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

Nature of Statutory Criteria/Case Summary: The Enrollee has requested authorization and coverage for residential detoxification and chemical dependency treatment program. The enrollee has been non-adherent with past treatment recommendations. The enrollee has not engaged in a recent evaluation of medical, psychiatric and substance use symptoms. The treatment team has recommended against residential treatment on several occasions due to the patients lack of treatment adherence. A study found, the requested services are not medically necessary. For dimension 1) acute intoxication and/or withdrawal potential, the progress notes indicate that the patient has no reported recent significant withdrawal symptoms. The clinical information provided does not support acute intoxication and withdrawal. For dimension 2) biomedical condition and complications, the patient does not have any reported comorbid conditions or complications. The clinical information provided does not support significant biomedical conditions and complications. According to the criteria, the patient must meet all six dimensions for placement in at the residential level of care. This enrollee does not meet the first two dimensions, and thus does not meet the criteria for residential treatment. Therefore, the requested residential detoxification and chemical dependency treatment program is not medically necessary for 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 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: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the brain. This patients initial clinical presentation was most consistent with migraine with no abnormal findings on examination or significant change in headache pattern described. Therefore, his initial presentation is consistent with Variant 4, which did not support an indication for initial computed tomography (CT) or MRI. However, the patient has repeated complaints of headache and multiple visits suggest Variant 7 presentation, chronic headache presenting with new features or increasing frequency. As a negative head CT scan is not the preferred imaging modality in the non-acute setting, this supports an indication for the requested MRI of the brain. The patient does describe worsening headache during the emergency department visit. The American College of Radiology (ACR) appropriateness criteria states that, further workup is indicated including neurologic imaging in patients for whom the frequency, severity, or character of headache changes in the setting of a prior history of benign headaches. The patients headache increased in severity, which is considered a red flag. Therefore, the requested MRI of the brain is medically necessary for evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 an osteogenesis stimulator.Findings:  Three physician reviewers found that there is sufficient support for the requested device in this clinical setting. Nonunion rates as high as 40% have been reported after fixation of os acromiale. In this patients case, more than five months have elapsed since the surgery. The records document a 3 mm gap, indicating the presence of an established nonunion. The current literature supports the use of an osteogenesis stimulator in this case. Therefore, the requested osteogenesis stimulator is likely to be more effective than other treatment options.Final Result: The reviewers determined that the requested device is 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 reviewers 1, 2 and 3 are board certified in orthopedic surgery 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: The patient has requested authorization and coverage for FORA V30a Blood Glucose Test Strips for 10 strips per day. Based on current data, the requested FORA V30a Blood Glucose Test Strips for 10 strips per day are supported as medically necessary for 90 days while the patients provider is performing the diagnostic evaluation for hypoglycemia. Hypoglycemia in a non-diabetic patient is a serious condition that can lead to mental status changes and loss of consciousness and seizures. This patient may have reactive hypoglycemia. The patient requires testing of her glucose levels whenever she has symptoms, to confirm that she is having a hypoglycemic reaction, and treat it if so. During the work-up, this increased frequency of testing is justified. Once the diagnosis is determined, the patient should undergo treatment, which should decrease the frequency of testing. Whether the diagnosis is reactive hypoglycemia tied to prediabetes or another cause, the need for testing should decrease once the etiology is found. Thus, the FORA V30a Blood Glucose Test Strips for 10 strips per day for 90 days is medically necessary for treatment of this patient.Final Result: The reviewer determined that a portion of the requested medical supplies are 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 internal medicine with subspecialty certification in diabetes, endocrinology 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 reimbursement for a tap water iontophoresis device. Findings:  Three physician reviewers found that there is sufficient support for the device at issue in this clinical setting. This patient has been diagnosed with primary focal hyperhidrosis. Researchers noted that iontophoresis is safe and effective for the treatment of palmar and plantar hyperhidrosis. The researchers also noted that this modality may be combined with other treatments, including Botox injections and topical antiperspirants. This patients condition has impacted her quality of life. Thus, the tap water iontophoresis device was likely to have been more effective than other treatment options. Final Result: The reviewers determined that the device at issue was likely to have been 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 reviewers 1, 2 and 3 are board certified in internal medicine 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: The patient has requested authorization and coverage for genetic testing for breast and ovarian cancer risk. Panel testing is considered the standard of care in this clinical setting. This patient meets the National Comprehensive Cancer Network (NCCN) criteria for genetic testing based on her family history. She is at risk to carry a BRCA1 or BRCA2 mutation or a variety of other mutations. Genetic testing is reasonable to evaluate her risk and establish strategies to decrease her risk of a second malignancy should she be shown to harbor an inherited mutation. Therefore, genetic testing for breast and ovarian cancer risk is 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 the requested services are 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 subspecialty certifications in medical oncology and hematology and is actively practicing. One reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. One reviewer is board certified in internal medicine with subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral injections of Synvisc-One. The medical evidence supports the services at issue in this clinical setting. Viscosupplementation is widely used for the treatment of knee osteoarthritis. Researchers compared the efficacy and safety of a single intra-articular injection of Hya-Joint Plus with a single injection of Synvisc-One in patients with knee osteoarthritis. The researchers noted that both were safe and effective for six months in patients with knee osteoarthritis. The literature indicates that both the single injection regimens as well as the multiple injection regimens are safe and effective. All told, the services at issue were medically indicated in this patients case. Therefore, bilateral injections of Synvisc-One 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a custom fabricated myoelectric arm brace to restore elbow and hand function. This patient had a right intracerebral hemorrhage. He has severe weakness and moderate to severe spasticity on his non-dominant hemiplegic side. The medical evidence has not demonstrated the benefit of the requested device on functional limitations in this setting, especially since the patients clinical presentation is complicated with moderate to severe spasticity. The requested device is not standard of care, and further studies are needed to establish the superior efficacy of the requested device in this patients case. Therefore, the requested custom fabricated myoelectric arm brace to restore elbow and hand function is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested device 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: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco. Findings:  The physician reviewer found that the Centers for Disease Control and Prevention (CDC) state that there is adequate support for short-term efficacy of opioids for reducing pain and improving function in non-cancer, nociceptive and neuropathic pain in randomized clinical trials lasting primarily =12 weeks. The American Society of Interventional Pain Physicians (ASIPP) guidelines for opioid therapy noted clinical evidence review found insufficient evidence to determine whether pain relief is sustained and whether function or quality of life improves with long-term opioid therapy. ASIPP guidelines recommend non-opioid pharmacologic therapywhen benefits outweigh riskscombined with non-pharmacologic therapy. In this case, the physical examination findings and imaging results do not support the continuation of opioid therapy. The medical records do not document an appropriate trial of non-opioid and non-pharmacological treatment for this patient which is consistent with current medical guidelines. Therefore, Norco is not medically necessary for treatment of the patients medical condition. 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 subspecialty certification in pain management 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 who was diagnosed with obesity. She underwent a sleeve gastrectomy and lost a significant amount of weight, resulting in loose and excess abdominal tissue. The patient reported frequent rashes and difficulty with hygiene due to the excess lower abdominal skin. The patients body mass index was 32.81. Her abdominal pannus was noted to cover the region of the mons pubis. No evidence was noted of a rash under the skin fold, and no active wounds or infections were present. Preoperative photographs demonstrate a large lower abdominal pannus that hangs below the pubis. There is also a smaller upper abdominal pannus overhanging the umbilical area. The patient has requested reimbursement for abdominoplasty with flank liposuction surgery that was provided. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient and were not reconstructive in nature. At issue in this case is whether abdominoplasty with flank liposuction surgery that was  provided was medically necessary for the treatment of the patients medical condition and whether the services at issue were reconstructive in nature. Abdominoplasty is typically performed for cosmetic purposes and involves the removal of excess skin and fat from the pubis to the umbilicus or above. When abdominoplasty or panniculectomy are performed solely to enhance a patients appearance in the absence of signs or symptoms of functional abnormalities, the procedure is considered cosmetic in nature. In this case, there is no report of intractable intertrigo, skin ulceration, chronic pain, or inability to walk as a result of the patients upper abdominal pannus. Therefore, abdominoplasty with flank liposuction surgery that was provided was not medically necessary for the treatment of this patient. An abdominal pannus is not an abnormal structure of the body. It is a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is consistent with the gain and loss of weight. Therefore, abdominoplasty with flank liposuction surgery that was provided on 11/28/18 was not reconstructive in nature.Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition and were not reconstructive in nature. Therefore, the Health Plans denial should be upheld.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:  The enrollee requested coverage for Guardant 360 Panel Testing for treatment optimization of non-small cell lung cancer status post biopsy.The enrollee was undergoing targeted treatment and was experiencing progression in her disease; therefore, Guardant 360 was performed to determine if there were any additional targeted therapy options available for her disease and to identify if there were any therapy resistant mutations. Findings:  The physician reviewers found that based on a review of existing evidence, there is no clinical indication for the use of whole genome/X home sequencing for cancer. While individual gene or syndrome specific gene panel testing based on established risk assessment and management guidelines may be appropriate, evidence is insufficient, conflicting and demonstrates an incomplete assessment of net benefit versus harm. Additional research has been recommended.  As per the literature only a  handful of genes are of any value in helping select therapy. Although there are scattered reports in the medical literature to suggest some benefits of the test, this is still not the standard of care and the test still needs several studies before any conclusions are made regarding its value. The medical literature has addressed new information in regard to plasma cell-free/circulating tumor DNA testing (liquid biopsy) for genetic alterations. Briefly, the panel indicated cell-free/circulating tumor DNA testing should not be used in lieu of tissue diagnosis.  Standards and guidelines for cell-free DNA/circulating tumor DNA testing for genetic alterations have not been established, there is up to a 30 percent false-negative rate, and alterations can be detected that are not related to the tumor. Cell-free DNA testing can be used in specific circumstances if the patient is not medically fit for invasive tissue sampling or if there is insufficient tissue for molecular analysis and follow-up tissue-based analysis will be done if oncogenic driver is not identified.  Review of the record does not show the enrollee is medically unfit to undergo invasive tissue sampling. Final Result: Three of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in Hematology and Oncology. One reviewer is board certified in Internal Medicine and Oncology. All 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: An enrollee requested reimbursement for hyaluronan injections. A review of the literature pertaining to viscosupplementation reveals mixed results. Studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Viscosupplementation is recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. In this case, there is no documentation of prior viscosupplementation. She had palpitations and deterioration of her eyesight from corticosteroid injections. As such, her options were limited. The osteoarthritis in her knees was reportedly mild. Therefore, she was not a candidate for a total knee arthroplasty. Based upon the degree of chronic knee pain and limited options with an inability to take corticosteroid injections, the services at issue were medically necessary. Therefore, hyaluronan injections 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 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.