurgitant jet is documented to be very eccentric and originating from A1 segment. Inclusion criteria in a trial required that the primary regurgitant jet originate from malcoaptation of the A2 and P2 scallops of the mitral valve. As noted by Nishimura and colleagues, current guidelines support percutaneous mitral valve repair as a class IIb indication only in patients with reasonable life expectancy who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal goal directed medical therapy for heart failure. In a randomized trial, the MitraClip procedure was found to be safe but less effective than surgical repair because residual mitral regurgitation was more prevalent in the percutaneous group. 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the fetal chromosomal microdeletion genomic sequence analysis (CPT code 81422 fetal chromosomal microdeletion(s) genomic sequence analysis) for evaluation of the enrollees pregnancy. Findings:  Three physician reviewers found that According to the American College of Obstetricians and Gynecologists (ACOG), cell-free DNA screening currently gives information about the three most common aneuploidies and about fetal sex but does not typically provide information about other aneuploidies. In addition, ACOG cautions that cell-free DNA screening tests for microdeletions have not been validated clinically and are not recommended at this time. Final Result: Three 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: One physician reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal fetal medicine and is actively practicing. One physician reviewer number  is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and is actively practicing. One physician reviewer is board certified in obstetrics and gynecology 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that based on the available documentation, the RTC services were not medically necessary for treatment of this patients medical condition. The patient was not a danger to himself or others. He was not manic, psychotic, agitated, or showing impulsivity. In addition, he was not gravely disabled, he was cognitively intact, and he was medically stable. He was psychiatrically stable such that he could have been managed at outpatient level of care. There had been no medication changes for at least one week. He was cooperative and engaged in all aspects of his treatment. His wife was supportive. The overarching themes he was dealing with were basically long-term issues which are traditionally dealt with on an outpatient basis. He did not require 24-hour supervision. All told, the patient was a candidate for treatment at a less restrictive level of care and did not require RTC services. 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: A 61-year-old male enrollee has requested reimbursement for carotid duplex scan for evaluation of the enrollee who had presented to his provider for annual examination. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. Since many strokes are due to atherosclerotic disease involving the carotid vessels within the neck, routine physical examinations will involve closely evaluating the patients for carotid bruits. Once discovered, a carotid bruit necessitates further evaluation. The American College of Radiology has established Appropriateness Criteria to direct providers to the most efficacious means to evaluate these vessels.  At the top of the list is carotid duplex sonography (CDS). The American Institute for Ultrasound in Medicine (AIUM), a national ultrasound society, has developed appropriate indications for carotid duplex ultrasonography.  Of note is that neither organization has recommended CDS for the routine evaluation of asymptomatic patients. Similarly, CDS has not been recommended for patients with simple hypercholesterolemia. In this patients case, he has had negative carotid duplex evaluations for the two prior years.  Minor degrees of stenosis would not necessitate any interventions.  One would nevertheless treat the patients hypercholesterolemia. The records do not indicate that this patient was reporting symptoms or signs related to his carotid arteries or neurologic status. The only indicator of possible vascular disease was hypercholesterolemia.  In summary, the medical literature does not support a yearly carotid duplex ultrasound studies in asymptomatic individuals. Therefore, the carotid duplex scan that was performed was not medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 57-year-old male enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to the 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for autonomic nerve functioning test (autonomic nrv parasym inervj, CPT 95921) for treatment of the enrollees autonomic disease.  Findings:  Three physician reviewers found that there is a lack of support in the medical literature for the services at issue in this clinical setting. The autonomic nervous system (ANS) is responsible for various elements functions including heart rate, body temperature, breathing, digestion, and sensation. They are involved in involuntary processes within the body. The ANS is composed of the sympathetic and parasympathetic nervous systems and their interplay.  Disease occurs when the parasympathetic and sympathetic are unbalanced or when there is direct damage to the ANS in various disease states including diabetes and Parkinsons disease. Some of the symptoms that can be linked to autonomic nervous system disease include dizziness, sweating abnormalities, and loss of appetite.  The autonomic system can be evaluated using the tilt table test, monitor of heart rate and blood pressure during specific situations, gastric emptying studies, quantitative sudomotor, axon reflex test, thermoregulatory sweat test, and urodynamics. Final Result: Three 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: All three physician reviewers are board certified in neurology 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: enrollee has requested authorization and coverage for Valcyte (450 milligram twice daily); laboratory testing complete blood count with differential, performed every three weeks for the first four months, then every six weeks thereafter; and laboratory test metabolic panel, comprehensive performed every three weeks for the first four months, then every six weeks thereafter for treatment of the enrollee who has a history of chronic fatigue syndrome. Findings:  The physician reviewer found that While there has been interest to link chronic fatigue syndrome to a viral infection, there is a lack of evidence to support this theory. The studies available are small and have shown only limited benefit to the treatment of chronic fatigue syndrome patients with antiviral agents.  In this patients case, the patient had elevated antibody levels to several herpes viruses.  However, these are common infections and observation does not imply any causal relationship between herpes and chronic fatigue syndrome. Moreover, the requested treatment option is not accepted as community standard and not supported by any solid medical evidence. For these reasons, Valcyte (450 milligram, twice daily); laboratory testing complete blood count with differential, performed every three weeks for the first four months, then every six weeks thereafter; and laboratory test metabolic panel, comprehensive performed every three weeks for the first four months, then every six weeks thereafter, are not medically necessary for treatment of this patients 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 internal medicine with sub-specialty certification in infectious 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.