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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intrauterine insemination (IUI) treatments. Findings:  The physician reviewer found that he decline in fertility with increasing female age is largely due to a rapid decrease in oocyte quantity and quality, with a higher proportion of oocytes displaying genetic abnormalities. Despite significant improvements in medical stimulation and laboratory culturing of embryos, the rate of success with in vitro fertilization (IVF) once female patients reach the age of 44 is negligible. Overall, assisted reproductive technology has a reasonable chance for success until a patient reaches 44 years of age. In addition, the medical literature and guidelines report that IVF has been shown to result in higher success rates than IUI. In this patients case, treatment with IUI is estimated to have a less than 3% probability of resulting in a live birth. For a fertility treatment to be supported as medically necessary, there must be a greater than 5% probability that the approach using the patients eggs will result in a live birth based on clinical history including diagnosis, menopausal status, and outcomes of previous infertility treatment. Based on this patients age and prior failure of 11 IVF cycles and 5 IUI cycles, her odds of conceiving using her own eggs below 3% with IUI. Given the patients history, the odds of aneuploidy are significantly increased while the odds of conceiving are extremely low. For these reasons, the requested IUI treatments are 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 obstetrics and gynecology with subspecialty certification in reproductive endocrinology and infertility 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 genetic testing (CPT 81519). Findings:  The physician reviewer found that Early breast cancer that is hormone receptor positive can be treated with tamoxifen alone in postmenopausal women. In this case, there is a 15% chance of recurrence, and it is this 15% that needs adjuvant chemotherapy. If all patients were treated with chemotherapy, then 85% of the patients would have never needed it. National Comprehensive Cancer Network (NCCN) guidelines support the use of Oncotype DX genetic testing. The Oncotype DX test is well validated by applying it in the patients of the NSABP B-14 trial, where 71% of these were post-menopausal, and the test has been validated over the years since completion of this trial. In this case, the patient was HR-positive and HER2-negative and had Oncotype DX Breast Recurrence Score genetic testing (CPT 81519) performed consistent with NCCN guidelines. Under these circumstances, the genetic testing (CPT 81519) at issue was medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ocrelizumab (Ocrevus) injection, inject 300 mg into the vein on day 1 and day 15, then inject 600 mg into the vein every six months. Findings:  The physician reviewer found that The records indicate that this patient presents with a history of relapsing remitting multiple sclerosis. The patients diagnosis is supported by imaging results suggestive of active lesions and clinical episodes requiring intravenous steroid infusion. Ocrevus is FDA approved for the indication of treating patients with relapsing remitting multiple sclerosis. In one clinical study, Ocrevus demonstrated superior efficacy on the three major markers of disease activity by reducing relapses per year, slowing the progression of disability, and significantly reducing MRI lesions when compared to Rebif over a two-year treatment period .Similarly, Lamb performed a review of the available medications for the treatment of patients with multiple sclerosis. The author found that Ocrevus is an effective and well tolerated medication for patients with relapsing multiple sclerosis. Moreover, this patients provider noted that although there are other medications available for the treatment of multiple sclerosis, the use of an infrequently dosed intravenous medication such as Ocrevus is likely to be more effective than alternatives and reduce the potential for medication error in a patient given the concerns for poor medication adherence. For these reasons, the requested ocrelizumab (Ocrevus) injection, inject 300 mg into the vein on day 1 and day 15, then inject 600 mg into the vein every six months is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested medication is 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 medication 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 reviewer 1 is board certified in neurology and is actively practicing. Physician reviewer 2 is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 3 is board certified in neurology with subspecialty certification in vascular neurology and is 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 Qelbree 200 mg capsule extended release. The records provided for review document that this patient has been diagnosed with attention-deficit/hyperactivity disorder (ADHD), predominantly inattentive type. The provider noted that the patient was previously treated with Qelbree with substantial benefit. Given the support for the patients diagnosis of ADHD, the patient is an appropriate candidate for treatment. However, given patients concomitant anxiety and ADHD as well as his history of severe substance use, treatment with stimulants for adult ADHD is contraindicated. Per the records, the patient has benefited from treatment with Qelbree 200 mg without any medication adverse effects. The patients provider has recommended continued treatment with Qelbree. Edinoff and colleagues noted that Qelbrees mechanism of action, clinical effects, and limited side effect profile point toward the drugs relevance in the treatment of ADHD. Singh and colleagues performed a meta-analysis to determine the safety and efficacy of Qelbree in the management of patients with ADHD. The authors reported that Qelbree was found to be significantly superior to placebo in 1,605 patients with ADHD across five randomized clinical trials. Moreover, treatment with Qelbree is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given this support, continued treatment with Qelbree is appropriate and consistent with the recommendations in the medical literature. Therefore, the requested Qelbree 200 mg capsule extended release 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 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 bilateral Gel One injections. Findings:  The physician reviewer found that Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has few available treatment options. The patient complains of severe chronic bilateral knee pain that has failed to respond to treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and bilateral corticosteroid injections. Furthermore, she is not a candidate for total knee arthroplasties due to the x-ray evidence of mild osteoarthritis. Given these findings, the requested bilateral Gel-One injections are medically necessary for 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of a portion of the thyroid gland for the purpose of performing a biopsy on the excised thyroid tissue. Findings:  The physician reviewer found that Grani and colleagues explain, Approximately 60% of adults harbor one or more thyroid nodules. The possibility of cancer is the overriding concern, but only about 5% prove to be malignant.  While surgery is the initial treatment for differentiated thyroid cancer, Singh Ospina and colleagues note, Patients with benign thyroid nodules are unlikely to suffer morbidity or mortality due to thyroid cancer. Follow-up strategies for these patients should consider this excellent prognosis and avoid causing unnecessary fear in patients. In this clinical setting, current medical literature does not support the medical necessity of the requested service. Therefore, removal of a portion of the thyroid gland for the purpose of performing a biopsy on the excised thyroid tissue is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not 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 sub-specialty certification in endocrinology, diabetes, 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation for 36 sessions.  Findings:  The physician reviewer found that The records document that this patient has a history of treatment resistant bipolar II disorder, anxiety, and depression. The provider reports that the patients symptoms have not adequately responded to treatment with medications from various classes of antidepressants and psychotherapy. The patients provider has recommended treatment with TMS. In 2020, the U.S. Food and Drug Administration (FDA) approved breakthrough device designation to TMS for the treatment of patients with bipolar depression. Multiple studies have demonstrated that repetitive TMS is an effective and safe intervention for patients with bipolar depression. McGirr and colleagues indicated that although bipolar disorder is characterized by episodes of mania/hypomania, depressive episodes present the greatest challenge for patients with the condition. The authors noted that neuromodulatory approaches such as repetitive TMS have been demonstrated to be efficacious in randomized doubleblind shamcontrolled trials for the treatment of patients with major depressive disorder. The authors concluded that more patients with bipolar depression treated with active repetitive TMS achieved clinical response as compared to patients who received placebo treatment. In addition, the requested TMS services for this patient are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Based on this patients records and the current peer-reviewed medical literature, the requested TMS services for 36 sessions  are medically necessary for 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mobile cardiac outpatient telemetry device. Findings:  The physician reviewer found that  non-real time, or off-line, monitoring devices such as extended 24-hour to 48-hour Holter monitoring, or off-line event monitoring, may detect symptomatic and asymptomatic dysrhythmias that occur frequently. Self-activated non-real time and non-continuous monitoring devices, or event recorders, are effective at recording symptomatic dysrhythmias during less frequent symptoms.  In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time, off-line, monitoring devices with auto-triggering capability may be used. The authors further note that patient-activated event recorders and other off-line monitoring devices are appropriate for initial evaluation of supraventricular dysrhythmias including atrial fibrillation. In this case, off-line analysis of a patient activated device, auto-triggered device, or extended continuous Holter monitor would be sufficient to identify dysrhythmias without jeopardizing the patients safety. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry has not been shown to improve health outcomes compared to standard monitoring techniques. In this case, there is no documentation to indicate that the patient was unable to effectively manage these standard monitoring devices and no indication that these were previously obtained to evaluate the patients condition. Therefore, mobile cardiac outpatient telemetry device was not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the mobile cardiac outpatient telemetry device at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the device at issue was not 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 upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with sub-specialty certifications in interventional cardiology and in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine and is 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 patients parent has requested reimbursement and prospective authorization and coverage for any or all residential treatment center (RTC) level of care.  Findings:  The physician reviewer found that he American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS-CASII framework, this patient meets the criteria for RTC services from 8/15/22 and forward.With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to a history of suicidal ideation and multiple suicide attempts by overdosing on insulin. During the period under review, the patient denied suicidal ideation or urges to self-harm.  In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to the patient struggling with lack of motivation, lack of energy, and poor appetite prior to RTC admission. During the period under review, the patient appears to have improved and progressed, but these gains/stabilization have been achieved while participating in the highly structured and protected RTC program. With regard to comorbidity, the records support a score of 4. The patient has major comorbidity, due to the presence of a neurodevelopmental disorder, attention deficit hyperactivity disorder (ADHD), insulin dependent type 1 diabetes requiring intensive monitoring, and a history of dietary restriction. The patient has a history of taking excessive insulin. Dietary restriction and excessive insulin intake may be life threatening, and hypoglycemia may cause mood disturbance and increased anxiety.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for nasopharyngoscopy with dilation of the eustachian tubes. Findings:  The physician reviewer found that Balloon dilation of the eustachian tube has been established as a safe and effective procedure for the treatment of eustachian tube dysfunction and obstructive otitis media. The American Academy of Otolaryngology guidelines related to the procedure, indications, and outcomes note that balloon dilation of the eustachian tube is appropriate for patients who have failed medical management, such as in this case. Conservative medical therapy in this clinical setting may consist of daily or twice daily nasal corticosteroid sprays, saline rinses and irrigations, oral antihistamines, short-term decongestant usage, and occasional short-term oral steroids and auto-insufflation. Notes documented that the patient had effusion and balloon dilation of the eustachian tube was attempted. While balloon dilation of the eustachian tube was more likely to have been more beneficial than other treatments for the right ear, the submitted records did not document any indication for the procedure for the left ear. Preoperative audiometry revealed no tympanometric abnormalities and only a sensorineural hearing loss in the left ear. The patients main complaint of hearing distortion in the left ear would not be expected to improve with balloon dilation of the eustachian tube. Therefore, nasopharyngoscopy with dilation of the eustachian tubes of the right ear was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found that a portion of the nasopharyngoscopy with dilation of the eustachian tubes at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Specifically, the reviewers found that nasopharyngoscopy with dilation of the eustachian tubes of the right ear was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the service 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 partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in otolaryngology  head and neck 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.