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 residential treatment care. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. In this case, substance use dominated the patients daily routine while he had tried and failed an array of therapeutic interventions. One day prior to the disputed timeframe, the patient had significant craving and dreams of substance use. He was depressed and evasive, and had poor insight. Two days later, the patient was prescribed, but did not take, an anti-craving medication, Naltrexone.  Later that day, he met with a psychiatrist. There was concern for social anxiety, but the patient was diagnosed with unspecified depressive disorder. The provider recommended duloxetine, but the patient declined the trial. However, gabapentin was increased. It was noted that the patient was doing well in the program but was struggling with post-acute withdrawal apathy, cravings and low frustration tolerance.  Essentially, he had yet to consolidate the issues that prompted the residential placement in the first place. Thereafter, the patient remained actively engaged in treatment, including family programming and aftercare planning. The services and setting were safe, appropriate and consistent with good practice. Additionally, the services provided were reasonably expected to improve his condition and prevent a more serious episode of illness, while the duration of care was consistent with community standards. In sum, residential treatment care was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the knee for evaluation of the enrollees knee pain.  Findings:  The physician reviewer found that the MRI of the knee performed was medically necessary for evaluation of the patients medical condition. MRI is the optimal means to evaluate an internal derangement. Plain x-rays are of limited value given that the menisci and ligaments are not visible on plain x-rays. The American College of Radiology (ACR) appropriateness criteria for acute trauma to the knee recommend MRI of knee for trauma due to a fall or twisting injury with either no fracture or a Segond fracture seen on a radiograph or suspected internal derangement. This scenario applies to this patient. For patients who have sustained recent trauma and have physical signs and symptoms suggestive of an internal derangement, an MRI is the most appropriate and relevant diagnostic imaging procedure. In the clinical setting of acute trauma with suspected internal derangement such as a ligament tear, and where surgery is likely, an MRI is clinically indicated and delaying the MRI is not medically reasonable. Final Result: The reviewer determined that the diagnostic procedure at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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 authorization and coverage for right T7-T8 epidural selective nerve block injections with monitored anesthesia care (MAC) for treatment of the enrollees back pain. Findings:  The physician reviewer found that review of the submitted documentation fails to support the medical necessity for the request for right T7-T8 epidural selective nerve block injections with MAC. In this case, the patient presents with thoracic pain. The documentation submitted for review fails to show physical examination findings of thoracic level radiculopathy such as segmental sensory loss or evidence of asymmetric abdominal reflex response or abdominal muscle weakness which could be assessed clinically by testing for Beevors sign. There is no imaging of the thoracic spine that corroborates a diagnosis of thoracic level radiculopathy. In addition, the patient was referred for physical therapy and Topamax appears to have been started which does not reflect a failure of conservative treatments. The duration of symptoms as well as pain severity are not documented. For the reasons provided, the request for right T7-T8 epidural selective nerve block injections with MAC has not been established as medically necessary for the treatment of the 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 physical medicine and rehabilitation 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50 mg/100 mg for 12 weeks. 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 50 mg/100 mg for 12 weeks is supported as 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 advanced lipoprotein testing for evaluation of the enrollees risk for heart disease. Findings:  Three physician reviewers found that there is insufficient data to support the use of advanced lipoprotein testing in this clinical setting. While some researchers have advocated the use of advanced lipoprotein testing  for the evaluation of cardiovascular risk to help make treatment decisions for patients with hyperlipidemia, the American College of Cardiology (ACC) guidelines do not support its use for the assessment or management of cardiac risk. Rather, the guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. According to the ACC, there is a lack of data to support the superior benefit of advanced lipoprotein testing over the basic lipid profile. In addition, the guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. For these reasons, the advanced lipoprotein testing was not likely to have been superior over the standard testing options available for evaluating this patients medical condition. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in 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: An enrollee has requested authorization and coverage for a cortisone shot for treatment of the enrollee who has a history of sacroiliac joint pain. Findings:  The physician reviewer found that the current peer reviewed medical literature indicates that the evidence is limited and insufficient to support short and long term relief from intraarticular SI joint corticosteroid injections. Additionally, evidence based medical guidelines state that therapeutic SI joint injections are not recommended (neither therapeutic SI intra-articular nor periarticular injections) for non-inflammatory SI pathology based on insufficient evidence in the literature. SI joint injections are recommended on a case by case basis as injections for inflammatory spondyloarthropathy (sacroiliitis). In this patients case, there is limited evidence on clinical examination relative to SI joint provocative testing and no documentation of imaging evidence suggestive of sacroiliitis. Current evidence based medical guidelines and peer-reviewed literature does not support the use of SI joint corticosteroid injection for this patients left SI joint dysfunction. Therefore, a cortisone shot is not medically necessary for treatment of this 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing for evaluation of the enrollee who has a history of left breast cancer. Findings:  Two physician reviewers found that there is sufficient support in the medical literature for a portion of the services at issue in this clinical setting. This patient meets the National Comprehensive Cancer Network (NCCN) guidelines which recommend BRCA testing for patients who are younger than 45. The BRCA portion of the test would also be indicated in view that the patients mother had ovarian cancer. However, this is a 25 gene panel that includes BRCA within it but also a variety of other suspected risk genes. Though many of these gene mutations are of real interest, and are being studied, for the most part, they have not been found to be significant enough to be the basis for any clinical decisions for the carriers or their family members. Such testing is not included in the guidelines from the major organizations. Accordingly, BRCA1 and BRCA2 of the genetic testing performed were more likely to have been superior over the other methods for evaluating this patients medical condition. Final Result: The reviewers determined that the services at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant 360 test for evaluation of the enrollees non-small cell lung cancer. Findings:  Two physician reviewers found that the National Comprehensive Cancer Network guidelines endorse broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients, thus facilitating prompt treatment or protocol inclusion. Broad molecular profiling, such as with Guardant 360 testing, is considered a standard of care for the treatment of patients with advanced non-small cell lung cancer. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A transgender enrollee has requested authorization and coverage for laser hair removal for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. Excessive facial hair in a female would be considered abnormal and is referred to as hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in female in areas that are normally found in males.  Accordingly, facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. This would include the face and parts of the genitalia. This patients excessive facial hair is more consistent with the male gender. Additionally, hormone therapy has not been effective in improving this patients medical condition. Therefore, facial hair removal is medically necessary for the treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is an abnormal body structure.  Hirsutism is a condition that is congenital in that the hair growth is determined by the genetic and hormonal makeup of the patient. As such, the requested facial hair removal can provide substantial improvement in the appearance of terminal hair and in the appearance in this patient. Moreover, the requested services are going to improve emotional function for this patient. Final Result: The reviewer determined that the requested services are medically necessary and are 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 dermatology 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 additional hydrocodone #5 for treatment of the enrollees tooth pain. Findings:  The physician reviewer found that based on the documentation submitted for review, additional hydrocodone #5 has not been established as medically necessary for treatment of the patients medical condition. The medical records show the patient presented with tooth caries, periodontal disease and pain. The patient was given a prescription for Ibuprofen. Ibuprofen is an anti-inflammatory and works to decrease pain and inflammation. Hydrocodone is indicated for acute short-term pain but with high risk of dependence. Opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. Based on current medical literature and the presented clinical records, the requested medication is not medically necessary for treatment of the patients medical condition. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the FoundationOne cancer assay providedFindings:  The physician reviewer found that  per a study, PARP inhibition has antitumor activity in cases of metastatic castrate resistant prostate cancer and that these responses are associated with DNA repair defects in tumor cells that can be identified through next generation sequencing assays. FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individual patients tumor in an attempt to identify markers than can help guide therapy decision making. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy (Michels, et al). Given this support, the BRCA2, ATM, BRCA1, PALB2, CHEK2, FANCA and HDAC2 portions of the FoundationOne testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the FoundationOne cancer assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewers 1,2 & 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 non-invasive prenatal testing for evaluation of the enrollees second pregnancy. Findings:  The physician reviewer found that the American College of Obstetricians and Gynecologists (ACOG) recommend cell free DNA testing as a screening option for women at increased risk of fetal aneuploidy. ACOG defines this high risk population as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first or second trimester screening test results. Since this patient is reportedly 36-years-old, the aneuploidy risk for this patient in this pregnancy warrants cell free DNA testing for aneuploidy. Thus, the requested non-invasive prenatal testing is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested testing is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal and fetal 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.