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 gastric sleeve surgery. The submitted documentation fails to demonstrate the medical necessity of the requested services. The requested services are not medically necessary since psychological clearance has not been obtained. Although the patient was evaluated, certain recommendations were not completed. There is a lack of clear national standards or guidelines on the use of cannabis before or after bariatric surgery. However, it is appropriate for the provider to establish best practices that are safe or reasonable given the potential concern of maladaptive eating behaviors that may be higher in patients who are using marijuana. Therefore, the requested gastric sleeve surgery 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 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

An enrollee has requested reimbursement for ThyGenX thyroid panel. The Health Plan has denied this request indicating that the services at issue were considered investigational for the evaluation of the enrollees indeterminate thyroid nodule.Findings:  While FNA biopsy of a suspicious thyroid nodule is an accurate means of assessing whether the nodule is benign or malignant, researchers found approximately 15% of FNA biopsy results are considered indeterminate. Until recently, studies have shown that the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The development of molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. Among these tests is ThyGenX, which analyzes a panel of DNA mutations and RNA translocation fusion markers to assess the risk of malignancy with good negative and positive predictive value, thereby, obviating the need for unnecessary surgeries. For the reasons stated above, ThyGenX thyroid panel was likely to have been more beneficial for the evaluation of this patient than any available standard therapy. Final Result: Two of the three reviewers have determined that the services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for computed tomography (CT) scan and reading of radiologic examination of the chest provided. This patient is a diabetic, hypertensive female with heart disease. She presented with left upper abdominal pain that had worsened with exertion and breathing. This patient had significant risk factors for acute coronary syndrome. Women, in particular, may report atypical symptoms such as abdominal pain when experiencing cardiac ischemia. A chest x-ray was necessary to rule out a cardiac event. Further, a CT scan was necessary to rule out an acute abdominal emergency such as aortic aneurysm, appendicitis or acute diverticulitis. Despite a final diagnosis of constipation, symptoms of upper abdominal pain in a patient with hypertension and diabetes is considered an emergency medical condition. The CT scan and reading of the radiologic examination of the chest provided were necessary for treatment of the patients emergency medical condition.Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in emergency 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for out-of-network surgical services on the basis that the services were emergent in nature. Fingertip crush injuries with laceration and distal phalanx fracture are common injuries and fortunately, the risk of infection is low. Studies have not found benefit to prophylactic antibiotics and have confirmed that operating room washout of the wound is unnecessary. The surgery was performed over two weeks after the accident and did not constitute emergent treatment. The surgical services were not necessary for treatment of an emergency medical condition as defined above.Final Result: The reviewer determined that the patient did not receive emergency medical services. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and hand surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for hydrocodone-acetaminophen 10 mg-325 mg, 100 tablets per 30 days. The Health Plan has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the patients pain. The submitted documentation does not support the medical necessity of the requested medication. Clinical practice guidelines do not support the use of opiates for chronic pain. While the use of opiates may be helpful in the acute setting, chronic use of opiates has been associated with limited efficacy and may lead to dependency and abuse. There are multiple alternatives without these risks. There is a lack of support for the requested medication in this clinical setting. Therefore, hydrocodone-acetaminophen 10 mg-325 mg, 100 tablets per 30 days are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication quantity 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: An enrollee has requested reimbursement for the gene test (Mammaprint). The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees carcinoma, left breast.Findings:  The Amsterdam 70-gene prognostic profile (MammaPrint) was one of the first gene expression arrays approved for commercial use. The clinical validity of the 70-gene prognostic profile has been demonstrated in multiple studies. Results from an international randomized trial suggest that this genetic profile may identify subsets of patients who have a low likelihood of distant recurrence despite high-risk clinical features. Based on the MINDACT results, the American Society of Clinical Oncology has suggested MammaPrint is one of several assays that might be used to determine prognosis for those with high clinical risk, hormone receptor-positive, HER2 negative breast cancer and three or fewer involved lymph nodes to inform decisions regarding chemotherapy. Observational studies have similarly suggested that the 70-genetic profile identifies patients with a low chance of recurrence, independent of nodal status, tumor grade, or hormone or HER2 receptor status. Accordingly, the gene test (MammaPrint) was likely to have been more effective than the standard options for evaluating this patients medical condition. Final Result: Two of the three reviewers have 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Orthovisc injections. This patient presents with chronic bilateral knee pain that was progressively worsening and is now severe. She is status post bilateral knee anteromedialization osteotomy and medial patellofemoral ligament reconstruction. She reported limited ability to participate in current rehabilitation due to pain. Clinical examination findings are consistent with reported imaging evidence of tricompartmental degenerative changes. Conservative treatment has included physical therapy, activity modification, home exercise, nonsteroidal anti-inflammatory drugs and corticosteroid injections, with limited relief. She reported significant benefit with prior viscosupplementation with Orthovisc. The evidence-based literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given the previous response and age of this patient, repeat Orthovisc injections are indicated. Therefore, bilateral Orthovisc injections are medically necessary for the treatment of this patient. 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Forteo. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of osteoporosis.Findings:  Current peer reviewed literature supports the use of Forteo for the treatment of osteoporosis following failure of first line treatment. However, current prescribing information from the manufacturer and U.S. Food and Drug Administration (FDA) does not support the use of Forteo for more than two years throughout the life of the patient based on the risk of osteosarcoma. Jeremiah and colleagues recommend first line treatment of osteoporosis which consists of fall prevention, smoking cessation, moderation of alcohol intake, and bisphosphonate therapy. Teriparatide (Forteo) is recommended as an alternative effective treatment for certain subsets of patients and for those who are unable to take or whose condition does not respond to bisphosphonates. These recommendations are supported by Levis and Theodore in their summary of comparative effectiveness review of treatment to prevent fractures in men and women with low bone density or osteoporosis. However, current Forteo prescribing information from the manufacturer and FDA guidance state that Forteo should not be taken for more than two years over the patients lifetime to mitigate the risk factors for osteosarcoma. This patient has previously used Forteo for a two year period. She sustained bilateral subtrochanteric fractures; a right femur fracture again in September, that healed on its own at that time; and bilateral femur fractures again, requiring additional surgery. Based on the provided record, there is no compelling rationale provided to support the medical necessity for the use of Forteo in this patient as an exception to the manufacturer and FDA indications. Therefore, the medical necessity for the medication Forteo for the treatment of the patients medical condition has not been established.Final Result: The reviewer has determined that 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for multilevel spinal fusion surgery. This patient presents status post L4-L5 anterior lumbar interbody fusion with posterior spinal fusion and decompression at L5-S1. She initially did well following surgery, but records indicate that she reported a return of symptoms. Conservative treatment in the postoperative period included medications, activity modification, bracing, and physical therapy, without benefit. She reports constant severe pain with significant functional limitations in activities of daily living and inability to work. However, current evidence-based criteria have not been met. There is no documentation that the decompression surgery has failed at the L5-S1 level. There is no current documentation from the spine surgeon relative to physical findings with corroborating postoperative imaging evidence of residual spinal stenosis, severe degenerative disc disease, and/or nerve root compromise at the L5-S1 level. There is no radiographic evidence of L5-S1 spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no discussion supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. There is no clear documentation that the patient has failed a comprehensive attempt at postoperative rehabilitation. Therefore, the requested multilevel spinal fusion surgery 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for Zepatier once daily for 12 weeks. Studies show that all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The studies recommend that treatment naive genotype 1b patients should be treated with regimens including or Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. Studies show that reduced survival with delayed treatment. For these reasons, the requested treatment with Zepatier once daily 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intensive applied behavioral analysis (ABA) therapy per week. Colleagues evaluated 726 children ages 1.5 to 12 years receiving ABA therapy and reported that the patients demonstrated increased progress towards learning objectives with increased intensity of treatment. The authors noted a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. Additional studies of ABA in patients with autism have recommended at least or more hours of weekly ABA to ensure optimal outcomes. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from hours of treatment per week. This patients records document that she has made progress in many areas, but continues to demonstrate significant behavioral concerns. The patient continues to require a high level of support to transition appropriately. Failure to master these skills places the patient at an increased risk for injury and makes it increasingly difficult to be successful in more generalized environments. Given these findings, the request for continued coverage of intensive ABA therapy per week is medically necessary for treatment of this 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 pediatrics with sub-specialty certifications in neurodevelopmental behavioral pediatrics and genetics 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 continued occupational therapy. The requested continued occupational therapy services do not need to be provided under the supervision of a skilled therapist. The patient has received prior occupational therapy and her current needs do not require a skilled therapist. The expected rehabilitation potential is not significant in relation to the extent and duration of therapy services requested. The specialized skill of a qualified therapist is not required to establish, design and/or deliver a maintenance program, maintain the patients current condition or to prevent or slow further deterioration. For these reasons, the request for continued occupational therapy is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 authorization and coverage for Orencia ClickJect Autoinjector 125 mg/mL. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees rheumatoid arthritis. Findings:  The available medical records do not document failure of traditional disease modifying antirheumatic drugs (DMARDs) such as methotrexate, Arava, or sulfasalazine.  The patients provider noted that treatment with traditional DMARDs is prohibited and contraindicated in patients who have had gastric bypass surgery; however, review of the the scientific data reveals there is a lack of peer reviewed medical literature to show that DMARDs is contraindicated in patients who have a history of gastric bypass surgery. Additionally, methotrexate is available in an injectable form if absorption of medication appears to be an issue.  On the basis of the available peer reviewed evidence based literature, Orencia ClickJect Autoinjector 125 mg/mL has not been demonstrated as medically necessary for treatment of this patients medical condition. Final Result: The reviewer has 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 internal medicine with sub-specialty certification in rheumatology 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.