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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Forteo 20 mcg/dose pen injection subcutaneously daily. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. The patient has been estrogen deficient for many years. She has a diagnosis of rheumatoid arthritis, a disease that causes bone loss. For treatment of this condition, her provider had treated her with prednisone, which promotes bone loss. The patient has osteoporosis as determined by the FRAX scores, calculated with information based on patients medical history. The FRAX score places patient at 27% risk for a major osteoporosis fracture and 9.1% risk of a hip fracture within 10 years. Based on this criteria the patient qualifies for pharmacological treatment. The National Osteoporosis Foundation (NOF) guidelines indicate that U.S. Food and Drug Administration (FDA) approved medical therapies should be considered with low bone mass (osteopenia) and a US-adapted World Health Organization Scientific Group (WHO) 10-year probability of a hip fracture greater or equal to 3% or 10-year probability of any major osteoporosis related fracture greater or equal to 20%. The choice of Forteo for treating this patients osteoporosis is well supported by the patients records. There is some medical evidence that have shown antiresorptive agents, such as bisphosphonates and denosumab, to decrease bone turnover. In theory, this mechanism could interfere with healing of bone. The medical literature has not been consistent on whether these agents are favorable or unfavorable for the healing of vertebral fusion surgeries. However, the medical literature is consistent in indicating beneficial effects of teriparatide (Forteo) in the healing of vertebral fractures and fusion surgery. The patient has an upcoming spinal fusion surgery. This patient has osteoporosis that must be treated with an FDA approved medication to prevent a major osteoporotic fracture. Therefore, Forteo 20 mcg/dose pen injection subcutaneously daily is medically necessary for the treatment of this patients osteoporosis. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: The patients parent has requested authorization and coverage for a Medtronic 670G hybrid closed loop system device. Findings:  Three physician reviewers found that in multiple studies collected in referenced meta-analyses, insulin pumps have been able to demonstrate improved mean blood glucose concentration, glucose variability, hemoglobin A1C and to reduce insulin requirements by 14% over multiple daily injections of insulin in patients capable and motivated to use the pump . It remains the best available option for type 1 diabetes. CGM systems including real-time systems have U.S. Food and Drug Administration (FDA) approval. In addition, the peer-reviewed literature and American Diabetes Association supports the use of long-term CGM devices in patients with type 1 diabetes with hypoglycemia unawareness and episodes of hypoglycemia. The Medtronic MiniMed 670G has the capability of adjusting basal rates to avoid hypoglycemia and suspending insulin delivery to avoid hypoglycemia. All told, the requested Medtronic 670G hybrid closed loop system device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 3 of 3 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 number one and two are board certified in pediatrics with sub-specialty certification in pediatric endocrinology and are actively practicing. Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing for evaluation of the enrollees cutaneous melanoma.  Findings:  The physician reviewer found that The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Gene Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for MyRisk cancer test for evaluation of the enrollees risk for cancer. Findings:  2/3 of the physician reviewers found that the current medical evidence supports a portion of the services at issue. In this patients case, she was evaluated with a gene panel, which included genetic testing for multiple cancer types. She meets the National Comprehensive Cancer Network guidelines to test for BRCA1 and BRCA2 since she and has a family history of ovarian cancer. As for the genetic testing for other cancers, there is a lack of prospective randomized controlled studies showing improved outcomes correlating the results obtained from similar expanded genetic panel tests with improved overall survival, progression free survival and / or quality of life. These tests have yet to be correlated with improved outcomes. Both National Comprehensive Cancer Network guidelines and American Society of Clinical Oncology guidelines encourage research to delineate the optimal use of panel-based testing, development of evidence-based practice guidelines as data emerges, and education of providers regarding challenges in the use of these tests. Therefore, BRCA1 and BRCA2 testing were likely to have been of greater benefit than other methods of evaluating this patient. However, the superior efficacy of the remainder of the genetic testing has not been established. Final Result: 2/3 of the reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an electric power scooter. Findings:  The physician reviewer found that there are no medical indications in the submitted records to establish the patient would be bed confined without a power mobility device. According to the documentation, the patient has health conditions that would be better addressed through higher levels of physical activity, rather than the lower levels of physical activity that a power mobility device would encourage. This was addressed in his primary care clinic visit, where health goals of keeping blood pressure under 140/90 and keeping his weight down were discussed. Per the patients documentation, there is no significant pertinent neurological or musculoskeletal impairments that would preclude ambulation with a cane or walker. There are no indications in the records to establish that the patient would be bed confined without a power mobility device. The patient has no significant pertinent neurological or musculoskeletal impairments that would preclude ambulation with a walker. There are also no significant pertinent neurological or musculoskeletal impairments that would preclude self-propulsion of an appropriately fitted manual wheelchair. Therefore, the requested electric power scooter is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 reimbursement for gene panel testing for evaluation of the enrollee who presented for prenatal care. Findings:  The physician reviewer found that The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine recommends cell free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. Since this patient is older than 35 years old, the aneuploidy risk for this patient, in this pregnancy, warrants cell free DNA testing for aneuploidy including monosomy X. For these reasons, the gene test performed was likely to have been of greater benefit in evaluating this patients medical condition than the available standard therapy. Final Result: Three reviewers determined that the services at issue were 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: Physician reviewer number one is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in obstetrics and gynecology 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 bioimpedance spectroscopy for evaluation of the enrollee who has a history of HER2 breast cancer. Findings:  The physician reviewer found that patient has risk factors for lymphedema including documented BMI greater than 25 and having had taxane chemotherapy. The patient is undergoing surgery that could include an axillary lymph node dissection, which would potentially benefit from bioimpedance spectroscopy measurements taken preoperatively. The plan was to also monitor the patient postoperatively for early signs of subclinical lymphedema and hopefully prevent chronic lymphedema from occurring. The medical literature indicates that bioimpedance spectroscopy provides a more accurate measurement than the measurement of arm circumference. It also has the potential to detect lymphedema earlier than circumferential measurements. For these reasons, bioimpedance spectroscopy was likely to have been more efficacious for the evaluation of this patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were 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: Physician reviewer number one is board certified in 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.Physician reviewer number two is board certified in 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.Physician reviewer number three is board certified in surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a positron emission tomography (PET) scan with computed tomography (CT) attenuation for evaluation of the enrollees metastatic cancer of unknown origin. Findings:  The physician reviewer found that This patients records document that the pathology diagnosis was not lymphoma but metastatic adenocarcinoma of unknown primary tumor. The patient underwent extensive work-up using standard imaging studies as well as endoscopy in an effort to establish a primary diagnosis without success. Since the detection of a primary tumor is critical to optimal therapeutic and possibly surgical treatment, positron emission tomography (PET) with computed tomography (CT) attenuation was indicated to try to identify the patients primary tumor. The National Imaging Associates (NIA) guidelines state that PET/CT is appropriate if there is an indication to localize for an invasive procedure for biopsy or surgery. Thus, the PET scan with CT attenuation was medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the diagnostic procedure at issue was 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 reimbursement for gene panel testing (BRCA testing and MyRisk) for evaluation of the enrollee, who has a family history of breast cancer. Findings:  The physician reviewers found that there is support for the services at issue in this patients case. The documentation noted that her mother developed breast cancer at age 53. Additionally, the patients mother reportedly tested positive for ATM mutation. The medical evidence supports the gene panel testing in this clinical setting. Thus, gene panel testing (BRCA testing and MyRisk) was likely to have been of greater benefit than other modalities for evaluating this patient.  Final Result: Two of three reviewers determined that the services at issue was 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:  Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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: An enrollee has requested reimbursement for skilled nursing services for treatment of the enrollee, who has a history of altered mental status. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. During the dates of service in dispute, the patient did not require any skilled nursing or rehabilitation services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time. He did not require skilled therapy to prevent deterioration with mobility or activities of daily living. The patient did not require skilled therapy to establish a safe and effective maintenance program. During the timeframe in dispute, the patient did not have any parental medications, complex wound care or nutrition given via a feeding tube. Per the records, his function had plateaued by the period of care under review and he did not require any further inpatient skilled rehabilitation services. The current medical evidence does not support the services at issue in this clinical setting. Therefore, skilled nursing services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine 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 a referral for the removal/destruction of skin lesions for treatment of the enrollees sebaceous cyst. Findings:  The physician reviewer found that Review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested referral. According to the documentation submitted for review, the patient presents with a growth located on the upper back without symptoms of pain, inflammation, intractable itching or interference with function. The patients provider evaluated the growth and the assessment was an epidermoid cyst. Based on the clinical documentation submitted for review, the requested referral for the removal/destruction of skin lesions is not supported as medical necessity for treatment of the patients asymptomatic, benign lesion. Final Result: The reviewer determined that the requested referral 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.