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 en bloc capsulectomy, testing to rule out breast implant-associated anaplastic large cell lymphoma and dual pedicle mastopexy. This patient has a history of Lynch syndrome which places her at a high risk of cancer.  The records document painful, severe capsular contractures. Appropriate intervention in this setting includes bilateral capsulectomy and implant removal, as this is likely to effectively treat her condition. These services are likely to address the patients functional concerns. Thus, the requested en bloc capsulectomy is medically necessary for the treatment of this patient.The requested testing to rule out breast implant-associated anaplastic large cell lymphoma is also medically necessary. The decision to analyze for breast-implant associated anaplastic large cell lymphoma would be an intraoperative decision, based on the appearance of the capsule and if there is any surrounding peri-implant fluid that may not have shown up on MRI. Thus, it is medically necessary to rule out this condition in the operative treatment. Cosmetic surgery is performed to enhance normal structures. The mastopexy, following treatment of capsular contracture, is considered cosmetic intervention. Therefore, the requested dual pedicle mastopexy is not medically necessary. The patients condition does not constitute an abnormal structure of the body. Grade II breast ptosis in the absence of functional impairment is not considered an abnormality, but rather is based on normal aging and weight gain/loss. Therefore, the requested dual pedicle mastopexy is not medically necessary and is not reconstructive in nature.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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for AmniSure testing.Findings:  Three physician reviewers found that the services in issue were not indicated under these circumstances. The determination of ROM during pregnancy is very important to determine next steps in management. In clinical practice, the diagnosis of rupture of membranes can sometimes be difficult and equivocal. The American College of Obstetricians and Gynecologists (ACOG) has noted that several commercially available tests for amniotic proteins are currently on the market, with high reported sensitivity for premature rupture of membranes (PROM), however, false-positive test result rates of 1930% have been reported in patients with clinically intact membranes and symptoms of labor. The standard of care usually includes a review of the patient's history and clinical exam, including a sterile speculum exam (SSE). If those findings are inconclusive, additional testing can be used. However, in this case, there is no documentation that a SSE was performed or reviewed before ordering the AmniSure test. Under these circumstances, the AmniSure testing that was performed was not more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services in issue were not likely to be more beneficial for treatment 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation. The submitted documentation supports the medical necessity of the services at issue. The records document severe depression. The patient does not appear to have any comorbid substance abuse or personality disorders. The evidence base for transcranial magnetic resonance has grown over the past several years. There is supporting evidence in the literature that numerous medication trials do not often yield higher levels of success. This patient has failed multiple medication trials in the past. Due to the patients level of depression and lack of response to antidepressant treatment, transcranial magnetic stimulation was medically appropriate. Therefore, transcranial magnetic stimulation 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 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 authorization and coverage for tofacitinib (Xeljanz) . The submitted documentation supports the medical necessity of the requested medication. Alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of which includes eyebrows, eyelashes and facial hair. Other autoimmune diseases are also linked. Treatment is challenging and aims at the regrowth (reconstruction) of hair. Although not life threatening or painful, its onset and erratic nature disturbs the lives of many.   Therefore, the use of tofacitinib (Xeljanz)  is scientifically justifiable for standard treatment resistant cases like this, and it is supported by medical literature and studies. Accordingly, under the present circumstances, tofacitinib (Xeljanz)  is medically necessary for treatment of the patients medical condition.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 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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services. The current medical evidence supports the services at issue in this clinical setting. The American Psychiatric Association treatment guidelines indicate that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, who lack sufficient social and vocational skills, and who lack substance-free social supports to maintain abstinence in an outpatient setting. Patients requires safe and stable living environments in order to develop their recovery skills. The submitted documentation supports residential treatment in this clinical setting. Residential treatment was in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. Per the records, the patient could not have been safely and effectively treated at a lower level of care. Therefore, residential treatment services were 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 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: An enrollee has requested reimbursement for a FoundationOne genetic assay.Findings: Two of the three physician reviewers found that the FoundationOne genetic assay was not indicated under these circumstances. It has not been established if molecular markers are useful in treatment determination (predictive markers) and prognosis other than for KRAS, NRAS, and BRAF mutation testing and Microsatellite Instability (MSI) or Mismatch Repair (MMR) testing. This is supported by both the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) Guidelines. Multiple clinical trials that are attempting to validate this personalized or precision medicine approach are in various stages of development and execution. Although preliminary data from some of these efforts have fueled excitement about the value and utility of these studies, their execution has also provoked many questions about the best way to approach complicating factors such as tumor heterogeneity and the choice of which genetic mutations to target. To date, it is unclear if molecular profiling is beneficial in identifying potential targets for treatment. It is also unclear, if targets are identified, whether targeted treatment is beneficial. Accordingly, the FoundationOne genetic assay provided to the patient was not likely to be more beneficial than any available standard therapy for the patients medical condition.Final Result: Two of the three reviewers determined that the services in issue were not likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in internal medicine, with subspecialty certification in medical oncology, and all three are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for OxyContin 20 mg ER tablets (60 per 30 days). The submitted documentation fails to demonstrate the medical necessity of the requested medication. She has tried and failed Ultram in the past. Thus, tramadol extended-release is not medically reasonable. However, fentanyl transdermal patches are a medically reasonable treatment option. While the Centers for Disease Control and Prevention has recommended tapering patients off opiates for non-cancer pain, this patient has opiate responsive pain, and a trial of fentanyl transdermal patch is medically appropriate. Therefore, OxyContin 20 mg ER tablets (60 per 30 days) is not medically necessary for the treatment of this patient.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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 testing. Findings:  The physician reviewer found that Molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network guidelines recommend broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. In sum, Guardant360 testing was likely to have been superior over other available methods of evaluating this patient. Final Result: Two of three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a laminotomy procedure. The submitted documentation supports the medical necessity of the services in issue. Studies show that conventional spinal decompression surgeries continue to be reliable treatments for symptomatic lumbar stenosis that is refractory to conservative management. In this case, the laminotomy performed at L5-S1 was made necessary by the presence of nerve root compression that required a decompressive procedure for adequate visualization and decompression of the nerve roots. In addition, there was a synovial cyst present at that level which needed exposure for an adequate resection. As such, the laminotomy at L5-S1 was reasonable, appropriate, and medically necessary. Accordingly, the laminotomy procedure was medically necessary for treatment of the enrollees medical condition.Final Result: The reviewer determined that the services in 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the head. Findings:  The physician reviewer found that in this case, the patient has a remote history of a traumatic brain injury (TBI). It is not explicitly noted if the patient has previously undergone MRI, but it can be inferred that neuroimaging would have taken place in the setting of his having undergone arteriovenous malformation (AVM) repair in the past. There is no mention of any abnormalities identified on prior imaging, outside of the AVM which was surgically corrected. Current practice guidelines indicate that there is not a clinical benefit from the performance of imaging in the setting of a chronic TBI unless there is evidence of new, persistent, or worsening symptoms in subacute to chronic TBI. This is because only then are MRI changes clinically meaningful. In this case, the patient is not noted to have had any new, persistent, or worsening symptoms in subacute to chronic TBI. The patient is also noted to have a seizure disorder which is well controlled on his current treatment regimen of Keppra. In general, neuroimaging is not performed in patients with a stable neurological disorder/seizure disorder, given the lack of clinical utility and a lack of meaningful changes in management. In this case, the records provided for review do not demonstrate any worsening of the patient's neurological condition. Nor is there any evidence of an acute new focal finding for which imaging would lead to a change in management or clinical care. Therefore, the provision of MRI of the brain in this setting is not medically necessary.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 neurology 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 fecal DNA gene testing. Findings: Three physician reviewers found that the evidence of the impact of Cologuard on patient care or health outcomes is lacking There is no empirical data on the appropriate longitudinal follow-up for an abnormal FIT-DNA test result followed by a negative colonoscopy; there is potential for overly intensive surveillance due to clinician and patient concerns about the implications of the genetic component of the test. Health outcomes using Cologuard have not been compared over the long-term with other screening methods for colon cancer. For these reasons, fecal DNA gene testing was not likely to have been more effective than other modalities for evaluating this patient. 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: Physician reviewers 1, 2 and 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Myomo (MyoPro) Motion-G elbow-hand orthosis.Findings:  Three physician reviewers found that the requested device is not indicated under these circumstances. The medical literature regarding this type of device is limited to preclinical work, developmental work, and small anecdotal reports of potential for benefit, some of which is industry-sponsored work. While this type of device can provide some functional benefits theoretically, it is not known whether users will adopt the device for regular functional use in the long-term (i.e., for use beyond the short-term as a novelty device), or if the device itself causes injuries with long-term use (e.g., at the shoulder due to the devices not insignificant weight). Many commercially available iterations of this type of device remain heavy, bulky, difficult to don, and difficult to use on a practical basis. It is unknown whether the requested device would exacerbate arm lymphedema or the constant neuropathic pain that this patient has and uses opioid analgesics to manage. Further study of an unbiased nature is required to better understand adoption of the device into actual functional use outside of research settings, and to establish safety. Although the patient has severe impairments that are not expected to improve with any further conventional management, the requested device is not reasonably expected to favorably impact the enrollees long-term clinical or functional outcomes. Therefore, the requested device is not likely to be more beneficial than any available standard treatment for the patients medical condition.Final Result: The reviewers determined that the requested device is not likely to be more beneficial for treatment 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 physical medicine and rehabilitation 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: A 41-year-old female enrollee has requested authorization and coverage for total hip arthroplasty. Review of the submitted documentation supports the medical necessity of the requested total hip arthroplasty. The patient underwent a sacroiliac joint injection for ankylosing spondylitis on the right side but continues to have pain. The radiology findings have included moderate osteoarthritis with high-grade chondromalacia of the weight bearing surfaces of the hip joint, subarticular cyst formation and marginal osteophytes. The clinical presentation is severely disabling. According to the patients provider, she has painful motion with significant restriction of motion and an antalgic gait. The patient has failed non-operative treatment and is in need of a total hip arthroplasty. Her difficulty with activities of daily living and inability to get out of bed at times are indications for a total hip arthroplasty. As the citations referenced above indicate, a significant number of total hip arthroplasties are approved for patients in the younger age group when other indications are present; such is the case with this patient. Younger age is not an absolute contraindication to total hip arthroplasty. Based upon the severity of the patients presentation, the requested total hip arthroplasty is medically necessary for treatment of her medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.