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 Synvisc One injections. Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Studies concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. Studies conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. In this case, the patient presents with a history of severe bilateral knee osteoarthritis. He has been treated every 6 to 12 months since 2014 with bilateral Synvisc injection series. His last injection series reported 80% improvement in pain and functional benefit allowing him to maintain an active lifestyle. He has requested additional viscosupplementation injections to delay total knee replacements. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given the previous response and to assist in delaying total knee replacement, repeat Synvisc injections are indicated. Therefore, the requested Synvisc One injections are medically necessary for treatment of the patients 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the sestamibi single photon emission computed tomography/computed tomography (SPECT/CT) scan for evaluation of the enrollees multi-nodular thyroid nodule. Findings:  The 3 physician reviewers found that the records provided for review document that the sestamibi SPECT/CT scan was done to help plan the patients surgery. If an adenoma was localized, a minimally invasive procedure would have been performed. Since an adenoma was not localized on imaging, four glands were localized at surgery and the other three were biopsied. Thus, when the study was ordered, it was appropriate. Accordingly, the sestamibi SPECT/CT scan provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the diagnostic procedure 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 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.Physician reviewer number two 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.Physician reviewer number three 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 Cuvitru 10 mg every seven days for treatment of the enrollees non-specified immunodeficiency disorder. Findings:  The physician reviewer found that Selective antibody deficiency with normal serum immunoglobulin concentrations is a deficiency of specific antibody response to polysaccharide antigens with intact response to protein antigens and normal serum level of IgG and IgG subclass. Immunoglobulin replacement therapy with intravenous immunoglobulin (IVIG) or subcutaneous immunoglobulin preparations is a treatment option for this group of patients with recurrent infections that persist after immunizing and providing antibiotic treatment. In retrospective, uncontrolled series of pediatric patients, immunoglobulin replacement therapy led to significant decreases in the number of infections. In these studies, immunoglobulin replacement therapy was discontinued after one to two years, and the antibody-mediated immunity was re-assessed four to six months after discontinuation.   The studies observed that responses to the polysaccharide vaccine sometimes improve after treatment. The mechanisms for this improvement are presently unknown. This patient has normal levels of IgG, IgA and IgG subclasses.  The patient does not have documented evidence of abnormal post-vaccination pneumococcal (polysaccharide) titers.  There is only one set of pneumococcal titer and it is unclear if it is pre or post-vaccine titer.  Furthermore, the patient has been receiving IVIG while these laboratory studies were performed which would affect the validity of the results. The lack of proper immunodeficiency workup including pre- and post-pneumococcal titer is acknowledged by her treating provider in the progress note. However, given that this patient is most at risk for infection in the winter, it is medically necessary to carry out the complete immunodeficiency workup until after the winter season. A complete immunodeficiency workup is required while stopping the therapy. Therefore, Cuvitru 10 mg every seven days is medically necessary for treatment of this 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 allergy and immunology 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 Otezla 30 mg. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The record shows that he has failed therapy with topical agents only (clobetasol cream). The documentation submitted does not demonstrate that he has tried and failed ultraviolet light phototherapy and/or oral systemic agent such as methotrexate, cyclosporine or acitretin, in addition to Enbrel and Humira. The records provided indicated that the patient does not prefer to take immunosuppressing biologic therapy.  There is no medical documentation to support an intolerance or contraindication to the use of methotrexate or acitretin in this patients case. Therefore, Otezla 30 mg is not medically necessary for the treatment of this patients medical condition. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation supports the medical necessity of a portion of the services at issue. Based on the records, a transition from the IOP level of care to the outpatient venue would have been safe and clinically appropriate. Although the patient expressed conviction to handle her pain without opioid medication in mid-October, it does not appear as if she had not consolidated the treatment gains necessary to succeed in the outpatient venue, and service delivery in a less restrictive setting would have been inadequate at that time. However, with continued milieu, medication, group and individual therapies, the patient made steady improvement in the weeks thereafter.  For example, she was noted to have improved ego strength and an enhanced locus of control. She was enjoying her poetry and developing more specific educational plans with a goal of obtaining a masters degree in social work.  She was making clinical progress. She was taking driving lessons and was more hopeful for the future. Her insight was improving. The patients mother attended a session and recognized her need for treatment and was agreeable to making changes to help her daughter.  The patient had a solid therapeutic foundation and was active in her treatment while there was no evidence that she had previously failed coordinated outpatient services. She was stable on psychotropic medications. She was not suicidal, homicidal or psychotic. She was not using opiates or experiencing a protracted withdrawal syndrome. She had a supportive family willing to engage treatment services. All told, IOP services were medically necessary from but not thereafter. Final Result: The reviewer determined that a portion of the services at issue was 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 authorization and coverage for panniculectomy for treatment of the enrollee who has a history of massive weight loss. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity for the requested procedure in this clinical setting. The patient is noted to have a significant lower abdominal pannus secondary to weight loss following bariatric surgery. In this patients case, there is sufficient detail in the medical documentation to support functional impairment related to chronic infection associated with her overlapping lower abdominal skin and pannus. The clinical documentation, including a review of the photographs, support that the likely primary source for this functional deficit is the lower abdominal pannus. Based on the medical documentation and photographs, the abdomen is well supported to be the source of functional problems. With respect to the Health Plans denial that the patients weight has not been stable for six months, the last two office notes do not show an appreciable change in this patients weight (218-221 pounds).  Additionally, although prior to any body contouring procedure a stable weight is recommended, this should not be considered an absolute contraindication to performing surgery.  This patient has evidence of chronic infection that is directly related to the overlapping lower abdominal pannus that would directly be addressed with a panniculectomy.  Therefore, panniculectomy is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure is medically necessary and is 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic test or evaluation of the enrollees pregnancy. Findings:  The physician reviewer found that Per the American College of Obstetrics and Gynecology (ACOG), carrier screening is recommended before or during pregnancy for many autosomal recessive conditions even in the absence of family history. According to ACOG, Screening for spinal muscular atrophy should be offered to all women who are considering pregnancy or are currently pregnant. Moreover, ACOG also recommends cystic fibrosis carrier screening for all women who are considering pregnancy or are currently pregnant. While fragile X carrier screening is usually recommended for women with a family history of fragile X related disorders or intellectual disability suggestive of fragile X syndrome, ACOG states that a patient with no family history may request fragile X screening and it would be reasonable to offer screening after informed consent. Therefore, the genetic test was likely to have been more effective than the standard options available for the evaluation of this patient. Final Result: The 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 reviewer number one is board certified in obstetrics and gynecology 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 obstetrics and gynecology 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 obstetrics and gynecology 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 patient has requested reimbursement for residential treatment center (RTC) services provided. Findings:  The physician reviewer found that on admission, the patient had no withdrawal symptoms and his CIWA was 2. He did not require a detoxification protocol. He was not a danger to himself or others. He was medically and psychiatrically stable. There were no emotional, behavioral, or cognitive factors requiring residential level of care. He was not aggressive, agitated, psychotic or manic, and although he described impulsive behaviors, these did not require 24-hour monitoring in a structured setting. He denied cravings and his levels of depression and anxiety were reported to be moderate. His drinking pattern was not on a daily basis and was of a mild-to-moderate binge nature. He was motivated, cooperative, and engaged in his treatment plan. His risk for relapse and ongoing difficulties with impulsive behavior, depression, and anxiety could have been effectively and safely managed at an ambulatory level of care. For these reasons, the RTC services provided were not medically necessary for treatment of this patients behavioral health condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that the residential treatment center services provided were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, as of the date of service in question, the patient was not in withdrawals, and was not at risk for imminent withdrawals. There was no suicidal, homicidal, or psychotic ideation, and no self-harm behavior. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was medically and psychiatrically stable. His medication assisted treatment was not attempted until later, at which time it was declined. He was motivated and appeared to be working the program. Although he continued to struggle with his emotions, over the course of treatment he became an accepting and participating member of the milieu.  By the date of service in question he could have been stepped down to an ambulatory level of care to work further on relapse prevention and developing coping skills in order to ward off the relapse risks he faced. As such as of the date of service in question, 24-hour supervision at residential level of care was not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Findings:  Three physician reviewers found that the National Comprehensive Cancer Network (NCCN) guidelines do not support the DecisionDx testing for use outside of the clinical trial setting. Moreover, there is a lack of peer-reviewed medical literature demonstrating that the results of the DecisionDx-Melanoma Assay would change the recommended therapy or long-term outcomes. Consequently, the DecisionDx-Melanoma Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 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 for residential treatment center services. Findings:  The physician reviewer found that according to the documentation submitted for review, by the date of service in question, the patient was not at risk for post-acute withdrawal symptoms. The patient was not a danger to himself or others, and he was not violent or aggressive. He showed no self-harm behaviors. There were no emotional, behavioral, cognitive, or impulsive issues requiring residential containment. He was medically and psychiatrically stable. His gout could have been treated on an outpatient basis. He was compliant and engaged in his treatment plan, and he had a sponsor. The patient was at risk for relapse as are all newly sober substance abuse individuals, however this is not an issue which meets criteria to remain in the residential setting. His symptoms of depression, anxiety, guilt and remorse could have been treated on an ambulatory basis, as could the continuation of his work on relapse prevention and the development and solidification of coping skills. This could have been accomplished at lower level of care, with concomitant community support such as a 12 step program and his sponsor.  For the reasons provided, the residential treatment center services provided during the dates of service in question were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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.