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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for clarithromycin (500 mg, two tablets once per day), rifampin (300 mg, one capsule twice per day), Malarone (250 mg, once per day), fentanyl transdermal patch (75 mg), and Norco (10-325 mg, once every six hours)for treatment of the enrollees diagnosis of Lyme disease.  Findings:  The physician reviewer found that this patient with Lyme positive testing received treatment with ceftriaxone which is indicated for patients with neuro-Lyme disease. Repeat testing for Lyme was negative per the records provided for review. Rifampin is a commonly used antibiotic not indicated for the treatment of Lyme disease. In addition, while there may be some efficacy of clarithromycin, it is not considered the standard of care when there are better, guideline based agents for the treatment of Lyme disease. Malarone is indicated for malaria and not Lyme disease. Atovaquone has been used for Babesia. The fentanyl patch and Norco are not indicated in the treatment on Lyme disease, but for pain. For those reasons, clarithromycin (500 mg, two tablets once per day), rifampin (300 mg, one capsule twice per day), Malarone (250 mg, once per day), fentanyl transdermal patch (75 mg), and Norco (10-325 mg, once every six hours) are not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in infectious disease 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 intensive outpatient program (IOP) for 30 to 60 days for treatment of the enrollees autism spectrum disorder and global developmental delay. Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. Recent medical literature supports early intervention services for children who are diagnosed with an autism spectrum disorder. In a recent article, children enrolled in a multidisciplinary team approach such as the Pediatric Minds Early Childhood Treatment Center demonstrated significant gains in overall functioning that were sustained on follow up evaluations two years later. Occupational therapy has also shown to be beneficial in the treatment of autism, addressing postural control and adaptive skills for long term independence. Lastly, the use of cognitive behavioral therapy has also been shown to be beneficial in the care of children with autism, successfully addressing common problems such as feeding difficulties. Given the proven benefit of early intervention in autism, coupled with the aforementioned efficacy of speech, occupational and cognitive therapies, IOP services are  medically appropriate and should be approved at the recommended rate of three hours per day, five days per week for 30 to 60 days. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 intensive outpatient services provided for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient had a serious addiction to alcohol which contributed to impairment across multiple functional domains.  He reported a family history and an early age of first use, both of which are associated with more severe cases of alcoholism. He had medical conditions that were impacted by his alcohol consumption.  He had strained relationships due to his drinking. He had a co-occurring psychiatric disorder and substance use disorder. He did well with intensive outpatient program services previously when treating his opioid addiction. During the disputed timeframe, the patient attended, participated and benefitted from the intensive outpatient program services. The treatment was reasonably expected to improve the patients condition and prevent a worsening episode of illness or relapse.  In sum, service delivery at the intensive outpatient program level of care was safe, appropriate and consistent with good medical practice while the duration of services aligned with community practice standards. Therefore, intensive outpatient services provided were medically necessary for the treatment of this patient. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx melanoma assay provided for evaluation of the enrollees malignant melanoma. Findings:  The 3 physician reviewer found that the staging and prognosis of cutaneous malignant melanoma is classically determined by the system as discussed by the American Joint Committee on Cancer (AJCC). As per this system, this patient would have been stage 1b, with an expected 10-year survival of at least 83%. DecisionDx is a study of 31 genes in melanoma cells which classifies the particular melanoma as either Class 1 with a five year distant-disease free survival of 73%, or Class 2 with five year disease-free survival of 46%. Colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx classification in patients who had sentinel node biopsy. However, it has not been demonstrated how the five year DecisionDx data compares to the 10-year AJCC data, and whether it can be used to make clinical decisions. Further, the National Comprehensive Cancer Network (NCCN) guidelines state there is interest in these newer genetic profiles, but only in the context of a clinical trial. Therefore, the DecisionDx melanoma assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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 medical oncology 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 medical oncology 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 bilateral knee replacement surgery for treatment of the enrollees knee pain. Findings:  The physician reviewer found that this patient presents with severe bilateral knee pain with significant functional limitation in activities of daily living. Clinical examination findings are consistent with x-ray evidence of bilateral severe knee osteoarthritis. Her body mass index is 46.19, with prior weight loss efforts reported as ineffective. Detailed evidence of long-term reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. She has been advised of the potential of increased complications undergoing total knee replacement due to her elevated body mass index.  She wishes to proceed with total knee replacements acknowledging that she exceeds the recommended body mass index level and there was increased risks for adverse outcome. Therefore, the requested bilateral knee replacement surgery 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services provided during a colonoscopy for treatment of the enrollee, who underwent a screening evaluation of the colon. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The Health Plan noted that MAC was not medically necessary because the provider performing the endoscopy could have injected a short acting pain medicine and short acting sedative.  Propofol is a short acting sedative anesthetic. The onset of action is dose dependent and on average is 30 seconds. The duration of action lasts 3 to 10 minutes depending on the dose. The administration of propofol necessitates a practitioner qualified to rescue the patient should they enter a state of general anesthesia. The determination of medical necessity of MAC should take into consideration many aspects of care including, but not limited to, the patients ASA classification. The selection and appropriate amount of sedation and/or anesthesia required for colonoscopy is not one size fits all. There is sufficient support for MAC in this clinical setting.  All told, anesthesia services provided during a colonoscopy were medically necessary for the treatment of this patient. 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 anesthesiology 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 surgical breast augmentation for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that the medical necessity of breast augmentation for transgender females with gender dysphoria is a case specific determination. Based on the patients diagnosis and history, her external anatomy should be more consistent with a female than a male.  Her examination detail and review of the photographs support that she has had insufficient breast development and thus continues to be more consistent with a male chest contour than a female one.  The patient is well documented to have gender dysphoria. Thus, her external anatomy should be more consistent with a female than a male. As stated above, despite her hormonal therapy, she continues to have evidence of a male chest contour with minimal breast development. Since the condition will not resolve even with hormone therapy, surgical intervention to treat this patients dysphoria is medically reasonable and appropriate. Therefore, surgical breast augmentation is medically necessary for the treatment of this patients gender dysphoria. Additionally, the requested surgical breast augmentation should be considered reconstructive in nature. The submitted clinical documentation and photographs support that she has abnormal breast development for a female. The patients abnormal condition is a result of her diagnosis of gender dysphoria. Her breast growth has not been sufficient despite hormonal therapy. The requested surgical breast augmentation would be to create a more normal appearance of breasts for a female and would be able to provide more than a minimal improvement in the appearance of female breasts. Thus, the requested surgical breast augmentation is reconstructive in nature and not cosmetic for treatment of the patients gender dysphoria.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollee, who has a family history of coronary artery disease. Findings:  The 3 physician reviewers found that this patient has increased coronary risk due to a family history of coronary disease.  In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Therefore, the superior efficacy of advanced lipoprotein testing performed has not been established. Final Result: The 3 reviewers determined that the services at issue were 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 cardiovascular disease 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 cardiovascular disease 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 and prospective authorization and coverage for denosumab (Xgeva) injections provided for treatment of the enrollees prostate cancer. Findings: Three physician reviewers found that Xgeva is a monoclonal antibody that binds to osteoclasts in bone. Along with zoledronic acid (Zometa), Xgeva has been approved by the U.S. Food and Drug Administration (FDA) for use in patients with bone metastases from prostate cancer. The goal of such therapy is to delay or prevent the worsening of the bone metastases producing clinical symptomatology and the need for radiation therapy. In one direct comparative study, Xgeva was found to be superior to Zometa. Moreover, Xgeva has been demonstrated to be beneficial in this clinical setting. Final Result: Three reviewers determined that the medication at issue was and is likely to be more benefitical for the treatment 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 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 reimbursement for residential treatment provided for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that On readmission, the patient was not a danger to herself or others. She was medically stable. She was on lithium and Seroquel after stabilization on the inpatient unit, but still had auditory and visual hallucinations of being possessed by the devil.  Although records describe her as being able to distinguish what is real versus what is not, she stated that she would consider an exorcism.  A statement such as this does not reflect an individual who believes this is not a reality.  She appeared to be in a hypomanic state in that her speech was rapid and grandiose, and her behavior and affect were elevated.  It was not until later that perception and ideation were described as normal. However, her thought process remained circumstantial, she was hyperverbal, and her mood was elevated. The patient expressed low cravings, denied depression and anxiety, and expressed the desire to remain sober.  Given her long history of instability, psychotic ideation, impulsivity, substance abuse, and noncompliance with medication, although she was not a danger to self or others and was not gravely disabled, residential treatment was medically necessary for a few days.  However, the submitted records fail to demonstrate longer residential treatment. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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.