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 DecisionDx-Melanoma testing for evaluation of the enrollees malignant melanoma. Findings:  The physician reviewer found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma assay should not be used outside of a clinical trial. In addition, the use of this type of testing is not considered to be standard of care in the treatment of the patients melanoma. Thus, the testing at issue is not expected to impact the treatment or outcome of the patients melanoma. All told, the DecisionDx-Melanoma testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All 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: Physician reviewers number one, two, and three are board certified in dermatology and 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 Prometheus Anser adalimumab (ADA) testing for evaluation of the enrollee who has a history of ulcerative colitis and intractable clostridium difficile colitis. Findings:  Two physician reviewers found that there is not currently sufficient medical evidence to support the effectiveness of Anser ADA compared with conventional courses of action in the management this patients medical condition. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Additionally, the ATLAS study showed that patients with loss of response may actually have high, rather than low, serum levels.  It is possible that active disease results in low adalimumab levels due to loss of adalimumab, rather than low adalimumab levels resulting in loss of disease control.  Additionally, controlled studies are lacking to show that use of the test results in improved long term health outcomes for patients with ulcerative colitis compared with conventional management. Final Result: Two 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 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: A 61-year-old female enrollee has requested reimbursement for Decision Dx Melanoma Gene Assay for evaluation of the enrollees melanoma.  Findings:  The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on Decision Dx Melanoma Gene Assay has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, Decision Dx Melanoma Gene Assay was not likely to have been more effective than other methods of evaluating this patient. Final Result: Two of 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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 computer assisted musculoskeletal surgical navigational (CPT code 0054T bone srgry cmptr fluor image) for treatment of the enrollees right hip degenerative joint disease secondary to osteoarthritis.Findings:  Two physician reviewers found that one study published a 10-year randomized controlled study of computer-assisted surgery for cup placement in total hip arthroplasty. Overall, 60 patients were randomized into two groups using either the computer assisted surgery technique or a conventional technique for cup placement. The authors concluded that computer assisted surgery for cup placement does not confer any substantial advantage in function, wear, or rate of survivorship at 10 years after total hip arthroplasty. Another study reported that there have been substantial advancements in computer assisted total hip arthroplasty but it is still controversial due to the steep learning curve, intraoperative technical issues, and increased operative time. Final Result: Two reviewers determined that the service at issue was 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: All three physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an 11-year-old male enrollee has requested authorization and coverage for SonoSite AV400 vein viewing system and Buzzy 4 Shots to perform laboratory testing for treatment of the enrollees medical condition. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested equipment in this clinical setting. He was diagnosed with a brain tumor as an infant and has since been diagnosed with multiple recurrences, undergoing surgical resection, radiation therapy, and chemotherapy. Most recently, there was concern for tumor recurrence. According to his caregivers, it is difficult to perform phlebotomy on him because of blood vessel caliber. There may also be a component of obesity and history of frequent phlebotomy with resultant scarring. In addition to the tumor, and as a result, he requires stress dose steroids for any challenging events (procedures, manipulations) due to lack of normal cortisol response to stress. This patient has well documented medical challenges that require specialized age appropriate services. Due to the difficulty in drawing blood from this patient, he requires specialized techniques and skill from pediatric laboratory personnel. For these reasons, SonoSite AV400 vein viewing system and Buzzy 4 Shots are medically necessary for treatment of this patient. 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 with sub-specialty certification in pediatric critical care 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 the residential treatment center (RTC) level of care services for treatment of the enrollees opiate use disorder. Findings:  The physician reviewer found that this patients post-acute withdrawal symptoms were not described other than his cravings and moods. There was no evidence that he was a danger to self or others. He was cognitively intact, and his level of emotional and behavioral issues were not severe enough to warrant ongoing RTC services. He demonstrated inappropriate behavior in group therapy. However, he was not manic, psychotic, or agitated. He was medically stable. He continuously expressed that he lacked interest in pursuing sobriety and relapse prevention. He was discharged on Suboxone, of which the management did not require the RTC setting. Given the patients lack of motivation and distinct, well-defined, and verbalized intent to resume drinking and use cannabis, the RTC services 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: An enrollee has requested reimbursement for loop recorder implant for evaluation of the enrollees atrial fibrillation and atrial flutter. Findings:  The physician reviewers found that there is a lack of medical evidence to support the superior efficacy of the services at issue in this clinical setting. In this circumstance, periodic monitoring for recurrent atrial fibrillation/flutter is usually initially assessed with serial 24-48 hour Holter monitoring and patient activated or auto rate change activated event recorders. The documentation provided does not indicate these have been tried or that the patient is not able to manage these external devices. Routine placement of implantable loop recorders after atrial fibrillation ablation is not recommended in either atrial fibrillation or ablation guidelines. Therefore, the loop recorder implant  was not likely to be superior over the other standard methods of evaluating this patients medical condition. Final Result: All 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and 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 59-year-old female enrollee has requested authorization and coverage for lumbar spine magnetic resonance imaging (MRI) for evaluation of the enrollees back pain. Findings:  The physician reviewer found that The records provided for review do not include any documentation depicting a significant change in symptoms since the patients MRI. In addition, there are no red flags to support an indication for a repeat MRI of the lumbar spine absent flexion extension x-rays and a repeat course of physical therapy. Given the lack of change in symptoms, a course of recent physical therapy, or findings on extension x-rays suggesting cause for concern, the requested lumbar spine MRI without dye is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is 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: 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 based on the Level of Care Utilization System (LOCUS) criteria, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is three (3), moderate risk of harm. The patient has no documentation of a prior suicide attempt and the patient did not have any suicidal ideation. The patient has a history of excessive alcohol use with blackout. This episode is led to her hospitalization and treatment. The patient does not have a history of seizures from withdrawal. The patients functional status score is three (3), moderate impairment. The patients substance use does seem to impair her ability to fulfill responsibilities. The patients medical, addictive, psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of alcohol use disorder. The patients recent substance use clearly had a detrimental effect on the patients life. The patient also has a history of gastric bypass. The patients recovery environment score is two (2), mildly stressful environment. The patient has some intermittent interpersonal conflicts with her family due to substance use. Otherwise, the patient has a supportive environment. The patients level of support score is two (2), supportive environment. The patients family is supportive. The patients treatment history score is one (1), fully responsive to Treatment and recovery. The patient has had no prior treatments for her substance use. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient is friendly and cooperative with staff. She is accepting of treatment and is willing to engage in psychotherapy and psychopharmacology. Based on these criteria, the patient has a total score of 16 and would meet criteria for outpatient treatment. The patients continued treatment for alcohol use disorder could have been provided in a less restrictive environment. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for reconstructive abdominoplasty for treatment of the enrollees diastasis recti. Findings:  The physician reviewer found that this patient presents with an abdominal bulge, abdominal pain, weakness and back pain attributed to a documented large diastasis recti of the abdomen. Work-up of other potential causes of her abdominal condition have not been able to identify a cause other than the diastasis recti. This has included multiple CT scans and plain radiographs. In addition, her condition has appeared to have worsened as the most recent CT evaluation noted the presence of the transverse colon within her protuberance. The repair of diastasis recti is not generally considered to be a functional treatment but can be an integral part to cosmetic procedures, namely abdominoplasty. As stated by the American Society of Plastic Surgeons (ASPS), abdominoplasty and panniculectomy are typically performed for purely cosmetic indications. However, the ASPS noted that there are however rare reconstructive indications for panniculectomy in cases unrelated to obesity or massive weight loss. This patient has evidence of back and abdominal pain with abdominal weakness. However, given that the repair of diastasis recti is not well-recognized as a reconstructive procedure, repair of the diastasis recti should not be considered medically necessary based on a functional treatment. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and reconstructive in nature. 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. However, the requested surgery is supported as reconstructive in nature. The patient has evidence of significant diastasis recti that can be considered an abnormal separation of the rectus muscles. In addition, the abnormal structure of the body is caused by pregnancy and age. Moreover, the requested surgery is being requested to improve the patients appearance and based on the photographs provided and the current medical literature, the patients preoperative appearance is severe. Thus, this is considered a significantly abnormal appearance. Finally, the requested surgery could offer more than a minimal improvement as the patients current condition is severely abnormal and the planned procedure would directly address abnormality. Thus, the requested reconstructive abdominoplasty is supported as reconstructive in nature, and therefore medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 63-year-old male enrollee has requested reimbursement for hospital stay for treatment of the enrollees hyponatremia and dehydration.  Findings:  the physician reviewer found that The hospital stay provided was not medically necessary for treatment of the patients medical condition. The documentation provided for review shows that the patients sodium level was 131 with a BUN of 27 and creatinine of 1.8. There is no documentation to show any symptoms associated with hyponatremia. The patient at baseline has chronic kidney disease. There is no indication that the patient had any vomiting or persistent dehydration after initial IV fluids at a lower level of care or that the patient required any parental nutrition. The sodium was not below 120 or greater than 150. There was no evidence of hemodynamic instability such as tachycardia or hypotension at the time of admission. There is no documentation that the patient failed to be adequately treated at a lower level of care. Inpatient admission was not medically necessary in this case. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Therefore, the services at issue 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 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.