Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency room services on an emergent or urgent basis. The physician review 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 back pain radiating to his right buttock that had been present for one week. He had not suffered any recent injury. He had no neurologic deficits. The patient was described as in no distress. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he 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 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 back pain that was described as moderate. The record documents the patient as alert and in no distress. This patients symptoms were not sudden in onset. There is no documentation to suggest a prudent layperson would believe that the absence of immediate medical attention would result in serious impairment to bodily function. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.  Two physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited due to breast density. Accordingly, digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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: All three reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested genetic testing (CPT codes 81211, 81201, 81292, 81295) for evaluation of her gastric cancer. Two physician reviewers found that in 2010, the International Gastric Cancer Linkage Consortium (IGCLC) broadened the consensus guidelines for E-cadherin (CDH1) mutation testing to include two gastric cancer cases in family, one confirmed diffuse gastric cancer under age 50, three confirmed diffuse gastric cancer cases in first or second degree relatives independent of age, diffuse gastric cancer in an individual under the age of 40, and a personal or family history of diffuse gastric cancer and lobular breast cancer, one diagnosed under the age of 50. The IGCLC also supports the inclusion of cases where expert pathologists detect in situ signet ring cells and/or pagetoid spread of signet ring cells adjacent to diffuse type gastric cancer. Thus, this patient meets criteria for Lynch syndrome testing as there are two confirmed gastric cancer cases under age 50. Thus, the Lynch syndrome testing (CPT code 81292 and 81295) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that a portion of 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 partially overturned.  Credentials/Qualifications:  One reviewer is board certified in oncology and hematology and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. In this case, the patient presented for a breast cancer screening with tomosynthesis. The study by Skaane and colleagues concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Based on the medical literature cited above, there is support for the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  Final Result:  Two 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: All three reviewers are board certified in diagnostic radiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Norco for treatment of her chronic low back pain.  The physician reviewer found that the submitted documentation fails to establish the medical necessity for the requested medication. The current standard of care for chronic low back pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Given the patient has failed to show improved function on this particular opioid and demonstrated lack of compliance with the medication, the requested medication is not medically necessary. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested dynamic pelvic magnetic resonance imaging (MRI) for evaluation of her medical condition.  Two physician reviewers found that the requested services are not likely to be superior over other modalities.  The concern for this patient is that her defecatory disorder is either due to dyssynergic defecation or an anatomical abnormality such as a rectocele.  The initial work-up beyond a physical examination and detailed history usually begins with an anal manometry study that incorporates a balloon expulsion test.  If dyssynergia is eliminated as a potential diagnosis, then defecography can be performed to rule out a rectocele.  There is a lack of support for the requested services in this clinical setting.  All told, the requested dynamic pelvic MRI is not likely to be of greater benefit than other methods of evaluating this patient.  Final Result:  Two reviewers determined that the requested services are 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 internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a percutaneous discectomy for treatment of his back pain. Two physician reviewers found that automated percutaneous lumbar discectomy was introduced in the 1980s using a suction curettage device for disc removal. Initial case series focusing on lumbar disc disease reported encouraging results. However, controlled trials have not confirmed these findings. According to the peer-reviewed literature, longer follow-up periods are needed to determine if percutaneous and endoscopic spinal surgery procedures are more effective than conventional procedures. Moreover, this patients documentation failed to demonstrate that he has exhausted all previous measures of conservative treatment. Accordingly, percutaneous discectomy was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two 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:   All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an annual biopsy and gene marker testing for treatment of her right thyroid nodule.   The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for an annual biopsy and gene marker testing has not been established. Genetic testing is clinically indicated when the patient presents with atypical cells of underdetermined significance or follicular lesion of undetermined significance or follicular neoplasm. In this case, the nodule has been biopsied and aspirated and found to be benign. In addition, the request for an annual biopsy is not medically necessary. The patient should be evaluated clinically on an annual basis. If there is a change in size or local symptoms then a biopsy should be considered, if clinically indicated. For the reasons provided, an annual biopsy and gene marker testing is not medically necessary for treatment of the patients medical condition. 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 endocrinology 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 maternal plasma cell-free fetal DNA sequencing (Verifi Prenatal Test) for fetal aneuploidy for evaluation of her medical condition. The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The American College of Obstetricians and Gynecologists (ACOG) committee opinion in regards to cell-free DNA screening for fetal aneuploidy recommends this screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. Based on the clinical documentation submitted for review, this patient does not meet the criteria.  The patients history is not enough to warrant cell-free DNA screening. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal-fetal 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 Xyrem for treatment of his severe narcolepsy with cataplexy.  The physician reviewer found that Xyrem is indicated for narcolepsy as well as for cataplexy. The patient has signs and symptoms of narcolepsy with cataplexy and his provider has determined that he is an excellent candidate for the use of Xyrem. There is no accepted alternative to Xyrem, and stimulant therapy would not replace the use of Xyrem. Nuvigil is considered stimulant therapy and would not replace the patients need for Xyrem. Thus, the requested Xyrem 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 sleep medicine with sub-specialty certification in pulmonary 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 magnetic resonance imaging (MRI) of the right breast for evaluation of her medical condition.  Three physician reviews found that this patient has had a benign pathology report in the past with radial scar identified.  The patient has no physical examination in the chart detailing a palpable mass.  The most recent extensive standard diagnostic breast studies, including digital mammography, tomosynthesis and ultrasound, revealed no equivocal or unexplained finding requiring further imaging for evaluation.  There is a lack of support for the requested MRI of the right breast based upon current guidelines.  All told, the requested MRI of the right breast is not likely to be superior over other methods of evaluating this patient.  Final Result: Three reviewers determined that the requested diagnostic procedure is 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 diagnostic radiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested anesthesia services provided during a colonoscopy for evaluation of her risk for colon cancer.  The physician reviewer found that the anesthesia services for colonoscopy were not medically necessary. Administration of general or regional anesthesia is considered medically necessary when the services are provided by a provider other than the provider performing the procedure and alternative types of anesthesia, sedation, or analgesia are not appropriate. A clinical document indicates that this patient has acid reflux and hypothyroidism. The patient was noted to have complained of abdominal pain and swelling and heartburn. The physical examination revealed normal consistency, no tenderness or masses, and normal bowel sounds of the abdomen and normal, nonpalpable of the liver and spleen. There was no documentation with evidence of prolonged or therapeutic endoscopic procedure requiring deep sedation, a history of or anticipated poor response due to intolerance, increased risk for complication due to comorbidity, evidence of pregnancy, or history of drug or alcohol abuse. There was also no documentation with evidence the patient was uncooperative or agitated during the procedure. For these reasons, the use of anesthesia during colonoscopy is not supported as medically necessary for evaluation of this 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Xeljanz for treatment of her alopecia areata.  The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting.  This patient has had numerous topical and systemic therapies with minimal sustained improvement.  This patients condition is a challenging condition to treat with few effective options.  The identification of tofacitinib (Xeljanz) as an effective therapy for alopecia areata, particularly of the universalis type, is significant as there is a lack of other effective treatment options.  Given that the patient has benefitted from a trial of this medication, when all other treatments have failed, there is support for the Xeljanz in this clinical setting.  All told, the requested medication Xeljanz is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested skilled nursing facility services for treatment of the enrollees medical condition.   The physician reviewer found that the patient underwent lower limb amputation.  Initiation of prosthetic rehabilitation was appropriate, and a long-term mobility goal would be independent community ambulation.  The patient has been undergoing inpatient rehabilitation, but has plateaued at ambulating very short distances with assistance.  Her physical therapy was discontinued, and she has been receiving maintenance therapy from non-therapy staff.  She has otherwise been receiving daily wound care for stable, chronic wounds.  Further care on and after this point could have been provided in the community setting with home services.  All told, skilled nursing facility services at issue were not medically indicated for the 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 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.