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

An enrollee has requested reimbursement for bilateral MRI of the breast. This patient underwent diagnostic mammography with breast ultrasound for clinical findings and dense breasts with architectural distortion. Since the diagnostic mammogram was inconclusive, the provider recommended a breast MRI. Inconclusive mammography is one of the recognized indications for breast MRI. Breast MRI has been shown to be more sensitive than mammography and was indicated to assist in identification of a lesion for biopsy. With a complicated physical examination and inconclusive mammogram, MRI was appropriate in guiding clinical recommendations for this patient. Therefore, the bilateral MRI of the breasts was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.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 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

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential services for some of the dates at issue. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Applying ASAM criteria, the patient demonstrated post-acute withdrawal as evidenced by Clinical Institute Withdrawal Assessment (CIWA) scoring with an elevated blood pressure, paroxysmal sweats, and tremor. Subsequent CIWA scores over the next few days were primarily positive for anxiety symptoms. The patient was noted to have attention deficit hyperactivity disorder (ADHD), but he did not undergo formalized testing or treatment for this diagnosis during his stay. As the patients vital signs stabilized, the records do not support the medical necessity of the services provided after that date. All told, a portion of the RTC services at issue was medically necessary for treatment of this patient.  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 with expertise 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for wireless capsule endoscopy. This patient has symptoms consistent with possible Crohns disease. Upper endoscopy and colonoscopy with biopsies have been performed, but most of the small bowel has not been evaluated. Capsule endoscopy is useful for the diagnosis of Crohns disease or determination of the extent of disease activity, and is superior to radiographic imaging tests such as small bowel follows through. Capsule endoscopy has proven to have a superior yield of data compared to all current forms of radiological testing of the small intestine. For these reasons, the requested wireless capsule endoscopy is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are 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 subspecialty 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested reimbursement for posaconazole 300 mg by mouth daily for 30 days. This patient has a history of cough, shortness of breath, rhinitis, and chronic maxillary sinusitis. Posaconazole is reserved for invasive fungal sinusitis, which generally occurs in severely immunocompromised patients. The medical literature does not support the use of posaconazole for patients with mild CT findings and no invasive fungal disease. Rare fungal elements are normal on sinus cultures and are found in over 90% of patients when the culture is properly performed, and this does not require treatment with posaconazole. All told, the posaconazole 300 mg by mouth daily for 30 days, was not medically necessary for treatment of this patient.Final Result: The reviewer determined that the medication at issue was 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

The patient has requested reimbursement for intraoperative radiation therapy. Intraoperative radiation therapy is a type of accelerated partial breast irradiation that condenses the entire therapeutic dose into a single fraction, permitting surgery and radiation to be completed in one day. The potential advantages include accurate delivery of radiation therapy directly to the surgical margins and a decreased dose of radiation to skin and subcutaneous tissue. Potential drawbacks include extended time in the operating room, the inability to verify the radiation dosimetry, and the lack of final pathology information at the time of radiation. The National Comprehensive Cancer Network (NCCN) does not support an indication for intraoperative radiation therapy. The NCCN noted that additional studies are needed to determine whether intraoperative radiation therapy has a role in the treatment of breast cancer. All told, the intraoperative radiation was not medically necessary for treatment of this patient.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 internal medicine with subspecialty certifications in medical oncology and hematology 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

An enrollee has requested authorization and coverage for laser therapy to treat hyperpigmentation. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the patients hyperpigmentation does not constitute an abnormal structure of the body. It is a postoperative response of the patients skin following right upper eyelid ptosis repair and Vivaer intranasal remodeling. Therefore, the requested laser therapy to treat hyperpigmentation is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. The reviewer also determined that the patients hyperpigmentation did not constitute an abnormal structure of the body and that the requested services were thus not reconstructive in nature. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The enrollee requested reimbursement for stab phlebectomy. The enrollee has a diagnosis of varicose veins in her left leg. This has caused pain, swelling, numbness, tingling, and stasis dermatitis. She tried compression stockings for a few years, but they did not help. She has tried over-the-counter anti-inflammatory medications that are helpful, but her symptoms return. The vascular surgeon determined the enrollee was a good candidate for excision of her varicose veins. A stab phlebectomy was performed. Local removal of varicose veins is the standard of care for those with symptomatic varicose veins, which are not responsive to conservative care with compression stockings, and which do not show axial reflux in the truncal veins. The stab phlebectomy was more beneficial than any other available standard treatments for this enrollee. Other procedures would have been inappropriate and inferior to this procedure.Final Result: The reviewers determined that the requested service was likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The reviewers are board certified in vascular surgery and are actively practicing.  All 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

The enrollee is requesting authorization and coverage for the medication, Vascepa, 1 GM. The enrollee has a medical history of hypertriglyceridemia and pre-diabetes. The enrollee reported adhering to a low carbohydrate diet. The provider prescribed Vascepa, 1 gram capsules. The enrollee stated that Vascepa is necessary as his triglycerides are still high; despite taking fenofibrate for four years. The recommendation for the use of omega-3 fatty acids, such as Vascepa, is that they should be used only in the setting of persistently elevated severe hypertriglyceridemia; greater than 500 milligrams per deciliter. The enrollees triglyceride levels are lower than 500 milligrams per deciliter, which is the threshold for treatment with triglyceride-lowering therapy, such as Vascepa.  Additionally, the provider reported that this enrollee is not taking the prescribed fenofibrate.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in family 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endoscopy with biopsies, colonoscopy with biopsies, and esophageal manometry test. The records provided for review document the presence of dysphagia and odynophagia. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines state that endoscopy is warranted as an initial test for evaluation of patients with dysphagia. In patients with dysphagia, there is concern for eosinophilic esophagitis, and endoscopic biopsy is currently the only method for diagnosis. In addition, this patients odynophagia could be due to etiologies such as candidiasis, esophagitis, and ulceration, most accurately diagnosed by endoscopy. Therefore, the requested endoscopy with biopsies is medically necessary for the evaluation of this patients dysphagia and odynophagia. In addition, the documentation states that colonoscopy is planned if testing for Clostridium difficile is negative. The most recent ASGE guidelines state that colonoscopy with biopsies is warranted for evaluation of diarrhea, and colonoscopy with biopsy is useful for diagnosis of microscopic colitis and other causes of diarrhea. Accordingly, the requested colonoscopy with biopsies is medically necessary for the evaluation of this patients diarrhea.Esophageal manometry is also supported for the evaluation of longstanding dysphagia. This patient may have a functional or esophageal dysmotility disorder as a cause for her dysphagia, even if a structural esophageal disorder is found on endoscopy. Thus, the requested esophageal manometry test is medically necessary for the evaluation of this patients dysphagia. All told, the requested endoscopy with biopsies, colonoscopy with biopsies, and esophageal manometry test are medically necessary for this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Genetic cancer screening (CPT codes 81321 and 81323). Applying the International Breast Cancer Intervention Study (IBIS) risk assessment tool, this patient has a 10-year risk of breast cancer of 7.6%, and a lifetime risk of breast cancer of 19%. Although there is ample data to support genetic testing in patients with a 20% lifetime risk of developing cancer, this patients lifetime risk of 19% falls just short of this cut-off. However, the National Comprehensive Cancer Network (NCCN) just released updated guidelines to direct genetic testing in this clinical setting. The NCCN states that testing is warranted for patients with a first-degree relative who would meet testing criteria. As this patients sister had breast cancer diagnosed at 30 years, she meets the requirement with a first-degree relative with breast cancer diagnosed under 45 years. Given these findings, the records support high-risk breast cancer screening, including genetic testing for hereditary predisposition to breast and ovarian cancers for this patient. All told, the requested genetic cancer screening (CPT codes 81321 and 81323) is medically necessary for this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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

1The enrollee is requesting authorization and coverage for for Synvisc One injections to both knees. The enrollee has bilateral osteoarthritis of the knees causing pain and swelling. An orthopedic evaluation indicated there was bilateral knee swelling and tenderness, with a positive McMurray and Appley compression sign. The enrollee received Synvisc One injections and reported that, within one to two weeks afterwards, her pain was greatly reduced and she remained pain free for six to eight months. The requested Synvisc One injection is approved by a governmental body for the treatment of knee pain in enrollees who have failed to respond adequately to conservative non-pharmacologic therapy and simple analgesics. Overall, viscosupplementation injections (Synvisc One) are supported as a standard of care for enrollees with knee pain who have failed conservative care. In this case, the enrollee has osteoarthritis in both knees and she has remained symptomatic, despite prior treatment; including medication management, exercise, and corticosteroid injections. Therefore, repeat injections would be medically necessary for symptom relief, and to delay possible surgical interventions.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested reimbursement for genetic testing, DecisionDX-Melanoma. The enrollee has cutaneous melanoma. The provider recommended DecisionDX-Melanoma genetic testing to direct this enrollees treatment, risk for recurrence, surveillance and follow-up. Literature reports routine molecular testing, including gene expression profiling, for predictive purposes, is discouraged until better use criteria are defined. The application of molecular information for clinical management, such as sentinel lymph node eligibility, follow-up, and/or therapeutic choice, is not recommended outside of a clinical study or trial. The use of this testing is not supported by scientifically based guidelines of national medical research or governmental agencies. Additionally, based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this enrollee.Final Result: The reviewer determined that the requested service was not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer are board certified in dermatology and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for budesonide EC 3 mg CAPDR-ER, 90 capsules every 30 days. Enteral budesonide is useful for induction of remission in the setting of mild to moderate ileal Crohns disease. Currently, there is limited data on trials comparing budesonide to prednisone. There are guidelines utilizing these pediatric data, published by the European Society of Pediatric Gastroenterology, Hepatology and Nutrition, and the Canadian Association of Gastroenterology, which endorse enteral budesonide as a treatment option for children with mild to moderate ileal Crohns disease. There is a lack of evidence to support using budesonide for maintenance of clinical remission. The Canadian Association of Gastroenterology strongly advises against using budesonide as a maintenance treatment, due to concerns for its ineffectiveness and increased risk of potential side effects such as adrenal suppression and poor linear growth. This patient has been treated with budesonide for chronic right lower quadrant pain, nodularity endoscopic appearance of inflammation on video capsule endoscopy, and hyperenhancement of the terminal ileum. As treatment for ileal Crohns disease, budesonide was appropriate for this patient. However, the medical literature and guidelines do not support ongoing treatment with budesonide. Since budesonide can potentially lead to adrenal suppression, a tapering of the dose would is appropriate prior to cessation. Ruemmele and colleagues noted that, budesonide can be tapered within 10 to 12 weeks. Given this support, budesonide EC 3 mg CAPDR-ER, 90 capsules every 30 days for three months is medically necessary for the patient. Final Result: The reviewer determined that a portion of the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatric gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.