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 referral to see an orthopedic specialist for evaluation of the enrollees joint pain. Findings:  The physician reviewer found that current evidence based medical guidelines state that initial management of pain includes referral to orthopedic specialists for evaluation of pain when there are indications for fracture or dislocation, infection, inflammation, or progressive neurologic or vascular deficit. Referral for orthopedic consultation is also supported if the patient has failed non-surgical treatments. The need for a clinical office visit with a health care provider is individualized based upon a review of the patient concerns, signs and symptoms, clinical stability, and reasonable physician judgment.  This patient presented with a complaint of a lot of joint pain.  However, there was no documentation by the primary provider of a specific history of injury, specific subjective complaints, or objective findings to support the medical necessity of an orthopedic referral. A diagnosis of pain in the joint of the hand was documented. The patient has additionally reported a fall with injury to her left shoulder, elbow and right knee. There was no record that her primary care provider has examined these body parts or that an initial conservative management has been attempted. There was no compelling rationale in the submitted documentation to support the medical necessity of a referral to an orthopedic specialist when initial evaluation and management of these complaints is within the armamentarium of the primary care provider. 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 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 Guardant360 laboratory testing for evaluation of the enrollees non-small cell lung carcinoma. Findings:  The physician reviewer found that the National Comprehensive Cancer Network Guidelines for non-small lung cancer, version 1.2018 states that adequate tissue is needed for molecular testing. If there is not available tissue, plasma testing can be done such as Guardant360. In this case, there is adequate tissue as evidenced by the reading of the pathology report. BRAF, ALK, EGFR, MET, RET, ERBB2, PDL1, ROS-1 can be performed on tissue. In addition, PET/CT demonstrating stage IV disease was not provided. Molecular testing is not indicated in stage III disease. The medical literature does not support the superior efficacy of this testing in this clinical setting. Accordingly, Guardant360 laboratory testing was not likely to have been more effective than the available options 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: Reviewer 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) for treatment of the enrollees major depressive disorder.  Findings:  The physician reviewer found that the patient is diagnosed with major depressive disorder. The patients illness is causing significant functional impairment. The patient has trialed many medications. The patient previously responded well to a standard course of TMS. Although the data is limited, the reintroduction of TMS is not uncommon when patients relapse. According to the Clinical TMS Society, TMS should be reintroduced until remission is reachieved with a starting point of three to five sessions per week for one to three weeks. Thus, a time-limited re-trialing of TMS is appropriate in this case. It is reasonably expected that the patient will experience a similar benefit from the disputed service and there is no evidence to suggest that reintroduction of TMS would be unsafe. As such, TMS at the frequency of three to five sessions per week for three weeks followed by clinical re-evaluation is medically necessary for treatment of the patients medical condition. 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 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 Percocet (acetaminophen and oxycodone) 15 mg for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. It is unusual to require narcotics three months after bunionectomy surgery. Self-escalation of dosage as well as a past history of alcohol abuse are red flags in prescribing opioids. The lack of urine toxicology screens or an ongoing opioid maintenance agreement are also of concern.  The clinical practice guideline does not support ongoing opiate prescribing in this clinical setting.  All told, Percocet (acetaminophen and oxycodone) 15 mg 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the gene panel testing for evaluation of the enrollees major depressive disorder, recurrent, moderate. Findings:  Three physician reviewers found that genetic testing was recommended in this case since the patient reportedly had adverse effects from SSRIs. The records provided for review did not specify which medications in the SSRI class were attempted, or what medications in other classes were tried and the outcomes. The Genecept report showed a broad range of medications which may be successful in treating this patients conditions. However, studies have shown that clinically useful predictors in genetic testing are scarce for antidepressant therapy, with results being inconsistent and only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability in the treatment of depression. Currently, there is a lack of large randomized trials supporting its use in this clinical setting. The existing studies suggest that there was no significant correlation between either genotypes or medication serum concentration and response treatment. Given these findings, the gene panel testing 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 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 psychiatry 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: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility care for treatment of the enrollees medical condition status post hip implant replacement.  Findings:  The physician reviewer found that the request for skilled nursing facility care provided were not and are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient is status post right hip removal of the prosthesis. The patient does not have a hip joint. The patient has made slow progress in physical therapy and further functional improvement with inpatient therapies is not likely. Skilled rehabilitation services are not clinically indicated for this patient. Further care can be provided in a custodial level setting. Thus, the documentation does not support continued skilled nursing level of care. 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for wearable cardioverter defibrillator vest services for treatment of the enrollees dilated cardiomyopathy. Findings:  Two physician reviewers found that the benefits of wearable cardiac defibrillators have been the subject of intensive study. However, the device has not been proven to be of substantial benefit for patients with newly diagnosed cardiomyopathy. Guidelines from the Heart Rhythm Society (HRS) and the American College of Cardiology (ACC) do not support use of the wearable cardioverter defibrillator in this patients clinical setting. Permanent ICD placement is recommended after a waiting period of 45-90 days, but a wearable cardiac defibrillator has not been proven beneficial for use in the interim. Based on these findings, the wearable cardioverter defibrillator vest services provided were not and are 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 services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the residential treatment center (RTC) services for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that overall, the records provided for review do not support the medical necessity of residential treatment center (RTC) level of care services provided for treatment of this patients behavioral health issues. There were no reports of post-acute withdrawals, the patient did not demonstrate any evidence of suicidal or homicidal ideation, and he had no self-harming behaviors. He was not violent or aggressive and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the RTC level of care. He was medically and psychiatrically stable to the extent that he did not require a 24-hour facility to render the remainder of his care. His liver enzymes and medication management could have been monitored on an outpatient basis. There was no evidence of a high degree of depression, mania, hallucinations, or any other significant symptom that would interfere with his care. The psychotic symptoms he presented with on admission were not specifically addressed in the progress notes and were described as likely secondary to schizophrenic spectrum versus substance induced psychosis. The patients bizarre associations were not reportedly addressed. Although verbalizing a desire not to remain in treatment, he was cooperative and participated in his treatment plan. While the patient required ongoing treatment to encourage sobriety, develop coping skills, work on a relapse prevention plan, and work on his relationships and mood lability, none of these were of a severity that required the 24-hour nursing and medical monitoring in a RTC setting. He could have been stepped down to an ambulatory level of care. 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 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 reimbursement for residential treatment center services. 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 post-acute withdrawal symptoms. The patient was not suicidal, homicidal, or gravely disabled. The patient was not psychotic or manic. The patient was not aggressive or violent. There were no emotional, behavioral, cognitive, or impulsive symptoms requiring residential level of care. The patient was medically and psychiatrically stable. There were no medication changes made until two weeks after admission, which included naltrexone. The patients vital signs were stable. The patient was motivated and appeared to be working the program. The patient had a stable home environment. The patient had not used any substances for a period of time. The patient could have continued recovery in an ambulatory setting with the assistance of a 12-step program, a sponsor, and counseling. For the reasons provided, the residential treatment center services provided were not medically necessary for treatment of the patients medical condition. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the specialized laboratory testing for evaluation of the enrollees ulcerative colitis. Findings:  The physician reviewer found that the Prometheus Anser IFX test is a quantitative measurement of serum infliximab and anti- infliximab antibodies. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. However, there are few well controlled clinical trials to confirm that use of the Prometheus Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. According to the American Gastroenterological Association (AGA) guideline recommendations on therapeutic drug monitoring (TDM) in patients with inflammatory bowel disease (IBD) treated with anti-TNF agents, there currently exists no defined cut-offs by which to judge low versus high titer anti-drug antibodies. Given that Prometheus Anser IFX testing has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established, the specialized laboratory testing 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 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 gastroenterology 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 intravenous infusion and ceftriaxone sodium 250 mg per injection for treatment of the enrollee, who has a stated diagnosis of Lyme disease. Findings:  Three physician reviewers found that the medical evidence does not support the services at issue in this patients case. There is a lack of clinical or laboratory evidence that the patient has Lyme disease. The evidence-based guidelines for the treatment of Lyme disease refer to the use of two grams of ceftriaxone for a period of 28 days for any form of Lyme disease (e.g. late disease with central nervous system, cardiac and/or joint manifestations). The literature does not indicate that extending the period of therapy is of benefit. Additionally, there is a lack of evidence indicating that the dose ordered is effective. Final Result: The reviewers determined that the services at issue were 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: Reviewer 1 is board certified in internal medicine and is actively practicing. Reviewer 2 and 3 are board certified in internal medicine with sub-specialty certification in infectious disease and is 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronate injection/Synvisc One injection.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Evidence-based peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Current guidelines do not support the use of these injections in patients with patellofemoral arthritis or chondromalacia patella, or for repeated use if the patient did not achieve significant improvement in symptoms for six months or more. In this case, the patient presents with persistent right knee pain, worse with weight-bearing activities. Clinical examination findings have been consistent with imaging evidence of patellofemoral and medial compartment chondromalacia, with no significant joint space narrowing documented. She is status post a series of viscosupplementation injections , with a lack of evidence of a significant improvement in symptoms for six months to support the medical necessity of repeat injections. She was again reporting increased pain and functional limitations . Evidence-based medical criteria have not been met to support the medical necessity of this request. Therefore, the requested hyaluronate injection/Synvisc One injection is 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 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.