Persius/hicric huggingface dataset:
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 individual weekly therapy for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that based on the documentation submitted for review, the request for individual weekly therapy is medically necessary for treatment of the patients medical condition. The patient presents with diagnoses of ADHD, anxiety disorder and major depressive disorder with symptoms that include anxiety, negative thought process, and difficulties with peer relationships, distractibility and problems focusing. In this clinical setting, individual therapy is a medically reasonable approach and meeting once each week is consistent with community standards of treatment. 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 with sub-specialty certification in child and adolescent 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: The parent of an enrollee has requested authorization and coverage for custom made shoe inserts/foot orthotics for treatment of the enrollees congenital abnormality of the lower limb. Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested custom made shoe inserts/foot orthotics. A review of the published literature does not support the benefit of orthotics for treatment of the patients flat foot deformity with associated tibial varum and internal tibial torsion. There is a lack of support in the peer-reviewed literature demonstrating that orthotics are more effective than standard therapy for the treatment of the patients medical condition. Final Result: The reviewers determined that the requested equipment 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 podiatry 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 trigger point injections for treatment of the enrollee, who has been diagnosed with trigeminal neuralgia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Trigger points are taut muscle bands which when pressed have a characteristic pattern of radiation.  A diagram showing the pattern of radiation is the standard procedure for documenting the trigger point.  In this patients case, there is no documentation of where her trigger points are and the pattern of radiation from those points. Further, there is a lack of support in the peer-reviewed literature for trigger points as therapy for trigeminal neuralgia.  The current medical evidence does not support the requested services in this clinical setting. 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for continued inpatient hospital stay .  Findings:  The physician reviewer found that the documentation provided fails to demonstrate the medical necessity for the services at issue. Several factors are considered when determining whether a patient is appropriate for transfer to a Long Term Acute Care Hospital (LTACH ) for respiratory care and weaning. First, the acute illness should be resolved. Second, the patient should not be dyspneic or hypoxemic during mechanical ventilation. Third, patients should have a stable airway and route to receive nutrition, which usually consists of a tracheostomy and enteral feeding tube.  In this case, the patient was responding to treatment for aspiration pneumonia with associated respiratory failure.  He stabilized and improved slowly but was still not stable enough to have surgery.  The patient had stable vital signs of 133/77, 98% oxygen saturation on an oxygen mask.  The repeat chest x-ray was improved, the laboratory results showed improvement in systemic inflammation and infection.  The patient was being monitored on telemetry and was receiving parental antibiotics and scheduled breathing treatments.  The patient was taking nutrition by mouth.  The surgical repair of the hip had been postponed due to his respiratory status, which had stabilized but not enough for surgery. He was clinically improving and diagnostic studies showed that the acute illness was resolved.  The patient continued to have hypoxic episodes when trying to wean off of supplemental oxygen.  The transfer to a LTACH was appropriate and the patient was stable for a lower level of care.  Therefore continued in-patient hospital stay was not medically necessary as the patient could have safely been treated at a lower 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the fetal DNA testing performed. Findings:  The physician reviewer found that the American Congress of Obstetricians and Gynecologists recommend cell free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined 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-trimester or second-trimester screening test results. In this case, because the patients pregnancy was conceived with donor eggs from a 22-year-old, the aneuploidy risk for this patient with this pregnancy is low. The sensitivity and specificity in a lower risk obstetric population are similar to the levels in a high-risk population but the positive predictive value is lower in this population, given the lower prevalence of aneuploidy in the lower risk obstetric population. Thus, fewer women with a positive test result will actually have an affected fetus, and there will likely be more false-positive test results. In addition, the detection rate for sex chromosome abnormalities is also lower than for trisomy 21 and 18. In view of all of these considerations, the fetal DNA 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: Physician reviewers 1,2 and 3 are board certified in obstetrics and gynecology 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 parent of an enrollee has requested authorization and coverage for dental general anesthesia. Findings:  The physician reviewer found that General anesthesia for pediatric dental procedures is generally considered to be a safe and effective practice. General anesthesia is often employed to facilitate extensive dental treatment particularly in younger pediatric patients who do not have the psychological or emotional maturity required to cooperate in an office setting. Typically, the combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for some pediatric patients. Upon review of the medical record, there is clear documentation of the need for extensive dental work for this patient. However, there is a lack of support in the documentation to suggest this patient meets criteria for the requested services. There is no record to show that this patient has a fear of needles and/or severe dental anxiety. In addition, there is no documentation of previous failed attempts to receive dental care with other dentists. Moreover, there is no indication that this patient has a significant cognitive impairment or is unable to cooperate and/or tolerate dental treatment in an office setting. There is no documentation to indicate that the use of local anesthesia and/or use of conscious sedation to control pain were not feasible based on the medical needs of this patient. For these reasons, dental general anesthesia is not medically necessary in this case.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 anesthesiology 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 Decision DX Melanoma Gene Assay for evaluation of the enrollees melanoma. Findings:  Three physician reviewers 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 the Decision DX Melanoma Gene Assay has not made it part of routine analysis after sentinel lymph node biopsy. There has also been a lack of consistency between various genes being used as biomarkers. As such, the test is very novel and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. 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 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 genetic testing for cancer susceptibility. Findings:  The physician reviewers found that according to the National Comprehensive Cancer Network (NCCN) guidelines, patients who are meeting one or more of these criteria warrants further personalized risk assessment, genetic counseling, and often genetic testing and management. In this case, the patient has a maternal grandmother who is a third degree relative diagnosed with breast cancer at age 72. This patient has two daughters who are second degree relatives, one of whom was diagnosed with breast cancer at age 47, the other diagnosed with ovarian cancer at age 26. Thus, the NCCN criteria are met in the patients maternal grandmother and the patient meets criteria for BRCA1 and BRCA2 testing based on NCCN guidelines that pertain to family history. However, the patients family history does not support an indication for any of the additional testing performed on the date of service in question. Given these findings, the BRCA1 and BRCA2 mutation testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 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: All three physician reviewers are board certified in clinical genetics 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 blood diagnostic test, Prometheus Anser ADA, provided.  Findings:  The physician reviewer found that  nn this patients case, Anser ADA was ordered to direct the management of the patients Crohns disease. However, the use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with Humira (adalimumab) may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature. These small studies demonstrated, at best, correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. A study found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. A review article reported that the available data do not allow final conclusions about the relevance of anti-adalimumab antibodies to the clinical efficacy of adalimumab, and another concluded that prospective controlled trials are direly needed to investigate the optimal tailored management in individual patients who lose response . Therefore, the clinical literature does not support that the blood diagnostic test, Prometheus Anser ADA, provided on the disputed  date was likely to have been more beneficial for evaluation of this patients medical condition than the available standard treatment options. Final Result: The  2 of 3 reviewers determined that the services at issue were not 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 upheld.Credentials/Qualifications: Physician reviewers 1,2 & 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment level of care provided during the dates of service in question. Findings:  The physician reviewer found that, due to the lengthy history of drinking and increased reports of consumption, a residentially-based detoxification and preliminary introduction to chemical dependency treatment was safe, appropriate and consistent with good medical practice. However, the clinical documentation does not demonstrate the medical necessity of treatment in a 24-hour supervised setting as of the first date of service in question.  First, the absence of significant comorbidity supported a less restrictive setting.  The patient completed detoxification and there was no evidence of the emergence of late alcohol withdrawal symptomatologies.  The patient was medically stable.  He did not have a degree of psychiatric impairment that would have necessitated a residential treatment setting. Second, the patient embraced recovery principles and was motivated in his quest for sobriety.  He was noted to be motivated for sobriety in a different way than he has been before  By the date of service in question, he had completed a month of residential treatment and had been actively participating in groups and engaged with a sponsor.  He had the availability of safe and sober housing with his parents.  He had no other addictions besides alcohol.  Aside from the failed outpatient services, the patient had no prior history of chemical dependency treatment in an intermediate setting such as an intensive outpatient or partial hospital program.  Further, he had not previously been prescribed long-acting injectable naltrexone, which far outperforms the oral preparation as an anti-craving medication.  All of this is significant in this case for two reasons. First, modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment; second, there was no evidence to suggest that comprehensive, evidence-based services provided a less restrictive treatment setting would have been insufficient or inadequate at the time.   Thus, the residential treatment provided during the dates of service in question was not medically necessary for the treatment of this patient. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the UroLift procedure. Findings:  The physician reviewers found that the UroLift procedure performed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is sufficient peer-reviewed literature supporting the procedure at issue. Authors of a study performed a systematic review and meta-analysis of reported symptomatic, functional, and sexual outcomes following the prostatic urethral lift procedure. The authors concluded that the prostatic urethral lift procedure is a well-tolerated procedure that produces improvement in urinary symptoms and function while preserving sexual function. In sum, UroLift is a well-tolerated procedure for BPH and provides immediate improvement in obstructive symptoms. All told, the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewers are board certified in urology 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 Butrans 15 mcg/hour patch for the treatment of the enrollees pain. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The patient has been on the requested medication for the past 18 months. She has recently had increased pain with decreasing activities of daily living. Her total dose is under 120 mg of morphine equivalent. She has followed her opiate maintenance agreement. The patient reported that she experiences pain 24 hours per day. Some degree of tolerance to opiates does develop over time. Given this patients increased pain, the requested medication is medically indicated. 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 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.