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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient substance abuse treatment. Findings: The physician reviewer found that the submitted documentation failed to demonstrate the medical necessity for the services at issue in this clinical setting. The Level of Care Utilization System (LOCUS) criteria is a method used to objectively determine if a patient meets criteria for length of stay. This is an accepted, national standard for determining the appropriate level of care for adults. There is no documentation of a history of any suicide attempts. The patients medical/addictive/psychiatric co-morbidity was a 3, significant co-morbidity. The patient has a significant co-morbidity of alcohol use disorder, marijuana use disorder, ADHD, generalized anxiety disorder, sexual addiction, and major depressive disorder. The patient will continue to use substance despite negative consequences. His recovery environment was also a 3, moderately stressful environment. The patient has limited support at this time. His support revolved around professional resources and community sponsors. Treatment history was a 3. The patient has an unclear response to treatment and ability to maintain a significant recovery. Engagement and recovery status was a 2, positive engagement and recovery. The patient was motivated for recovery and was compliant with treatment recommendations.  According to the LOCUS criteria, this patients total score is 19. The patient continued to need treatment for his alcohol use disorder, marijuana use disorder, sexual addiction, ADHD, generalized anxiety disorder, and major depressive disorder. However, based on the LOCUS criteria, the patient could have been treated at a less restrictive environment like an intensive outpatient program.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 40-year-old female enrollee has requested authorization and coverage for Botox for treatment of the enrollees chronic migraine. Findings:  The physician reviewer found that The U.S. Food and Drug Administration (FDA) has approved Botox for headache prophylaxis in patients with adult chronic migraine who experience headaches on 15 or more days per month, each lasting more than four hours. The available medical records provided for review indicate failure of multiple medications for prophylaxis of migraine. The medical records indicate chronic headache of migraine type that are occurring 15 or more days per month.  The headaches have not responded to first-line treatment options. As such, Botox is likely to be more effective than other treatment options in this patients case. Final Result: All three reviewers determined that the requested services are 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing performed for evaluation of the enrollees malignant melanoma.Findings:  Three physician reviewers found that the DecisionDx melanoma assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx test has shown accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. The test is currently not standard of care, has not been demonstrated to provide a beneficial effect on health outcomes. Overall, there is not enough published data to support its routine use. Final Result: The 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 physician reviewers are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the wireless capsule endoscopy (SmartPill Monitoring System) CPT code 91112 for evaluation of the enrollees gastroparesis. Findings:  The physician reviewer found that The SmartPill wireless capsule endoscopy is U.S. Food and Drug Administration (FDA) approved for evaluation of gastric emptying in gastroparesis, colonic transit in constipation and evaluation of generalized dysmotility. The device is recognized for assessment of gut dysmotilities by both the American Neurogastroenterology and Motility Society as well as by the American Gastroenterology Association. However, wireless capsule endoscopy has not been widely accepted as standard of care in clinical practice outside of tertiary care specialty centers and has not been demonstrated to be superior to gastric motility or colon transit testing. In this patients case, the available records do not support that she underwent a conventional gastric emptying scan prior to consideration of SmartPill deployment. Thus, the requested wireless capsule endoscopy (SmartPill Monitoring System) CPT code 91112 is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested diagnostic procedure is not likely to be more beneficial for evaluation of the enrollees medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty 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.Physician reviewer number two is board certified in internal medicine with sub-specialty 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.Physician reviewer number three is board certified in internal medicine with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted records do not support the medical necessity of the services at issue.  The record does not demonstrate that 24-hour supervision was clinically indicated. The patient could have been treated at a less restrictive level of care such as intensive outpatient program (IOP) treatment. As noted by colleagues, Multiple randomized trials and naturalistic analyses that compared IOPs (Intensive Outpatient Programs) with inpatient or residential care found comparable outcomes.  Moreover, in their review colleagues found that Results for the effectiveness of residential treatment compared with other types of treatment for substance use disorders were mixed. Findings suggested either an improvement or no difference in treatment outcomes. It was noted that the patient had a strong probability of not relapsing. She had strong family support system. She had a sponsor. She was not a danger to self. This patient could have been treated at a lower level of care such as at an IOP. In sum, the residential treatment services provided were not medically necessary 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 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: A male enrollee has requested authorization and coverage for Ampyra 10 mg ER for treatment of the enrollees relapsing-remitting multiple sclerosis. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested medication. Ampyra is U.S. Food and Drug Administration (FDA) approved to improve walking speed. Additionally, there are other data demonstrating improvement of measures of quality of life function in patients with multiple sclerosis with this drug.  In this patients case, the medical evidence supports the requested medication over the Health Plans alternatives. Baclofen is used for spasticity or stiffness in the legs associated with multiple sclerosis. It does not aid in improving walking speed, fatigue or other measures of daily living function, which is what Ampyra does. Dexamethasone is a potent steroid used for a few days in multiple sclerosis patients experiencing an attack. It calms down an attack acutely, but is not a long-term treatment. Rebif is a thrice weekly injection used to reduce the likelihood of an attack, but this medication does not change functional daily living capacity. Therefore, Ampyra is unique in its action by improving neurologic function in daily living. In sum, Ampyra 10 mg ER is 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 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 authorization and coverage for right breast capsulotomy for treatment of the enrollees infiltrating ductal carcinoma and not reconstructive in nature.Findings:  The physician reviewer found that The Womens Health and Cancer Rights Act (WHCRA) mandates coverage for all stages of breast reconstruction. The WHCRA states that mastectomy may require certain services relating to the mastectomy and coverage includes all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses and treatment of physical complications of the mastectomy, including lymphedema. The records provided for review document that this patient has continued deformities following her breast cancer reconstruction, which is an abnormal condition. The abnormal condition is due to breast cancer, and correction of the condition is a stage of her reconstruction. Moreover, the requested procedure will provide a more than minimal improvement in the patients appearance. As noted in the medical literature, the outcome and quality of breast reconstruction can change over time. Breast reconstruction is now understood to be a multi-stage process including revisions. In this patients case, the requested revision of the implant pocket is one medically necessary stage of her reconstruction to restore her breasts to her pre-mastectomy appearance. Given these findings, the requested right breast capsulotomy is supported as medically necessary and reconstructive in nature for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chiropractic services for treatment of the enrollees scoliosis and back pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of evidence-based guidelines recommending chiropractic treatment in this clinical setting. The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) guidelines do not recognize chiropractic care as an accepted treatment for scoliosis. 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 chiropractor 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 Pathfinder TG testing provided for evaluation of the enrollees possible pancreatic cancer. Findings:  Three reviewers found that the molecular markers are often performed on pancreatic cyst fluid given the difficulty in determining the risk of malignancy. A biomarker panel consisting of the immunoassays TIMP1 and LRG1, along with CA 19-9 improved the detection of early-stage pancreatic cancer, relative to CA 19-9 alone, and is supported by the National Comprehensive Cancer Network (NCCN) guidelines. Final Result: Two of three physician reviewers determined that 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 overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for knee replacement surgery for treatment of the enrollees bilateral knee pain with diagnosis of degenerative joint disease. Findings:  The physician reviewer found that as noted in the medical literature, total knee arthroplasties in obese patients six months after total joint replacement revealed excellent pain relief and substantial functional gain that was similar to the findings in other patients. While obesity is associated with a greater risk of early complications, obesity is not a deterrent to total knee arthroplasty to relieve refractory symptoms. One study referenced 13,673 total knee arthroplasties and found that the improvements in patient reported outcomes were similar without regard for BMI. Final Result: The reviewer determined that the requested surgery 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for comprehensive orthodontic treatment including braces for treatment of the enrollee who has been diagnosed with malocclusion.  Findings:  The physician reviewer found that there are several objective tools that have been developed as a means of measuring the need for orthodontic treatment among a population. One such tool is the HLD, which was used in this patients case. An HLD score typically greater than 26 qualifies for treatment as a severe need. In this patients case, the scores computed were 15 or 17, well under the threshold for necessity. There are several medical or dental conditions, which may exempt this patients HLD score and qualify a patient automatically. One such condition is a craniofacial anomaly or severe traumatic occlusion causing clinical attachment loss.  However, the documentation provided does not describe medical conditions which would automatically qualify this patient for the requested treatment. While this patient may show an improvement in chewing with orthodontic treatment, the records provided do not meet the threshold of medical necessity. As such, with an HLD score of 15 or 17 and no qualifying exemption, the requested services are not indicated for treatment of this patient.  For these reasons, the requested services are 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 dentistry with expertise in orthodontics 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 authorization and coverage for Otezla 30 mg for treatment of his rhematoid arthritis. Findings:  The physician reviewer found that Otezla is indicated for the treatment of psoriasis and psoriatic arthritis. However, there is a paucity of peer-reviewed evidenced based literature to support the use of Otezla in the treatment of rheumatoid arthritis. Given the absence of current scientific data supporting an indication for Otezla in treating patients with rheumatoid arthritis, Otezla 30 mg tablet is not indicated as medically necessary in this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient psychiatric services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patient suffered from dementia, Alzheimers type, with significant impairment in cognition and ability to perform ADLs. The documentation noted that he was more calm and cooperative.  The records indicated that he was still resistive to care, but he was not aggressive.  This appeared to be his baseline, along with requiring 3:1 assistance to perform ADLs and 1:1 supervision.   Haldol was increased and the 1:1 supervision was discontinued.  Once this was done, the patient was pleasant, calmer, and cooperative.  He had one episode of agitation, requiring Haldol. However, this episode would not have necessitated ongoing inpatient hospitalization stay. Final Result: The reviewer determined that 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 sub-specialty certification in geriatric 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.