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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic stimulation (TMS) therapy for treatment of his behavioral health condition.  Findings:  The physician reviewer found that TMS therapy was medically necessary for treatment of the patients medical condition. There is sufficient support in the peer-reviewed medical literature for the services at issue in this clinical setting. TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. The American Psychiatric Association (APA) has endorsed TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. In this case, the patient had pursued, but not exhausted other standard therapies used to treat depression. However, considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS represented a safe, appropriate treatment consistent with good medical practice that was reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the services at issue were medically necessary for treatment of 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency services on an emergent basis or urgent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a headache. She also had been experiencing sinus congestion, rhinorrhea, sore throat and earache. She did not report any symptoms of confusion, or disorientation. The patient was mildly tachycardic, but was afebrile. She was described as in no acute distress. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services at question did not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, the patient presented with headache, sinus congestion, rhinorrhea, sore throat and earache. She did not report any symptoms of confusion, disorientation, or fever. She was described as in no acute distress. The patient did not require any intravenous medication. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. The patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. In sum, based on the patients clinical presentation on the date in question the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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 genetic testing for evaluation of his medical condition. Findings:  Three physician reviewers found that the genetic testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is a lack of large randomized trials supporting the use of genetic testing in this clinical setting. In addition, genetic testing is not clinically indicated for choosing and managing medication. The medical literature does not support the use of genotyping when choosing an antidepressant. Even less is understood about its utility in the treatment of anxiety disorders. In sum, genetic testing to determine psychiatric drug therapies lacks evidence-based research showing its effectiveness in choosing a medication regimen. Therefore, the gene testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in psychiatry 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:   An enrollee has requested neurofeedback treatments once or twice weekly, monthly or bi-monthly cognitive rehabilitation sessions with a clinical psychologist and twice a week meetings with a cognitive rehabilitation coach to practice the cognitive exercises prescribed by the clinical psychologist during the cognitive rehabilitation sessions for treatment of her medical condition.  Findings:  The physician reviewer found that there is a lack of sufficient support in the peer-reviewed literature for neurofeedback treatments in this clinical setting. The study by Choobforoushzadeh and colleagues assessed the use of neurofeedback in 24 patients with MS. Although the results at two-month follow-up were positive, larger studies with long-term follow-up are needed to confirm these findings. There is currently a lack of medical literature supporting neurofeedback for the treatment of the cognitive effects of MS. In addition, neurofeedback treatments are not the standard of care in this clinical setting. Therefore, the request for neurofeedback treatments once or twice weekly has not been established as medically necessary for treatment of the patients MS.   However, monthly or bi-monthly cognitive rehabilitation sessions with a clinical psychologist and twice week meetings with a cognitive rehabilitation coach to practice the cognitive exercises prescribed by the clinical psychologist during the cognitive rehabilitation sessions were and are medically necessary for treatment of the patients medical condition. Young and colleagues performed study of 95 adult ADHD patients, already treated with medication (MED), who were randomly assigned to receive treatment of 15 sessions of cognitive behavioral therapy. The authors concluded that the study provides evidence for the effectiveness of cognitive behavioral therapy for ADHD symptoms. In this case, the patient presents with a longstanding history of MS, depression, anxiety and ADHD. Cognitive rehabilitation has been shown to be effective in the treatment and management of the patients medical conditions when used together with medications. Therefore, the monthly or bi-monthly cognitive rehabilitation sessions with a clinical psychologist and twice a week meetings with a cognitive rehabilitation coach to practice the cognitive exercises prescribed by the clinical psychologist during the cognitive rehabilitation sessions were and are medically necessary for treatment of the patients medical condition.   Final Result: The reviewer determined that a portion of the services at issue was and 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested air and associated ground ambulance transportation services for treatment of the enrollees medical condition. Findings: The physician reviewer found that air and associated ground ambulance transportation services are medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, a work-up for renal transplantation has been approved at an out of state transplant facility. The patient does not have the option of going to another transplant center. The kidney transplant process takes a great deal of time with referral, wait, appointments, work-up, and approval. The process of getting listed at another center and approved could take up to two years. According to Meier-Kriesche and colleagues, Longer waiting times on dialysis negatively impact on post-transplant graft and patient survival. These data strongly support the hypothesis that patients who reach end-stage renal disease should receive a renal transplant as early as possible in order to enhance their chances of long-term survival. Given that the patient has been approved for transplant and going to a closer facility would be a significant hardship, the requested air and associated ground ambulance transportation services would provide him with the highest standard of care and is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the request 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 internal medicine and nephrology 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 parent of an enrollee has requested coverage for eating disorder intensive outpatient program (IOP) services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that the requests for eating disorder IOP services are medically necessary for treatment of the patients anorexia nervosa. The documentation submitted for review supports placement at the IOP level of care. The patient continues to exhibit high anxiety at meals and distress when presented with menu options. In this clinical setting, the gains that have been made in IOP are fragile and there is a strong possibility of relapse at a lower level of care. In the absence of IOP services, he would be at risk for medical complications and would likely require a higher level of care. Thus, IOP services are medically necessary for treatment of the patients behavioral health 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 psychiatry with sub-specialty 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for OxyContin four times daily or OxyContin two times daily for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the clinical notes document chronic low back pain and pelvic pain.  Per the medical evidence, OxyContin should not be dosed on a four times daily regimen. OxyContin is appropriately dosed twice daily, as this is an extended release, high-dose opioid regimen.  In this patients case, the clinical notes support the medical necessity of OxyContin two times daily for the treatment of her pain.  However, there is a lack of support for OxyContin four times daily. Final Result: The reviewer determined that that a portion of the requested medication quantity 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 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 an endoscopic lumbar sympathectomy for treatment of her medical condition.   Findings:  Two physician reviewers found that there are a number of recent articles in the peer-reviewed literature that suggest or show excellent outcomes for patients with plantar hyperhidrosis following endoscopic lumbar hyperhidrosis. These articles also show sustained benefit in these same patients without a need for further surgery or procedures. The overall goal of intervention in this patient is to achieve sustained, lasting benefit combined with the lowest possible risk. Per the records, standard treatments have failed. Therefore, it is highly likely that endoscopic lumbar sympathectomy will provide successful, clinically relevant, sustained relief of this patients hyperhidrosis. In sum, the requested procedure is likely to be more effective than any standard available treatment options for this patient. Final Result: Two reviewers determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  One reviewer is board certified in neurological surgery and is actively practicing. Two reviewers 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency services on an emergent or urgent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with mild abdominal pain with dysuria and hematuria. The patient denied fevers, vomiting, or other systemic symptoms. Her vital signs were normal and she was not in acute distress. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the requested services did not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, the patient presented with mild abdominal pain with dysuria and hematuria. The patient denied fevers, vomiting, or other systemic symptoms. She related her symptoms were consistent with prior urinary tract infections. A patient with a history of urinary tract infection would likely have known that immediate medical attention was not necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested monitored anesthesia care (MAC) for treatment of his medical condition.   Findings:  The physician reviewer found that there is sufficient support in the medical literature for the services at issue in this clinical setting. According to Alharbi and colleagues, propofol used for sedation during colonoscopy has become increasingly popular and is attributable to its deep sedative effect, rapid onset of action, and short recovery time, resulting in greater patient and endoscopist satisfaction with the procedure while increasing the efficiency of endoscopy units. In addition, per the Centers for Medicare and Medicaid Services (CMS), anesthesia associated with colonoscopy is a covered benefit. Given the support in the peer-reviewed literature, the requested MAC services were medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a seat lift for treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the requested equipment in this patients case.  The natural history of multiple sclerosis is typically a relapsing and remitting pattern.  During this period, exercise to improve fatigue, mobility and quality of life is considered an important component of disease management.  In this case, the records indicate that the patient has an end-stage form of progressive multiple sclerosis, with various impairments including visual, cognitive and motor impairments.  The available records do not establish that the patient is able to ambulate safely.  She has a wheelchair, and there are no indications that the patients wheelchair does not meet her seating and mobility needs.  The requested equipment is not medically necessary for the patients mobility-related activities of daily living.  All told, the requested seat lift is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in physical medicine and rehabilitation 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 a vertical laparoscopic sleeve gastrectomy for treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this patients case.  The records do not document a BMI of 35 or greater with serious weight-related comorbid conditions such as diabetes, hypertension or sleep apnea.  Sleep apnea is not documented, as the patient had a normal AHI.  The records do not document a dietary evaluation.  There is a lack of support for the requested services in this patients case.  All told, the requested vertical laparoscopic sleeve gastrectomy is not medically indicated for the treatment of this patient. 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 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.