Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay.Findings:  Three physician reviewers found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for patients with high depth of invasion, 0.76 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx-Melanoma assay for melanoma has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma assay was not likely to have been of greater benefit than other methods of 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for genetic testing.Findings:  Two of the three physician reviewers found that according to the patients medical records, MMRpro model predicted a significantly high likelihood of having a Lynch syndrome related mutation. The records document the likelihood of any Lynch syndrome related mutation. However, it is not clear which data was used calculate this risk. These risk calculations are not consistent with the patients family history. Per the records, this patient was diagnosed with cancer when she was older than years of age, and she had one second-degree relative who had cancer. According to evaluation using PREMM5 model, the patients likelihood of having a Lynch syndrome mutation was only approximately %. The medical evidence supports testing when the risk is greater than 5% or when the tumor shows microsatellite instability, which this patients tumor did not. Thus, genetic testing was not likely to have been more effective than other methods of evaluating this patient.Final Result: The reviewers determined that the services at 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 reviewer 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 3 is board certified in clinical genetics and genomics and is 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

An enrollee has requested hyperbaric oxygen (HBO) therapy. The submitted documentation does not support the medical necessity of the requested services. The patient has had long-standing progressive hearing loss and tinnitus. The evidence for HBO therapy has been limited to small case series from Europe and Asia, with very little evidence from well-controlled studies in the United States. The evidence for HBO therapy is based on its possible effect on sensorineural hearing loss, as referenced by colleagues. However, this evidence points to the necessity of very early (less than 14 days from onset of hearing loss or tinnitus) intervention with hyperbaric oxygen, as noted by colleagues. In this case, HBO therapy has been requested years after the patients CVA and would be undertaken months after the patients audiogram. Given its current limited evidence based support in the medical literature, and the fact that HBO therapy would be distant in time from the onset of hearing loss or tinnitus, the requested HBO therapy is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested therapy 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 otolaryngology 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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Prolia. The submitted documentation does not support the medical necessity of the requested medication. Biophosphonates are considered first-line treatment for osteoporosis in most women. Prolia is relatively safe, but there is no long-term safety data at this time, as opposed to bisphosphates, which have been used for years. Prolia has the risks of hypocalcemia, osteonecrosis of the jaw, atypical femur fractures, and serious infections. Denosumab is an alternative to IV zoledronic acid for women at high risk for fracture, difficulty with the dosing requirements of oral bisphosphonates, and who prefer to avoid intravenous bisphosphonates due to side effects, or who have chronic kidney disease.In this case, the patient has a history of normal kidney function and no pending dental issues. The records fail to demonstrate any gastrointestinal symptoms or inability to take oral bisphosphonates. There is no history of contraindication to bisphosphonates or chronic kidney disease. Given the patients history, the current guidelines would recommend oral bisphosphonates. Reclast or zoledronic acid is preferred if oral bisphosphonates cannot be tolerated. Prolia would not be recommended as an alternative in her case. The records fail to demonstrate any contraindication to oral bisphosphonates or IV bisphosphonates. Under these circumstances, Prolia is not medically necessary for treatment of the 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 internal medicine, with subspecialty certification in rheumatology, 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 endoscopic plantar fasciotomy and micro revision of the calf tendon. The submitted documentation supports the medical necessity of the requested services. Plantar fasciotomy is offered to patients with recalcitrant plantar fasciitis. Endoscopic plantar fasciotomy and gastrocnemius recession/revision of calf tendon have become the surgical standard of care after the failure of conservative treatments for plantar fasciitis. In this case, the patient has recalcitrant plantar fasciitis. The submitted documentation reflects that the patient has tried and failed numerous conservative treatments, including physical therapy, icing, shoe gear modification, custom foot orthotics, anti-inflammatory medications, boot immobilization, night splinting, and stretching. Under these circumstances, the requested endoscopic plantar fasciotomy and micro revision of the calf tendon are medically necessary to treat 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 podiatry 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

An enrollee has requested authorization and coverage for the medication Copaxone. The submitted documentation supports the medical necessity of the requested medication. Colleagues conducted a systematic review of the clinical effectiveness of glatiramer acetate (Copaxone) and found that Copaxone has fewer side effects and has a demonstrated benefit in the treatment of multiple sclerosis. They concluded that compliance with treatment is critical for the best outcome of treatment. They also concluded that Copaxone is an effective treatment for multiple sclerosis due to its side effect profile being better than comparable treatments.In this case, the submitted records reflect that the patient has done well clinically with Copaxone. Copaxone is a Food and Drug Administration (FDA) approved treatment for MS. As noted above, Copaxone has been identified as having a side effect profile that is better than comparable treatments for multiple sclerosis. Concern has been raised about the side effect profile in a generic version of Copaxone, as biologics may differ in physical activity and chemical structure, despite being generic or biologically similar in classification. As such, compliance with any new therapy is unlikely and may lead to poor response and possible failure, if such treatment is instituted. Under these circumstances, Copaxone is medically necessary for the 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 neurology, with subspecialty 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Intensive Outpatient Program (IOP) services. In cases such as this, an evidence-based, objective, instrument such as the Level of Care Utilization System (LOCUS) is indispensable in determining the necessary and appropriate level of care for adults to ensure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. Using LOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include (1) risk of harm, (2) functional status, (3) medical, addictive and psychiatric comorbidity, (4) recovery environment (a. stressors and b. supports), (5) treatment and recovery history, and (6) engagement. The composite score is then used to determine the level of care needed.Using the six LOCUS dimensions to determine the necessary level of care for the patient during the period in issue, the patient had no risk of harm, as evidenced by the lack of current suicidal ideation (score=1). She demonstrated a fairly functional level in school (score 2-3). There were no recent substance issues and she was overall medically stable with no acute co-morbidities (score=2). The records indicated she had a stable living environment (score=2) and a supportive recovery environment (score =2). The patient demonstrated moderate levels of response to treatment (score =3). She demonstrated good cooperation with the treatment (score=2). Thus, the patient had a composite score of 14-15. This score correlates with a treatment intensity level of two, which is low-intensity, community-based services. It indicates that the patient could have safely been treated in a less restrictive setting during the period in issue. Therefore, the Intensive Outpatient Program (IOP) services provided during the period in issue 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 subspecialty certification in child and adolescent 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

An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The submitted documentation supports the medical necessity of the services at issue and the requested services. The American Psychiatric Association (APA) guidelines for major depressive disorder note that admission to an intensive day program may be indicated for severely ill patients who lack adequate social support outside of a hospital setting, who have complicating psychiatric or general medical conditions, or who have not responded adequately to outpatient treatment. The APA treatment guidelines for substance use disorders recommend that care higher than outpatient 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 and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.In this case, the patient stated that he was, [G]ood at covering his depression until it was too late and reached a crisis point, thereby indicating that he was not able to manage his depression without support and guidance. The patient also stated that cannabis took over his life. The patient indicated that he was concerned about his depression and how it led to cannabis use. He also acknowledged that cannabis use then worsened his depression. He explained that he wanted to be able to maintain self-control, i.e. not use drugs, at moments of peak crisis. The patient improved with intensive outpatient services three times a week, but he was at times teetering, given the severity of his illness and the poor quality of his support outside. Accordingly, the IOP services that the patient received were in accordance with generally accepted standards of medical practice and were clinically appropriate for his illness. Under these circumstances, the intensive outpatient program (IOP) services provided to the patient were and are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and the requested services were and 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 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 reimbursement for Residential Treatment Center (RTC) services. The submitted documentation supports the medical necessity of the services at issue. An RTC is considered a medical intermediate-level institution that is designed to provide psychosocial and/or educational rehabilitation. Dialectical Behavior therapy for PTSD within an RTC program has promise for reducing chronic PTSD that is related to childhood sexual abuse. The American Psychiatric Associations Practice Guidelines for The Treatment of Patients With Borderline Personality Disorder note that the indications for partial hospitalization (or brief inpatient hospitalization if partial hospitalization is not available) include dangerous, impulsive behavior that is unable to be managed with outpatient treatment, complex comorbidity that requires more intensive clinical assessment of response to treatment, and symptoms of sufficient severity that are unresponsive to outpatient treatment. RTC services fall within the spectrum from partial hospitalization to inpatient hospitalization.In this case, the patients low self-esteem, instability, impaired functioning in moving her life along, paucity of healthy interpersonal relationships, labile mood, and impulsivity as characterized by multiple suicide attempts indicate a likely additional diagnosis of Borderline Personality Disorder. The patient required a safe and stable living environment in order to develop her recovery skills. Given the severity of the patients illness, the RTC services at issue were in accordance with generally accepted standards of medical practice and were clinically appropriate for the patient's illness. Accordingly, the RTC services at issue were medically necessary to treat the patients medical condition.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the transportation services. The Health Plan has denied the services at issue as not medically necessary. Findings:  The physician reviewer found that the current evidence-based medical literature recommends non-operative treatment of acute shoulder dislocations in older patients, as well as younger patients not requiring extensive overhead use. A short period of rest and immobilization followed by activity modification and physical therapy is indicated for most patients in order to avoid unnecessary procedures. In this case, the patient sustained a left shoulder dislocation injury due to a fall while out of the country. He was evaluated in the local emergency department and diagnosed with a displaced comminuted anterior glenoid fracture. He was placed in an immobilizer and was advised that surgical treatment was indicated within a three-day window. He opted to return to the U.S. for evaluation and treatment. The patient secured commercial airline transportation. He was subsequently evaluated by the provider who recommended conservative treatment. Given the standard of care for this patients medical condition, the earlier return flight was not indicated and would not have changed the patients course of treatment. Accordingly, the transportation services 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.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Relpax. The Health Plan indicated that the eletriptan may be considered for approval after a trial and inadequate response or intolerance to both generic Imitrex and generic Amerge.Peer-reviewed publications support Relpax for abortive treatment of migraine headaches. A.A. indicated that Relpax was approved by the Food and Drug Administration (FDA) and is used for the abortive treatment of migraine headaches. Studies noted that Relpax was approved by the FDA and is used for the abortive treatment of a migraine headache. It is recommended to be used up to two times per week.  The medical records document headache frequency, severity, and associated signs and symptoms with demonstration of a diagnosis of migraine headaches. With a demonstrated diagnosis of migraine headaches, Relpax is supported as medically necessary for the patients medical condition and therefore, the Health Plans denial should be overturned.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 neurology with subspecialty 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.