Persius/hicric huggingface dataset:
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 speech therapy for treatment of the enrollees mixed receptive-expressive language impairment. Findings:  The physician reviewer found that review of the submitted documentation fails to demonstrate the medical necessity of the request for speech therapy. Although speech therapy is indicated for children with autism, at this time speech therapy is not medically necessary for the patient. The patient does not yet have the behavioral and attention skills needed to benefit from speech therapy. ABA therapy is clinically indicated at this time to address the patients pre-language skills. Based on the clinical documentation submitted for review, the request for speech therapy has not been established as medically necessary for 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the DecisionDx-Melanoma testing performed.Findings:  The physician reviewer found that the DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. The test has not been demonstrated to provide a beneficial effect on health outcomes. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma Assay 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 & 3 are board certified in dermatology 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 100 Freestyle Lite Strips per month for treatment of the enrollees diabetes.  Findings:  The physician reviewer found that the prevalence of diabetes is increasing worldwide and there is great concern regarding long term diabetic complications. Poorly treated diabetes can lead to microvascular complications such as retinopathy, nephropathy, and neuropathy as well as macrovascular complications such as cardiovascular disease, cerebrovascular accidents, and peripheral vascular disease. Recent studies have demonstrated that long term rates of microvascular complications are greatly decreased through close monitoring of blood glucose levels. Therefore, it is important that patients with diabetes are able to adequately test their blood glucose levels at home. It is important that this patient check fingersticks regularly in order to optimize glycemic control. This will help to prevent long-term diabetic complications and help prevent short-term complications of glycemic variability. The requested quantity of 100 test strips is medically necessary for proper management of this patients diabetes. Therefore, the request for 100 Freestyle Lite Strips per month is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 endocrinology, diabetes and metabolism 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 services to be performed in a single surgery (redo right pelvic floor repair, right adductor repair, right adductor compartment decompression, right rectus abdominis compartment decompression, right high rectus compartmental decompression, right oblique compartment decompression, right oblique repair(s), rib resection and steroid injection). Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. In this patients case, there is a lack of objective evidence of core muscle injury that would necessitate surgical intervention. Per the medical evidence, surgical release of abdominal musculature is not indicated except in cases of component separation to repair fixed abdominal wall defects associated with fascial weakness. This patient does not have a hernia or evidence of fascial abnormality. Surgical release for chronic pain increases the patients risk for scar tissue formation and additional neuropathy. Perioperative risks include wound infection, poor wound healing or bleeding. The current evidence does not support rib resection for chronic pain. Furthermore, operative inspection of additional surrounding rib structures, and core muscle release, is not supported as a combination procedure because imaging indicates normal surrounding thoracic structures and abdominal wall. However, the medical evidence supports the requested steroid injection. In this patients case, the requested steroid injection is medically necessary for the treatment of his chronic pain. The remainder of the requested services are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of the patient has requested authorization and coverage for baby formula Alimentum (HCPCS B4161-EF ped hydrolyzed/amino acid) for treatment of the enrollees milk protein allergy. Findings:  The physician reviewer found that based on this patients medical history and the documentation provided for review, the requested Alimentum formula is medically necessary. This patients declining weight-for-age percentile is concerning for pending growth failure. There is evidence in the medical records of a milk/soy protein allergy, which is a clinical diagnosis and cannot be identified on the basis of laboratory testing. An extensively hydrolyzed formula is sufficiently hypoallergenic to be tolerated by 95% of infants with this condition. However, even when well-tolerated in regard to symptom control, extensively hydrolyzed formulas may not be palatable. When an infant is orally fed, and refuses the appropriate formula, growth failure can result. As this patient has refused Nutramigen formula, the requested replacement Alimentum is supported as medically necessary. Final Result: The reviewer determined that the requested service 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 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 was diagnosed with urothelial carcinoma and underwent genomic molecular testing for the evaluation of this patient.  Findings:  The physician reviewers found that the utility of this test is considered experimental in this clinical setting. Therapy and achieved outcomes for urothelial (bladder) cancer are not based on panel testing. These recommendations are well summarized in National Comprehensive Cancer Network Practice Guidelines. Additionally, to demonstrate clinical utility of panel genetic testing, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. There is a lack of such trials currently published. The available literature on its clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions on its clinical utility. In addition, there is potential for harm if ineffective therapy is given based on test results, because there may be adverse effects of therapy in absence of a benefit. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, genomic testing (targeted genomic sequence analysis panel) was not likely to have been more effective than the standard therapy available for the evaluation of this patients medical condition. Final Result: Two of 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 internal medicine with sub-specialty certification in medical oncology 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: An enrollee has requested authorization and coverage for skilled nursing facility services for treatment of bilateral lower ankle fractures. Findings:  The physician reviewer found that the documentation provided do not support the medical necessity of the requested services in this clinical setting. Generally, there is little evidence to support significant rehabilitation interventions during the immobilization period following ankle fractures outside of compensatory skills. The marginal benefits of supervised exercise in the setting of ankle fractures are questionable.  In this patients case, there are no complex wounds or other skilled needs requiring ongoing inpatient level of care. The patient sustained bilateral ankle fractures and has non weight bearing restrictions on one lower limb.  He is allowed limited weight bearing on the other lower limb, but he is not tolerating significant weight bearing.  The record appears to indicate that this patient has plateaued in terms of his mobility and general self care, given these limitations/restrictions. The patient has progressed to a functional level where further care can be provided in a lower level of care.  The patient is supervised for transfers and independent with wheelchair mobility.  There are no ongoing goals or needs requiring inpatient level rehabilitation. The patients weight bearing limitations/restrictions are not expected to be advanced or increase in the near term.  According to the records provided, this patients care is custodial in nature and not medically necessary. The record notes that this patient could be provided with the requisite durable medical equipment in order to return to the community with custodial level assistance. 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 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 authorization and coverage for myoelectric upper extremity orthosis (1 unit code HCPCS-L3999 upper limb orthosis and 90 days CPT 99201 outpatient office visits) for treatment of the enrollees left brachial plexus injury. Findings:  The physician reviewers found the myoelectric elbow wrist hand orthosis is of greater functional benefit than conventional treatment. This device can provide rapid functional gains when used by patients with a paralytic upper limb, such as in this case. The proposed device will allow some functional use of the patients left upper limb for assistance with activities of daily living and feeding. The records indicate that there is no expectation of neurological recovery of the brachial plexus. As such, the myoelectric device will allow functional use of an otherwise nonfunctional limb. For the reasons provided, the request for myoelectric upper extremity orthosis (1 unit code HCPCS-L3999 upper limb orthosis and 90 days CPT 99201 outpatient office visits) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested device is 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: Physician reviewers number one, two, and three are board certified in physical medicine and rehabilitation 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: An enrollee has requested authorization and coverage for ankle surgery for treatment of the enrollee's ankle pain. Findings:  The physician reviewer found that the documentation provided does not support the requested procedure at this time. Ankle arthrodesis is a common treatment used for patients with end stage ankle arthritis. The surgical goal of ankle arthrodesis is to obtain bony union between the tibia and talus with adequate alignment [slight valgus (0-5)], neutral dorsiflexion, and slight external rotation positions) in order to provide a pain free plantigrade foot for weight bearing activities. This patient describes turning in of the foot and that her foot is painful. However, the documentation available does not include a detailed evaluation of the ankle after the surgery to include radiographic evidence of a solid union and description of the position of the foot. The patient has seen five ankle surgeons for a second opinion, all of whom told her to go back to the initial surgeon. Final Result: The reviewer determined that the requested procedure 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that the medical services provided on the first day were necessary for treatment of an emergency medical condition. The patient presented on the first day with increased back pain, paresthesias and weakness of her legs after a fall. The imaging and evaluation performed on the first day were emergent for evaluation of the patients medical condition. However, the medical services provided for 3 days after were not necessary for treatment of an emergency medical condition. The patients surgery was performed on the second day, 24 hours after the patient presented to the hospital. The surgery at issue did not warrant emergency surgery. The records do not demonstrate that the patient had cauda equina syndrome or other findings supporting emergency surgery. Based on the clinical documentation submitted for review, the services day 2-4 were not emergency medical services.  Final Result: The reviewer determined that the patient received emergency medical services on a portion of the dates of service at issue. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the special blood test CPT code 81422.Findings:  The physician reviewer found that the special blood test, CPT code 81422 performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the American College of Obstetricians and Gynecologists (ACOG) practice bulletin for screening for fetal aneuploidy A microdeletion syndrome is caused by a chromosomal deletion encompassing contiguous genes that is too small to be detected by conventional cytogenetics. Given the rarity of these disorders, it is uncertain what a positive or negative screening test result means. Cell free DNA screening tests for microdeletions have not been validated clinically and are not recommended at this time. For women who wish to know whether their fetus has a microdeletion, the best option is to undergo prenatal diagnostic testing with microarray of fetal cells from [chorionic villus sampling] CVS or amniocentesis. As such, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1,2 & 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: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing care provided. Findings:  The physician reviewer found that skilled nursing care provided was not and is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has function deficits due to a brain tumor (glioblastoma). There is a lack of peer-reviewed literature supporting rehabilitation in this clinical setting. Roberts and colleagues studied intensive rehabilitation for glioblastoma, finding that there was functional benefit but not survival benefit. In this case, the patient has received an adequate trial of skilled nursing care level of care without functional benefit. Thus, the medical documentation provided does not support the medical necessity for continued skilled nursing level of care.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400 mg-100 mg tablets. Findings:  The physician reviewer found that the physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients. Delay in treatment may result in decreased survival. Therefore, Epclusa 400 mg-100 mg tablets are medically necessary for the treatment of this patient. 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.