Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for a dental procedure (D7953) performed on 11/30/16 for treatment of the enrollees dental condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. D7953 is a benefit to rebuild the bone after an extraction. This patient presented with a dehiscence or cleft in the bone of the tooth socket at extraction, with periodontal probe depths of 6 to 11 mm.  In this setting of loss of bone as described, the literature shows a bone graft to be an effective means of preserving or restoring the bone to the extraction site to allow placement of an implant.  The documentation indicates that implant support may have been compromised without the procedure. Therefore, dental procedure (D7953) performed on 11/30/16 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 dentistry 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 female enrollee has requested authorization and coverage for Linzess for treatment of the enrollees constipation and bloating.Findings:  The physician reviewer found that Linzess is indicated to restore colonic function in chronic constipation. This medication is U.S. Food and Drug Administration (FDA) approved for chronic constipation. It has a different mechanism of action than osmotic laxatives, and can be effective even if those have failed. In multicenter, randomized, blinded, placebo-controlled, phase III clinical trials, Linzess significantly increased weekly spontaneous bowel movements while reducing abdominal pain in patients with chronic constipation.  In this case, the patient reports failure of two formulary alternatives, lactulose and polyethylene glycol.  Additionally, she reports a valid contraindication to the alternative Amitiza, which has a warning regarding syncope in the package insert.  For these reasons, Linzess is 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 58-year-old female enrollee has requested authorization and coverage for removal of the enrollees left breast implant for treatment of the enrollees chest pains.Findings:  The physician reviewer found that based on the medical documentation provided for this review, it is not clear if the left breast implant is the source of her pain.  The patient does not have evidence of significant capsular contracture, infection or other process related to her implants that is the likely cause of her pain.  There is no medical indications for explantation of her implants. Therefore, it is unlikely that left breast implant removal would resolve or improve her functional complaint of pain. Although capsular contracture can cause pain and can be an indication for implant removal, the medical documentation does not support that this is present for this patient.  As such, implant removal would not likely address her functional complaint of pain. Therefore, left breast implant removal is not medically necessary for treatment of this patients medical condition. 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 29-year-old female enrollee has requested authorization and coverage for eye movement desensitization reprocessing (EMDR) for treatment of the enrollees post-traumatic stress disorder (PTSD). Findings:  The physician reviewer found that The patient has not demonstrated evidence of danger to self or others. She endorsed decreased anxiety and depression, improved sleep and appetite, her nightmares had ceased, and she had returned to work. She was learning coping skills to deal with others and move forward. She completed group therapy on 8/24/17. Overall, the records do not demonstrate the symptom complex of PTSD. All told, the requested EMDR is not medically necessary for treatment of this patients behavioral health issues. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the implantable ambulatory event monitor for evaluation of the enrollees atrial fibrillation. Findings:  The physician reviewer found that based on the records provided the patient is a 67-year-old female with a history of symptomatic paroxysmal atrial fibrillation. In this setting of symptomatic atrial fibrillation manifested by frequent palpitations identification of cardiac rhythm during symptoms should be able to be effectively accomplished by off-line monitoring devices such as serial Holter monitors, patient-activated event monitors or auto-triggered event monitors. The records provided do not indicate the patient is unable to manage these devices or that these devices have been tried and failed. Implantable loop recording to monitor for symptomatic atrial fibrillation in this setting has not been shown to improve cardiac outcome incremental to that achievable with offline monitoring devices. For the reasons provided, the implantable ambulatory event monitor 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 device 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 reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 Epclusa 400/100 for eight weeks for treatment of the enrollees hepatitis C virus.Findings:  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 for 12 weeks is recommended as first line therapy for treatment naive, genotype 2 patients. This recommendation is based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. However, eight weeks of therapy, as requested in this case, is not recommended.  For these reasons, the request for Epclusa for eight weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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: A male enrollee has requested authorization and coverage for IgE testing (CPT code 82785) and positron emission tomography/computed tomography (PET/CT) of the whole body (CPT code 78816)  for evaluation of the enrollees T-cell lymphoma. Findings:  The physician reviewer found that Serum IgE is a test for a quantitative level of a naturally occurring antibody that can be markedly elevated in patients with T-cell lymphoma along with eosinophilia. This may be diagnostic of a distinct disease with overlap between myeloproliferative disorder and T-cell lymphoma. The test for serum IgE is considered a routine part of the work-up of patients with cutaneous lymphoma. In addition, the requested whole body PET/CT scan to properly stage the patient is supported as medically necessary in this clinical setting. PET/CT scans are indicated to stage patients at initial diagnosis and before the start of systemic therapy. These imaging studies are also indicated to assess the effects of systemic therapy. All told, the requested IgE testing (CPT code 82785) and PET/CT of the whole body (CPT code 78816) are medically necessary for evaluation of this patients cutaneous T-cell lymphoma. Final Result: The reviewer determined that the requested diagnostic procedures are 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 internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for one-on-one discrete trial training (applied behavioral analysis (ABA) services), 12 hours per week, and one-on-one monthly onsite supervision for parents 10 hours per month for treatment of the enrollees medical condition. Findings:  The physician reviewer found that based on the clinical documentation provided for review, the diagnosis of autism spectrum disorder has not been established. An in-Plan evaluation by a developmental pediatrician assessed the patient with expressive language delay. The patients out-of-Plan assessment noted a diagnosis of autism disorder based on DSM-4 criteria. An in-Plan evaluation was negative for autism. The patients parent report tantrum and non-compliance behaviors. However, these behaviors are not sufficient to support a diagnosis of autism. Given the lack of sufficient support demonstrating a diagnosis of autism spectrum disorder, the request for one-on-one discrete trial training ABA services, 12 hours per week, and one-on-one monthly onsite supervision for parents 10 hours per month are not 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-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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 66-year-old male enrollee has requested authorization and coverage for surgery to fuse back bones (lumbar spinal fusionfor treatment of the enrollees lower back pain. Findings:  The physician reviewer found that The submitted documentation supports the requested services in this patients case. This patient presents with a one year history of progressively worsening low back pain and neurogenic claudication. Significant functional difficulty is documented in ambulation and standing tolerances. He is status post L4-S1 lumbar instrumented fusion in 2013. Evidence of long-term reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. This patients symptoms are consistent with imaging evidence of moderate to severe central canal narrowing and severe bilateral lateral recess narrowing with potential impingement on the bilateral L4 nerve roots. There is imaging evidence supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Removal and replacement of the existing L4-S1 hardware would be supported with extension of the fusion to L3. The current medical evidence supports the requested services in this clinical setting. All told, the requested surgery to fuse back bones (lumbar spinal fusion) is 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the computer-assisted musculoskeletal surgical navigation system used during knee replacement surgery for treatment of the enrollees left total knee arthroplasty. Findings:  Two physician reviewers found that there is sufficient support in the peer-reviewed literature for the service at issue in this clinical setting. The study analyzed data from the Australian Orthopaedic Association National Joint Replacement Registry to examine the effect of computer navigation on the rate of revision of primary total knee arthroplasty. The authors concluded that Computer navigation reduced the overall rate of revision and the rate revision for loosening/lysis following total knee arthroplasty in patients less than sixty-five years of age. Thus, the use of computer navigation in total knee arthroplasty when utilized by a surgeon skilled in the use of that technology is likely to be beneficial, particularly in a patient younger than 65 years of age. For the reasons provided, the computer-assisted musculoskeletal surgical navigation system used during knee replacement surgery was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: the reviewers determined that the service 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: Reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lap-band removal and gastric bypass surgery for treatment of the enrollee, who is status post Lap-band placement. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. The Lap-band is a mechanical device which has a high explant rate secondary to complications related to the device, failure of the device to result in intended weight loss and/or intolerance to the device. This patient has worsening gastroesophageal reflux disease.  Per the medical records, she requires Lap-band removal to prevent secondary complications of prolapse, erosion and slippage. Therefore, the requested Lap-band removal is medically necessary for the treatment of this patient.  However, the medical necessity of gastric bypass surgery cannot be determined at this time. There is a lack of documentation of a recent multidisciplinary evaluation, including a detailed dietary evaluation, documentation of understanding of micronutrient deficiencies, as well as a psychological evaluation that documents understanding of revisional surgery and increased risks. At this time, the records do not document complications of the Lap-band that require emergent surgical intervention with conversion to gastric bypass that would preclude completion of an updated multidisciplinary evaluation. The last evaluation was completed prior to the Lap-band 7 years ago. There is no record of either the original multidisciplinary evaluation or an updated multidisciplinary evaluation specifically in regards to this patient as a candidate for revisional surgery. Therefore, the requested gastric bypass surgery is not medically necessary for the treatment of this patient. All told, a portion of the requested services (Lap-band removal) is 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 with expertise in bariatric 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 female enrollee has requested authorization and coverage for Synvisc One injection for treatment of the enrollees osteoarthritis of the left knee.Findings:  The physician reviewer found that current evidence-based guidelines and literature support repeated cycles of viscosupplementation treatment to delay time to total knee replacement in patients with knee osteoarthritis who failed conservative treatment. There is no maximum amount of injections established by high-quality scientific evidence. This patient presents with a history of left knee osteoarthritis. Functional difficulty has been documented in prolonged weight-bearing and with stairs, squatting, and getting up from a low sitting position. Conservative treatment has included exercise, corticosteroid injections, physical therapy, and medications. She has undergone prior Synvisc injections, with good benefit reported. The current medical evidence supports the requested service in this clinical setting.  All told, the requested Synvisc One injection is medically necessary for the treatment of this patient. 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 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.