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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for special blood testing (advanced lipoprotein testing). Findings:  Two of the three physician reviewers found that 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 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) 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. Thus, special blood testing (advanced lipoprotein testing) was not likely to have been superior over other available methods of evaluating this patient. Final Result: The reviewers determined 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Zepatier. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Zepatier when nonstructural (NS) 5A resistance testing is not available.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for music therapy services. The submitted documentation fails to demonstrate the medical necessity of the requested services. A recent review of music therapy in mood disorders in children and adolescents concluded that music-based interventions may be efficient in reducing the severity of internalizing symptoms in children and adolescents. While these results are encouraging with respect to the application of music-based intervention, rigorous research is necessary to replicate existing findings and provide a broader base of evidence. More research adopting well controlled study designs of high methodological quality is needed. Studies show that more research on the efficacy of music therapy in children and adolescents with psychiatric illness is needed. Studies show  that no significant effects were found for two trials involving children with mood disorders and related psychopathology. These findings offer limited qualitative evidence to support the effectiveness of music on health-related outcomes for children and adolescents with clinical diagnoses. The current medical evidence does not support the requested services in this clinical setting. Therefore, music therapy 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 pediatrics and neurology with special qualification in child 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: A 44-year-old female enrollee has requested authorization and coverage for splanchnic nerve blocks. This patients records do not document that all primary pharmacological treatments and non-pharmacological treatment options have been exhausted. Specifically, there is no mention of behavior therapy despite much research to support its use. Also, not all non-opioid medications have been optimized or tried. Moreover, splanchnic nerve blocks for the treatment of non-malignant or non-pancreatic abdominal pain have limited research to support its use. For these reasons, the requested splanchnic nerve blocks are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for treatment with a neuromuscular specialist, electromyography (EMG) and nerve conduction study. Neuromuscular disorder is a broad term that refers to diseases that affect the nerves that control the muscles. There are a number of pathologies that fall within this term.  Weakness, muscle twitching and stiffness are common complaints that may or may not be associated with neuromuscular pathology. Evaluation of patients with these complaints encompasses a thorough history, physical examination, neurological imaging, neurophysiologic evaluation, and serum testing. Per the submitted documentation, this patient has undergone evaluation by multiple neuromuscular specialists. During his work-up, he underwent imaging, serum laboratory testing, and neurophysiologic testing which have been reported as unremarkable. The medical evidence does not support the requested services in this clinical setting. There is a lack of support for additional evaluation with EMG or nerve conduction study in this patients case. Additionally, the records do not support treatment with a neuromuscular specialist in this setting. Therefore, treatment with a neuromuscular specialist, EMG and nerve conduction study are not medically necessary for the evaluation and treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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: A patient has requested authorization and coverage for lumbar spinal fusion multilevel, which includes surgery for a single level fusion at L3-L4 and a cervical surgery to remove hardware and instrumentation from the patients neck. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients degeneration of lumbar intervertebral disc disease and cervicaglia. The submitted documentation supports the medical necessity of the requested services. There is substantial medical literature with regard to the performance of fusion procedures for degenerative disease of the lumbar spine with or without the presence of instability. In this patients case, the providers assessment noted there is adjacent segment disease at L3-4, retained instrumentation cervical spine posteriorly, and   bone scan confirmation of worsening endplate reactive change consistent with axial instability at that level. The fusion at L4-5 is solid. Based on the current guidelines, in the presence of adjacent segment disease and instability at L3-4, the requested anterior and posterior fusion procedure at L3-4 is likely to be beneficial for the patients degenerative disc disease. The patient has a bulging disc at L3-4. The bone scan demonstrated evidence of instability, which has not responded to nonoperative treatment. With regard to the request for cervical implant removal for continuing pain, the literature indicates a substantial improvement in pain levels in the majority of patients undergoing similar procedures. The medical records document the presence of a solid fusion. As such, removal of hardware from the cervical spine is supported. Therefore, lumbar spinal fusion multilevel, which includes surgery for a single level fusion at L3-L4 and a cervical surgery to remove hardware and instrumentation from the patients neck, is reasonable, appropriate, and 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections. Researchers noted that in cases of atypical facial pain that have failed medication management, Botox may be used successfully to treat atypical facial pain. Medical literature noted that atypical facial pain can be resistant to treatment with medications and that when medical therapy has been tried and failed, Botox treatment of the masseter and pterygoid muscles may be beneficial for long-term relief of such pain. The medical records indicate ongoing chronic facial pain that has failed conservative treatment with medications. Accordingly, the requested Botox injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested Botox injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested Botox injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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: A patient has requested authorization and coverage for Cosentyx 300 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients hidradenitis suppurativa (HS) with Hurley state 3, synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome. The submitted documentation does not support the medical necessity of the requested medication. The patient is requesting coverage for Cosentyx for treatment of hidradenitis suppurativa. The patient has tried and failed multiple therapies, including Humira, doxycycline, isotretinoin and zinc. Cosentyx is an injectable biologic, which is U.S. Food and Drug Administration approved for the treatment of psoriasis. However, the U.S. Food and Drug Administration has not approved an indication for hidradenitis suppurativa. The medical literature reveals a limited number of case reports of patients who have shown improvement of hidradenitis with Cosentyx. Currently, its use in hidradenitis suppurativa would be considered of unproven efficacy. There is insufficient medical evidence from controlled studies to show the benefit of this medication for this condition. Therefore, Cosentyx 300 mg is not medically necessary for the 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transportation. This patient has a history of complex congenital heart disease and presented with a febrile illness due to infection with concern for possible cardiac involvement. In this circumstance, transfer to a center with experience in complex congenital heart disease is medically necessary to properly evaluate and treat for potential coexisting cardiac conditions, including endocarditis. Since an active infection was present, this treatment could not have been safely delayed and constituted a medical emergency. The patients complex congenital heart disease could not have been safely and effectively managed at a facility without physicians trained in and experience with adult congenital heart disease. Therefore, transportation was necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services.Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hypoglossal nerve stimulator implantation. The submitted documentation supports the requested services in this clinical setting. The patient has severe obstructive sleep apnea and has not been able to tolerate the CPAP device. He has undergone septoplasty to address the nasal obstruction without substantial improvement. Per the records, this patient is an appropriate candidate for hypoglossal nerve stimulator implantation. Therefore, the requested hypoglossal nerve stimulator implantation 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 otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gastric bypass surgery with laparoscopy in conjunction with hiatal hernia repair. This patient has longstanding history of morbid obesity and is status post lap band removal and conversion to sleeve. The records document that the patient has sustained complications of the sleeve procedure with worsening GERD and dysphagia which may be related to the residual gastric cardia and hiatal hernia. The patients pH monitoring was consistent with severe GERD. In specific clinical setting, the standard treatment for GERD secondary to sleeve gastrectomy complications is conversion to Roux-en-Y gastric bypass surgery. This patient lost pounds with the sleeve gastrectomy and remains morbidly obese. The patient has completed an updated multidisciplinary evaluation as recommended by the American Society of Metabolic and Bariatric Surgery guidelines for repeat bariatric surgery. Medical necessity of conversion to Roux-en-Y gastric bypass surgery and hiatal hernia repair for treatment of post sleeve gastrectomy GERD with persistent morbid obesity is therefore determined. Accordingly, the requested gastric bypass surgery with laparoscopy in conjunction with hiatal hernia repair are supported as medically necessary for treatment of this patients medical condition. 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 surgery with sub-specialty certification in bariatric 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 test.  Findings:  Two of the three physician reviewers found non-small cell lung cancer, particularly adenocarcinoma, should be tested for specific mutations. Although tissue diagnosis is proven to be the most reliable, blood DNA analysis is considered a reasonable alternative in situations where tissue biopsy is not feasible. Guardant360 assay is a blood-based assay of a large array of mutations. In this particular case, where the initial diagnostic biopsy was not sufficient for mutation analysis, it would be reasonable to evaluate for these mutations in the blood rather than expose this patient to further needle biopsy. In sum, Guardant360 test was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for BRCA 1 and 2 Comprehensive Duplicate/Deletion and BART testing. Findings:  Two of three physician reviewers found that there is a lack of support for the requested services in this clinical setting. There are multiple guidelines as to who should be tested for cancer susceptibility genes, with most of the focus being on BRCA. In this patients case, neither the personal history of melanoma nor the family history support BRCA testing. In sum, BRCA 1 and 2 Comprehensive Duplicate/Deletion and BART testing are not likely to be of greater benefit than other available methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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 reviewers 1, 2 and 3 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.