Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing.Findings:  Two of the three physician reviewers found that in this circumstance, guidelines for the management of coronary disease and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of treating coronary disease, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, particle sizing, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although the results of some of these specialized tests may be abnormal and considered independent risk markers for recurrent coronary events, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. According to current guidelines, high intensity statin medication is recommended with a goal LDL of less than 70 mg/dL regardless of results related to lipid particle sizing. In sum, advanced lipoprotein testing was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the spinal muscular atrophy (SMA) carrier testing. Findings:  Three physician reviewers found that recently, genetic carrier screening before and/or during pregnancy for certain genetic disorders has become an integral part of patient care. According to the American College of Obstetricians and Gynecologists (ACOG), screening for spinal muscular atrophy should be provided to all women who are considering pregnancy or are currently pregnant. The ACOG noted that spinal muscular atrophy in an autosomal recessive disease characterized by degeneration of spinal cord motor neurons that leads to atrophy of skeletal muscle and overall weakness. Due to the severity and relatively high carrier frequency, carrier screening for spinal muscular atrophy in the general prenatal population is warranted. On the basis of the current ACOG recommendations, the spinal muscular atrophy (SMA) carrier testing was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three physician reviewers found the spinal muscular atrophy (SMA) carrier testing was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the spinal muscular atrophy (SMA) carrier testing was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in obstetrics and gynecology and are actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology with subspecialty certification in maternal and fetal 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral removal of implants and bilateral capsulectomy with explantation. The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. One medical study performed a systematic review of contracture management and noted that there was limited clinical evidence behind the surgical management of capsular contracture. In this case, the patients symptoms predate the diagnosis of a capsular contracture. There has been no other work-up to rule out other etiologies for the patients symptoms, and the records do not document that conservative therapy was attempted to relieve these symptoms. No photographs were submitted for review that confirm the diagnosis of capsular contracture. There is no mention of tenderness on examination during either visit with the plastic surgeon. There is no indication as to the reason for the rapid progression of a contracture between the two visits with the plastic surgeon, with progression from no contracture to a grade 4 contracture. The patients complaints of movement of the implants with bending over and pain do not imply capsular contracture and can be related to changes that can naturally occur in cosmetic breast augmentation over time. Additionally, the submitted documentation does not demonstrate that the requested services are reconstructive in nature. This patients medical condition does not constitute an abnormal structure of the body. There are no supporting photographs that document a capsular contracture in this patients case. Although the patient reported movement of the implants with bending over and pain, this does not imply capsular contracture. There is no evidence of congenital defects, developing abnormalities, trauma, infection, tumors, or disease in the records provided. Thus, the requested bilateral removal of implants and bilateral capsulectomy with explantation are not reconstructive in nature and are not medically necessary 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 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 genetic testing, BRCA1 and BRCA2 full sequence analysis.Findings:  Two of the three physician reviewers found that this patient was diagnosed with breast cancer. Additionally, the records document that her brother was diagnosed with pancreatic cancer. This patient meets criteria for genetic risk evaluation based on her personal history of breast cancer and family history of a first-degree relative with pancreatic cancer. Due to her increased risk, she is a candidate for BRCA1 and BRCA2 testing. This testing may have a significant impact on patient management. Studies found that preventive oophorectomy in patients with BRCA1 or BRCA2 mutations reduced ovarian, fallopian tube, and peritoneal cancers by 80% and all-cause mortality by 77%. The medical evidence supports the requested services in this patients case. In sum, the requested genetic testing, BRCA1 and BRCA2 full sequence analysis, is likely to be of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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 and 3 are board certified in clinical genetics and genomics and are actively practicing. Physician reviewer 1 is board certified is clinical biochemical genetics 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 computed tomography (CT) perfusion with contrast. Findings:  The physician reviewer found that the acute management of strokes has undergone a fundamental change in the last several years. Typically, a patient presents with stroke symptoms, and a decision must quickly be made regarding whether thrombolytic therapy is indicated. This might include venous administration of tissue plasminogen activator (tPA), intra-arterial administration of tPA, or even surgical/radiologic thrombectomy. However, there is an upper time limit in which tPA is most effective. Thus, a provider must distinguish whether the suspected stroke is ischemic or hemorrhagic. This is generally easily accomplished with a simple unenhanced CT scan of the brain. In an ischemic stroke, the next step is to determine which patients will likely benefit from aggressive therapy. Performance of a perfusion MRI study can help determine the presence of salvageable brain tissue. In the medical literature, it is noted that our analyses provide support for the hypothesis that perfusion computed tomography improves the identification of patients likely to respond to thrombolysis, and also those in whom natural history may be difficult to modify with treatment. Further, the American College of Radiology (ACR) reported that use of perfusion CT may be appropriate when stroke is considered. In this particular patient, the MRI was not conclusive, and a perfusion CT perfusion study was a reasonable alternative. For these reasons, the CT perfusion with contrast was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three physician reviewers found the CT perfusion with contrast was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the CT perfusion with contrast was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in diagnostic radiology and are actively practicing. Physician reviewer2 is board certified in 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 enrollees parent has requested authorization and coverage for sphenopalatine ganglion (SPG) nerve blocks/occipital nerve blocks. This patient presents with near-continuous cluster migraine headaches that are refractory to her routine treatments and have substantially interfered with her ability to perform activities of daily living. Findings:  Three physician reviewers found that according to the most recent literature, sphenopalatine ganglion blocks have been shown to provide pain relief in patients with cluster headaches and migraine headache. While this technique is not considered first-line therapy for patients with migraines, it has adequate support in the scientific data as a safe and effective option for patients with refractory cluster or migraine headaches. This patient has become significantly disabled by her headaches despite aggressive medical management. Therefore, the requested sphenopalatine ganglion (SPG) nerve blocks/occipital nerve blocks are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three physician reviewers found the requested sphenopalatine ganglion (SPG) nerve blocks/occipital nerve blocks are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested sphenopalatine ganglion (SPG) nerve blocks/occipital nerve blocks are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in neurology with special qualification in child neurology and are actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certification in pediatric critical care 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center (RTC) services. The submitted documentation supports the medical necessity of both the services at issue and the requested services going forward. The American Psychiatric Association treatment guidelines for Substance Use Disorders recommends that residential treatment, or similar care higher than outpatient, is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. Such patients require safe and stable living environments in order to develop their recovery skills, thus qualifying for ASAM Level III treatment, which is at least residential treatment center services similar to what the patient received at the facility in this case. The evaluation of treatment documentation requires an understanding that patients conditions wax and wane. A relatively positive documentation by one patient on one day does not indicate a spontaneous cure or that the patient is in the clear, for it simply denotes progress and that treatment is working, which is an indication to continue not cease treatment. While the purpose of detoxification is to make a patient physically stable and safe, rehabilitation is the essential component that should follow detoxification, and the purpose of rehabilitation is to help the patient maintain sobriety and reduce risk of relapse. In this case, given the severity of the patients illness, Residential Treatment Center services were and are in accordance with generally accepted standards of medical practice and are clinically appropriate for the patient's illness. Accordingly, the Residential Treatment Center (RTC) services at issue, and the requested services, were and are medically necessary for treatment of the patients condition.Final Result: The reviewer determined that the services at issue and requested services 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 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 tocilizumab (Actemra) injections. Chronic antibody mediated rejection (ABMR) is the most common cause of graft failure and is more difficult to treat than acute AMBR, since tissue damage has occurred to the renal allograft. Chronic ABMR is also more common in patients who develop de novo donor specific antibodies (DSA) following kidney transplant. In terms of treatment, there is a lack of published randomized controlled clinical trials evaluating the efficacy of the various available therapeutic options for ABMR. Djamali and colleagues reported on a case series of patients treated with Actemra and noted that significant reductions in DSA and stabilization of renal allograft function were observed at two years. Given these preliminary data, additional clinical trials are needed to establish whether Actemra has a role in the treatment of ABMR. At this juncture, the current peer-reviewed medical literature does not support Actemra as likely to be more beneficial for treatment of this patients ABMR than standard available therapies. One reviewer found that Actemra is likely to be more beneficial for treatment of this patients ABMR than standard available therapies.Final Result: Two of the three reviewers determined that the requested medication 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:  One reviewer is board certified in internal medicine with subspecialty certification in nephrology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in nephrology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in nephrology 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: The enrollee has requested authorization and coverage for a consultation with a surgeon. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees chronic obstructive pulmonary disease, morbid obesity, and rheumatoid arthritis. A review of the records indicates that the enrollee has been diagnosed with chronic obstructive pulmonary disease, morbid obesity, and rheumatoid arthritis. The enrollees provider noted that the enrollee had been using a wheelchair. Knee pain was also noted. The enrollee was noted to have tried dieting but was unsuccessful with weight loss. The enrollee bariatric was 5 feet 7 inches tall, and weighed 323.3 pounds. The enrollees body mass index (BMI) was 50.62. The enrollees provider has recommended a consultation with a bariatric surgeon for the enrollee.Bariatric surgery is a reasonable consideration for adults with a BMI =40 kg/m2, or a BMI of 35 to 39.9 kg/m2 with at least one serious comorbidity, who have not met weight loss goals with diet, exercise, and drug therapy. In this case, the enrollee is morbidly obese, with a BMI of 50.62 but there has been no formal trial of weight loss through diet and/or drug therapy. The only medical documentation regarding prior diet trial generally describes that prior weight loss attempts through diet have not been successful. Because there has not yet been an adequate trial of medical weight loss (diet, pharmacologic interventions), the requested consultation with a bariatric surgeon is not medically necessary for treatment of the patients medical condition.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 family practice 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 laboratory testing (CPT code 87486 - infectious agent detection by nucleic acid, DNA or RNA). Applying the recommendations from the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS), additional testing for the presence of community acquired pneumonia (CAP) may be indicated for patients who present with signs and symptoms concerning for respiratory disease. This patients records do not document symptoms concerning for respiratory disease or exposure to a pathogen to support the testing performed. Moreover, the performance of this assay has not been validated in clinical settings. The standard of care in this patients preoperative assessment would include blood testing and cultures. Given these findings, the laboratory testing (CPT code 87486 - infectious agent detection by nucleic acid, DNA or RNA) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the laboratory testing (CPT code 87486 - infectious agent detection by nucleic acid, DNA or RNA) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the laboratory testing (CPT code 87486 - infectious agent detection by nucleic acid, DNA or RNA) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in infectious disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.