Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for ADA and ATA blood testing, TPMT gene analysis testing, and COL-CHR/MS blood testing. The literature for reactive drug level testing with anti-TNF levels is primarily observational. There is currently low quality evidence to support this testing to assist in decision making regarding treatment. Based on this data, the requested ADA and ATA blood testing are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found that the requested ADA and ATA blood testing and TPMT gene analysis testing are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while COL-CHR/MS blood testing is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that a portion of 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 partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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: Upheld Decision of Health Plan

The patient is requesting coverage for fertility treatment with intrauterine insemination. The patient reports she has made multiple attempts at intracervical insemination, which were unsuccessful, and the next step is intrauterine insemination. The American Society for Reproductive Medicine indicates infertility is a disease, defined as the failure to achieve a successful pregnancy after 12 months or more of appropriate, unprotected intercourse or donor insemination. There is no evidence that this patient is infertile as the records do not support 12 failed inseminations or an inability to conceive, despite adequate sperm exposure. She is a healthy woman, and the diagnosis of infertility is not supported without adequate sperm exposure. Only if she fails to conceive with adequate sperm exposure will she be labeled as infertile. The requested future intrauterine insemination (IUI) is not medically necessary to treat the medical condition.Final Result: The reviewer determined that the requested services are not medically necessary
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for DecisionDX-Melanoma. The enrollee underwent a punch biopsy of a mole on her right frontal scalp. The pathology report showed melanoma. The DecisionDX-Melanoma genetic test assay was ordered. The report indicates the DecisionDx-Melanoma class was 1, and the sub-class was 1B. A class 1B signature is associated with a low risk of recurrence within five years. The results of the DecisionDX-Melanoma test revealed the claimant as class 1 B, which suggests a very low risk of metastatic potential. Furthermore, based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this claimant. The DecisionDX-Melanoma assay was not known to be effective at the time it was performed, based on a lack of scientific evidence showing the results will accurately guide individual care and health outcomes. In this case, the testing would not have been considered effective or useful in treatment planning. The initial evaluation for risk of metastasis in those with cutaneous melanoma uses professional society staging criteria. The DecisionDx-Melanoma gene panel is not recommended by any standard treatment guidelines.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Pain Management 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:  The enrollees parent is requesting authorization and coverage for speech therapy services twice per week. The enrollee has developmental delay, speech delay, expressive language delay, and dyslexia. He is followed by a developmental-behavioral pediatrician and has been receiving speech therapy services since he was two and a half years old. The physician recommended speech therapy services for 50 minutes per session, at a frequency of two times per week. The enrollees mother reports her son is still showing articulation problems and problems composing sentences. She reports he has problems associating with other children because of his speech problems. Records show the enrollee performed poorly on standardized testing before starting speech therapy. This enrollee has received speech therapy for seven years. Each evaluation/evaluator has used a different standardized test, and it is therefore nearly impossible to assess accurately his response to treatment. Additionally, he continues to demonstrate variable degrees of deficits in various aspects of his speech and language. This is a poor response to intervention. Children who catch up to their peers do so by age seven. Deficits remaining after that time, as seen in this enrollee, are disorders, which are unlikely to resolve.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for inpatient psychiatric hospitalization services. The enrollee has paranoid schizophrenia. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, and recovery environment, level of support, and treatment and recovery history. The enrollees composite LOCUS score correlates with Level 5, medically monitored residential treatment center; however, due to the enrollees functional status, the more appropriate level of care is Level 6, inpatient level of care.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested reimbursement for Lynch Syndrome genetic analysis testing. The enrollee has a medical history of Lynch syndrome. The genetic counselor determined the enrollees personal and family history is suggestive of a predisposition hereditary cancer. The report confirmed the enrollee was positive for a mutation, which is consistent with a diagnosis of hereditary non-polyposis colorectal cancer, also known as Lynch syndrome. The genetic cause of the illnesses affecting the enrollee and his family members was already known, based on results of prior testing. The new test only confirmed the results of the prior test. While an enrollee may be an appropriate candidate to undergo this type of genetic testing in certain situations, this testing was not appropriate for this enrollee.Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in clinical cytogenetics and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox 200 mg every 12 weeks. In 2016, the American Academy of Neurology (AAN) updated its guidelines to support the use of Botox for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. A 2018 review of the current evidence of Botox in the prevention of chronic migraine by Frampton and Silberstein reported that the available data has demonstrated that Botox is an effective and generally well-tolerated option for the prevention of chronic migraines. The authors found that Botox may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. In this case, the patient has history of chronic migraines that has not adequately responded to oral preventative medications. The use of Botox for this patient has been effective in increasing the number of headache-free days and improved quality of life. The combination of Botulinum toxin and Ajovy has further increased the number of headache-free days and extended the efficacy of Botox therapy. All told, the requested Botox 200 mg every 12 weeks is medically necessary for 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the stress echocardiography. Based on the records provided for review, the patient has no coronary risk and presented with nonagonal chest discomfort associated with a normal cardiac physical examination, a normal electrocardiogram, and normal serial troponins. In this circumstance, the patients pretest likelihood of coronary stenosis was low. Thus, further evaluation with stress testing was not supported. In this setting, according to the Bayesian approach to stress testing, a positive stress test result would likely represent a false positive result as opposed to a true positive result. The patients baseline electrocardiogram was normal, she was able to ambulate on a treadmill, and there were no murmurs on examination to warrant stress echocardiographic evaluation. All told, the stress echocardiography was not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the services at issue not were 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 internal medicine with subspecialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ NuSpin 10 mg (J2941). The records provided for review document that this patient has been growing below the third percentile for age and gender for at least two years. The patient was noted to grow 1.75 cm in one year. These factors indicate abnormal growth. In addition, bone age testing was delayed by two years, and the patients testicular size is 3 mL at 12 years of age. Moreover, the patient has a strong family history of constitutional delay of growth in his father and brothers. His current height is significantly below what would be expected from a diagnosis of constitutional delay of growth below -2.25 standard deviations below the mean for age and gender. He passed a growth hormone stimulation test, thus he does not have growth hormone deficiency. The patient was not able to have an MRI of the pituitary. However, it is unlikely a structural lesion would be found, given his growth hormone stimulation test results. His good weight gain excludes poor nutrition as the underlying reason for his poor growth. The patients mother is short for an adult female. She is 4.11, which indicates that she might have an undiagnosed genetic condition that leads to short stature. The possibility of a genetic syndrome in this patient cannot be excluded. This patient had an excellent initial response to growth hormone therapy. Given these findings, the requested Nutropin AQ NuSpin 10 mg (J2941) is medically necessary for 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 pediatrics with subspecialty certification in pediatric 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: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for intensity modulated radiation treatment delivery. The enrollee has prostate cancer. He had a radical prostatectomy and has been on anti-testosterone therapy. The cancer was staged as stage IV A; no distant metastatic disease, but concern for involved pelvic lymph nodes. Further imaging showed evidence of lymph node involvement.  The enrollees radiation oncologist recommended intensity modulated radiation therapy. The required dosage is higher than normal tissues can tolerate, particularly the bladder and rectum.  Intensity modulation is the accepted way to deliver the dose safely while minimizing the dose to normal surrounding tissues; preventing both short and long-term side effects and complications. For this enrollees situation, the target is the prostate bed, with the surrounding normal structures requiring ways to prevent complications, just as if the prostate was being treated primarily. Because of the required dosage, it is medically necessary and reasonable to use intensity modulated radiation therapy to protect the normal tissues.  This dose will exceed rectal and bladder tolerances. Only intensity modulated radiation therapy can avoid the rectum and bladder and keep those structures within tolerances.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in radiation 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting reimbursement for intensity modulated radiation therapy (IMRT). The enrollee has stage 4 rectal cancer. The enrollee had received chemotherapy and was doing well.  His physical exam did not reveal any significant abnormalities.  The physician recommended an evaluation for intensity modulated radiation therapy concurrent with chemotherapy, because it was necessary to increase the dose to the cancer while reducing the dosage to closely adjacent vital organs.  Literature demonstrated the use of intensity modulated radiation therapy with chemotherapy in the management of rectal carcinoma is associated with a clinically significant reduction in gastrointestinal toxicity when compared with three-dimensional conformal radiation therapy. Professional society guidelines indicate that, for rectal cancer, the use of intensity modulated radiation therapy should be limited to a clinical trial or other unique clinical situation. The records do not indicate intensity modulated radiation therapy is superior and must be used over three-dimensional planning.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in radiation 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for right breast implant replacement surgery. The enrollee has a history of breast augmentation. She experienced pain during a mammogram. She reported that two days later she noticed deflation of her right breast implant. An evaluation by a plastic surgeon showed the right implant was smaller. The treatment options discussed were observation, removal of the implants, or replacement of the implant. The enrollee's breasts are not currently causing any health problems, and she will not suffer any adverse health consequences if plastic surgery on the breasts is not performed.  In fact, breast augmentation puts the enrollee at risk for functional problems. A study concerning the psychological benefits of breast augmentation showed that, though improvements in body image were found postoperatively and remained throughout the study, improvements in health-related quality of life were not observed.  The proposed surgery will not improve the health-related quality of life, and the surgery will increase the risk for health problems in the future.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for residential treatment center (RTC) level of care. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. The enrollees composite LOCUS score correlates with Level IV, medically monitored non-residential services.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lyrica (pregabalin) capsule 75 mg. This patients records document degenerative arthritis and possible myofascial pain syndrome. However, her provider did not document specific tender points on physical examination, qualifying the patient for a diagnosis of fibromyalgia. In addition, there is no documentation of increased intraocular pressure or glaucoma to demonstrate that tricyclic antidepressants or muscle relaxants are contraindicated in this patient. Although the patient has been treated with gabapentin, Cymbalta, and amitriptyline, none of these medications was tried at a therapeutic maximized dose. Moreover, the records do not include documentation that the patient has exhausted behavioral therapies for management of her condition. All told, the requested Lyrica (pregabalin) capsule 75 mg is not medically necessary for treatment of 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 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.