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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mental health residential treatment services rendered for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that : The medical literature supports a portion of the services at issue as medically necessary. Prior to admission into the residential treatment facility, the patient had very serious episodes where she would threaten suicide, cut herself, restrict her food and water intake, and act impulsively. She required residential treatment and DBT treatment. During the period from 1/19/15 through 3/31/15, the patient was at times aggressive, throwing objects, defiant, angry, depressed, and impulsive. Based on the documentation, it was unlikely that the patient could have been treated for her symptoms in a less restrictive environment. However, on 4/1/15, the patient improved enough that she could have been managed in a less restrictive environment. The patient had been utilizing her DBT skills and was expressing herself better and not using alarming terms such as suicidal threats to express her feelings. Her provider felt that she was stable and made no medication changes. Her team also felt that she was improving in the ways she was expressing herself. She was utilizing her toolset to manage her emotions. She continued to have episodes of mood lability, but she no longer required 24 hour supervision. Final Result: The reviewer determined that a portion of the services at issue were 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested services for laser hair removal for treatment of the enrollees gender dysphoria. Facial hair removal is within accepted standards of practice, and clinically appropriate for the treatment of gender dysphoria. The patient was born with genetics to grow terminal hair in predominantly male locations.  It would be abnormal for a female to have terminal hair on the face and chest. Facial hair in a female would be considered abnormal and is referred to hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in areas that are normally found in males. This would include the face and chest. A female would be expected to have terminal hair in the scalp, axilla and on the arms and legs and genitalia. The abnormal hair is congenital, in that the hair growth is determined by the genetic and hormonal make-up of the patient. In this patients case, the requested facial hair removal can provide substantial improvement in the appearance or give the patient a normal female appearance to the extent possible. Moreover, the requested services are likely to improve emotional function for this patient. Therefore, the requested laser hair removal is medically necessary and is reconstructive in nature for the treatment of this patients gender dysphoria.Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a wireless capsule endoscopy for evaluation of the enrollees small intestinal ileitis. Findings:  Three physician reviewers found that capsule endoscopy is indicated as per the American Society for Gastrointestinal Endoscopy (ASGE) guidelines to assess for inflammatory bowel disease such as Crohns disease, which is a patchy disease that can involve any portion of the small bowel. In addition, the use of wireless capsule endoscopy was shown in a prospective blinded evaluation to be superior in its ability to detect small bowel pathology missed on small bowel radiographic studies and computerized tomography (CT) radiographic examinations. Final Result: Three reviewers determined that the requested diagnostic procedure is 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 physician reviewers 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who presented for a breast screening mammogram.Findings:  Two physician reviewers found that this tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Final Result: Two reviewers determined that the service 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 overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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 the Decision Dx melanoma gene expression profile test for evaluation of the enrollees malignant melanoma. Findings:  Three physician reviewers found that the Decision Dx melanoma assay was developed from profiles of ocular melanoma samples and it is not clear that cutaneous melanoma behaves in the same manner to support a similar outcome. In addition, the National Comprehensive Cancer Network (NCCN) diagnostic and treatment guidelines indicate that this type of genetic testing should not be used outside of a clinical trial. Overall, the Decision Dx melanoma assay is not considered standard of care or part of the work-up for patients with melanoma. Final Result: 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: All three physician reviewers 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center from 11/1/16 forward. Findings:  The physician reviewer found that the patient had finished detoxification and did not have any severe acute post withdrawal symptoms. There was no evidence that on 10/31/16 the patient had any suicidal or homicidal thoughts. The patient did not have any mania or psychosis. The patient was calm and cooperative with treatment. She did not have any aggression and was compliant with her medications. She did not have any medical problems that would require 24-hour care. She was able to perform her activities of daily living. There is a chronic risk for relapse, but she had progressed enough to be treated in a lower level of care and no longer required 24-hour supervision. In group therapy notes, the patient reports that she feels that she is able resist temptations to use substances. The patient does have some ambivalence about behavior change, but she no longer requires 24-hour supervision. The patient continues to require treatment for her substance use problems, but the patient has improved enough to be discharged to a less restrictive environment such as a partial hospitalization program. Final Result: The reviewer determined that 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 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 Synagis injections for treatment of the enrollees hypoplastic left heart syndrome, cerebral palsy, and pulmonary hypertension. Findings:  The physician reviewer found that the use of Synagis in this patient is not medically necessary. The use of Synagis has remained under strict criteria so that its use maximizes patient benefit and efficacy while not being overused. The most widely accepted guidelines for the use of Synagis are published by the American Academy of Pediatrics (AAP) Committee on Infectious Diseases and Bronchiolitis Guidelines Committee, and were last updated in 2014. These guidelines indicate there is no established role for RSV prophylaxis after 24 months of age for any patient regardless of any risk factors. The majority of hospitalizations that occur due to RSV are within the first three months of life and are most associated with prematurity. At this time, Synagis is only indicated in children under two years of age regardless of the presence of chronic heart, lung, or immune system disease. This prophylactic measure is not medically indicated for this patient. Therefore, the requested Synagis injections in this patient are not medically necessary. 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 pediatrics with sub-specialty certification in pediatric infectious 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  The 3 physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records document dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, digital breast tomosynthesis performed was likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: The 3 reviewers determined that the service 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 overturned. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing for evaluation of the enrollees colon cancer. Findings:  2/3 of the physician reviewers found that Oncotype DX Colon Cancer Assay has been shown to have prognostic value, but to date has not shown predictive benefit of standard chemotherapies.  At this time, information is lacking regarding the extent to which assay results do or do not classify patients into distinct groups with clinical relevance.  National Comprehensive Cancer Network guidelines state that there are insufficient data to recommend the use of multi-gene assays, such as the Oncotype DX assay, to determine adjuvant therapy.  The services at issue were not likely to be more beneficial than using standard risk factors to determine the need for chemotherapy.  Therefore, gene testing performed was not likely to have been superior over other methods of evaluating this patient. Final Result: 2/3 of 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 hair removal.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The primary care provider ordered a serum testosterone level which was normal.  The patients facial hair does not constitute an abnormal structure of the body.  There is no documentation of impaired functioning due to this benign condition.  The requested hair removal is not expected to provide more than a minimal improvement in the patients appearance. Final Result: The reviewer determined that the requested services are not reconstructive in nature and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for home oxygen for treatment of the enrollees obstructive sleep apnea (OSA) and hypoxemia. Findings:  The physician reviewer found that the records indicate that this patients OSA has been treated with CPAP. There is no oximetry on CPAP demonstrating hypoxia. Also, there is no documentation of a portable O2 system and the patients chest was noted to be clear on room air during multiple office visits. She does not have a history of smoking, chronic obstructive pulmonary disease (COPD), or interstitial lung disease. The right to left shunt was calculated as 3.6% but the most recent O2 saturation on room air was 97%. Overall, she does not meet the criteria of persistent O2 saturation of 88% or lower and her OSA has been treated with CPAP. All told, the requested home oxygen is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer 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 internal medicine with sub-specialty certification in pulmonary 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  The 3 physician reviewers found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breast tissue was heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, bilateral digital breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.  Final Result: The 3 reviewers determined that the service 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 overturned. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.