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

Nature of Statutory Criteria/Case Summary: The parent enrollee has requested authorization and coverage for sinus surgery. Pediatric rhinosinusitis is a common sequela of upper respiratory infections in children. It is usually a self-limited disease, sometimes requiring antibiotic therapy. Chronic rhinosinusitis (CRS) in children is difficult to treat, with resultant frequent recurrences and failures. The available medical treatments include antibiotics, topical nasal corticosteroids, and nasal lavage with saline solutions. Adenoidectomy is among the most frequent surgical procedures performed on children, but randomized studies have failed to prove that adenoidectomy alone is sufficient to manage CRS. Instead, functional endoscopic sinus surgery is a minimally invasive technique which restores the sinus ostia patency and can re-establish ventilation and drainage through the natural pathways. Surgery may be indicated in children with complications of acute rhinosinusitis, severe recurrent acute rhinosinusitis, rhinosinusitis in cystic fibrosis with or without polyposis, chronic rhinosinusitis refractory to maximal medical management, allergic fungal sinusitis, and paranasal sinus mucoceles. In this patient with CRS who is status post adenoidectomy and has been treated with maximum medical therapy, sinus surgery is supported as medically necessary. 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 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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for physical therapy with a therapist that does not use assistants and can treat more than two body parts per therapy sessions. Based on the available records, the provider did not document a rationale for continued supervised physical therapy. For each of the patients diagnoses, she has received treatment including initial supervised therapy followed by transition to an independent home rehabilitation program. Without documentation of a condition that requires the services of a skilled physical therapist, the requested physical therapy is not indicated. Thus, the requested physical therapy with a therapist that does not use assistants and can treat more than two body parts per therapy session is not medically necessary for treatment of this 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara 90 mg/mL injections every four weeks.  Researchers found a relationship between serum concentrations and efficacy. The authors found that trough concentrations of ustekinumab of 0.8 or greater were associated with maintenance of clinical remission in a higher proportion of patients than patients with lower trough concentrations. This patients level is 1.9 ug/mL at the current dosing, which suggests that interleukin targeting may not be beneficial. Overall, there is a lack of peer-reviewed data supporting the requested dosage increase in this clinical setting. Thus, the requested Stelara 90 mg/mL injections every four weeks is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested Stelara 90 mg/mL injections every four weeks is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication regimen is 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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: A 54-year-old female enrollee has requested authorization and coverage for radiofrequency ablation. Findings:  The physician reviewer found that The American College of Obstetricians and Gynecologists (ACOG) has weighed in on both the surgical and alternative conservative management options of uterine leiomyomas. Treatment options include myomectomy or hysterectomy, uterine artery embolization (UAE), radiofrequency ablation, or a progestin only contraceptive such as Depo-Provera, Micronor, Nexplanon, or a Mirena intrauterine device (IUD). In this case, the patient presents with enlarging fibroids, along with symptoms of heavy and painful periods. There is no documentation that the patient has failed first-line medical therapy. Therefore, the requested radiofrequency ablation is not supported as medically necessary for treatment of this patients uterine fibroids. 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the IgG testing (CPT code 83516). As noted in the current peer-reviewed medical literature, this panel of laboratory testing is important in the diagnosis of myopathies and myositis. These tests can help facilitate a treatment pathway by diagnosing the various phenotypes associated with these diseases. In this clinical setting, the test was recommended to help establish the patients form of myositis. The provider noted that Raynauds is not the patients primary diagnosis. Thus, the IgG testing (CPT code 83516) was likely to be more beneficial for further evaluation of the patients medical condition than any available standard testing.One reviewer found that the IgG testing (CPT code 83516) was not likely to be more beneficial for further evaluation of the patients medical condition than any available standard testing.Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with sub-specialty certifications in pulmonary disease and critical care medicine and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease and is 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 parent of an enrollee has requested authorization and coverage for pulsed dye laser (PDL) treatment to the left lower lip. The submitted documentation fails to demonstrate the medical necessity of the requested PDL treatment in this patients case. The medical records indicate that the lesion has been asymptomatic, but may be enlarging. There has been no bleeding. Given the lack of associated symptoms, the request for coverage of pulsed dye laser treatment would be considered cosmetic and not medically indicated. Therefore, the requested PDL treatment to the left lower lip is not medically necessary 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a follow-up visit with a bariatric surgeon. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients morbid obesity with associated co-morbidities. The submitted documentation supports the medical necessity of the requested services. Bariatric surgery includes a variety of procedures performed on people who have been diagnosed with morbid obesity. Bariatric surgery has been shown to promote significant long-term loss of weight, recovery from diabetes, improvement in cardiovascular risk factors, and a significant decline in mortality. Studies have demonstrated that the success of bariatric surgery is dependent to a large degree with adherence to follow-up care. For this reason, the American Society of Medical and Bariatric Surgery has stated in their guidelines that patients who have undergone bariatric surgery should have close follow-up care. Therefore, a follow-up visit with a bariatric surgeon is medically necessary for the treatment of this patient.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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the tumor treatment field (TTF) therapy (with Optune Plus transducers, CPT code E0766). According to the current National Comprehensive Cancer Network (NCCN) guidelines for the adjuvant treatment of glioblastoma, TTF therapy has a category 1 recommendation only for patients with supratentorial disease, as in this patients case. In addition, a large multi-institutional prospective controlled trial randomized recurrent glioblastoma patients to receive chemotherapy or treatment with the Optune device. The authors concluded that efficacy and activity with this chemotherapy-free treatment device appears comparable to chemotherapy regimens that are commonly used for recurrent glioblastoma. Toxicity and quality of life clearly favoured TTF. As this patient has already been treated with chemotherapy and radiation, the requested addition of the TTF therapy with Optune Plus transducers, CPT code E0766, is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the TTF therapy with Optune Plus transducers, CPT code E0766, is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that TTF therapy with Optune Plus transducers, CPT code E0766, is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the genetic tests (CPT codes 81200, 81242, 81260-81290, and 81330) performed on 12/15/17. The Health Plan has denied this request indicating that the services at issue were considered investigational for the evaluation of the patients pregnancy.Findings: The services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. It has been long recognized that a number of serious medical disorders are common in the Ashkenazi Jewish population. These are recessive genetic conditions. In order to reduce the incidence of these serious and lethal conditions, genetic testing has been recommended by the American College of Obstetricians and Gynecologists. This testing is readily available by commercial genetic testing facilities. Therefore, the genetic tests (CPT codes 81200, 81242, 81260-81290, and 81330) that were performed on 12/15/17 were likely to be more beneficial for treatment of the patients medical 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: All three reviewers 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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Otezla. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients psoriasis vulgaris. The submitted documentation of the patients medical needs supports the medical necessity of the requested medication. The patient is requesting coverage for Otezla for treatment of chronic plaque psoriasis. Otezla is Food and Drug Administration approved for the treatment of psoriasis and psoriatic arthritis. The Health Plan requires failure of two preferred injectable biologic agents prior to covering Otezla. As the patient has shown improvement with psoriasis since taking Otezla, the request for coverage of Otezla should be approved and is considered medically necessary for this patient. Accordingly, Otezla are medically necessary 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services. This patient had a tracheostomy and external ventricular drain (EVD) in place at the time of transport. The patient has been diagnosed with lupus with central nervous system complications resulting in altered sensorium. The patient required skilled nursing services during the flight given their need for intensive care services. The patient was in a stable but guarded condition during the days of the flight. Therefore, the flight provided was for the transport of a patient for emergency medical services and the patient received services during the flight including the management ventilator settings during the flight. For these reasons, the services were necessary for treatment of the patients emergency medical condition.Final Result: The reviewer determined that the services at issue necessary for treatment of the patients emergency medical condition. Therefore, the Health Plans denial should be 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the blood test (Guardant360 biopsy-free tumor sequencing test). Per medical guidelines, evaluation for T790M mutation is appropriate in this clinical setting. Guardant360 testing offers a comprehensive panel of molecular genetic markers on an individual patients tumor in an attempt to identify markers than can help guide therapy decision making. Guardant360 provides genetic testing to guide therapy, and this is the subject of an ongoing phase II trial, the entire panel was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. However, as the patient showed evidence of progression while on Tarceva, the portion of the Guardant360 test analyzing for the T790M mutation was indicated. Thus, the T790M portion of the blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the Guardant360 testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the blood test (Guardant360 biopsy-free tumor sequencing test) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that a portion of the testing 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 partially overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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 authorization and coverage for Percocet. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. In addition, there is no mention that behavior therapy has been completed despite much research to support its use. Moreover, not all non-opioid medications classes have been optimized or tried. All told, the requested Percocet is not supported as medically necessary for treatment of this patients chronic pain. 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.