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 acupuncture and an epidural for treatment of the enrollees pain.  Findings:  The physician reviewer found that The physician reviewer found the submitted documentation supports the medical necessity of a portion of the requested services. Epidural steroid injections are indicated for acute radicular pain, spinal stenosis, neural foraminal stenosis, post laminectomy pain syndromes or acute herpes zoster.  This patient does not have any of these indications. Thus, an epidural steroid injection is not medically necessary for the treatment of this patient. Acupuncture may have efficacy in widespread pain syndromes, with only minimal side effects and complications. As acupuncture has provided some benefit in this patients case, it is medically appropriate. All told, the requested acupuncture is medically necessary for the treatment of this patient.  However, the records fail to demonstrate the medical necessity of the requested epidural. Final Result: The reviewer determined that a portion of the requested services is 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for computed tomography (CT)-guided microwave ablation left hepatic lobe mass with anesthesia. Findings:  Three physician reviewer found that the request for CT-guided microwave ablation left hepatic lobe mass with anesthesia is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The medical records fail to indicate that this patient is not a candidate for additional chemotherapy or radiation. In addition, there is a lack of peer-reviewed evidence that microwave ablation of this patients left hepatic mass will provide a better clinical health outcome that available standard therapies of surgical resection or additional chemotherapy and radiation. For the reasons provided, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the requested services are 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 reviewer number one is board certified in interventional radiology and diagnostic radiology and is actively practicing. Physician reviewers number two and number three are board certified in radiation 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for individual therapy every two weeks for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that The physician reviewer found the submitted documentation supports the medical necessity of the requested services. The literature indicates that psychotherapy for bipolar disorder is effective for symptom management. The literature does not specify the exact frequency of psychotherapy. Typically, the frequency is dictated by the symptom presentation of the patient. In this case, the patient has mood symptoms that have continued over the past several months.  The progress notes indicate tearfulness and episodes of increased depression and anxiety.  She has been participating in therapy, but her symptoms are not significantly improving as evidenced by her PHQ-9 scores and clinical symptoms. The medical evidence supports the requested services in this clinical setting. Therefore, the requested individual therapy every two weeks 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for methylenetetrahydrofolate reductase (MTHFR) gene mutation testing for evaluation of the enrollees inability to break down a variety of different substances. Findings:  The physician reviewer found that in recent years, genetic polymorphisms in the methylenetetrahydrofolate reductase (MTHFR) gene have been associated with adverse reactions to the smallpox vaccine. Similarly, mutations in the MTHFR gene have also been implicated in medical conditions. While MTHFR mutations have been implicated in several disease processes, routine sequencing for MTHFR mutations is not considered standard of care. Recent meta-analyses have disproven an association between hyperhomocysteinemia and risk for coronary heart disease and between MTHFR polymorphism status and risk for venous thromboembolism. There is growing evidence that MTHFR polymorphism testing has minimal clinical utility even in the setting of thrombophilia. All told, the requested MTHFR gene mutation testing is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested testing 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 pediatrics with sub-specialty certifications in neurodevelopmental behavioral pediatrics and genetics 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 reimbursement for Synvisc (hyaluronan) injections for treatment of the enrollees bilateral knee pain. Findings:  The physician reviewer found that colleagues concluded that there is a general lack of reliable evidence that any specific brand is superior to others. However, some clinically important reductions in pain have been noted, after closer review of systematic reviews and meta-analyses, using higher molecular weight and cross-linked formulations. Synvisc and Synvisc One are crosslinked with molecular weight 5-6 M (million Daltons). Euflexxa (2.4-3.6 M) and Orthovisc (1-2.9M) are not cross-linked. Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. This patient presented with severe bilateral knee pain, left greater than right. Pain interfered with sleep and activities of daily living. The patient had failed to improve with ibuprofen. The patient had prior viscosupplementation years prior which helped for over years. X-rays showed severe degenerative arthritis of both knees, bone on bone in the left knee. Clinical examination documented limited range of motion with crepitus. She received Synvisc One injections into both knees on with excellent relief reported on the right side and no relief on the left side. Records documented that a subsequent corticosteroid injection was performed to the left knee. There was no documentation of additional Synvisc One injections in the submitted medical records. Criteria were met for the use of viscosupplementation for this patients medical condition. However, current evidence based medical guidelines and peer reviewed literature state that there is a general lack of reliable evidence that any specific brand is superior to others. There is no compelling rationale presented to support the medical necessity of Synvisc One over the formulary viscosupplementation agent. Therefore, Synvisc (hyaluronan) injections were not medically necessary for the treatment of the patients medical condition. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Per the medical records provided, the patient has a longstanding history of difficulties with impulse control, aggression, and emotion regulation. The patient met with a child psychologist starting at age and had an Individualized Education Plan starting in school with placement in a highly structured classroom with an aide. Prior to admission to the residential facility, the patient ran away from home several times and was failing classes at school.  The patient was admitted for ten days to an inpatient facility after he engaged in self-injurious behavior via cutting on his face and arms and posted these images on social media with a message about being depressed. The patient was documented as not willing to participate in treatment during the hospitalization. Upon admission to the residential treatment facility, the patient was described as angry, irritable and guarded.  The patient was placed on 1:1 precautions.  The patient was documented as displaying angry, impulsive, and aggressive behavior and physically assaulted a staff member.  The patient was described as anxious, tearful, and overwhelmed with significant rigidity.  The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth. The CASII utilizes dimensions that are relevant to the patients clinical status when determining appropriate level of service intensity.  Based on the patients clinical history provided and documentation as outlined above, the patient met CASII criteria for non-secure 24 hour psychiatric monitoring. The patients clinical status, in addition to current medical literature, support that the treatment at the residential level of care.  Therefore, residential treatment center services were medically necessary for 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 psychiatry with sub-specialty certification in child and adolescent 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patients parent has requested authorization and coverage for Nutropin AQ NuSpin 20 mg for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found the patient has a normal IGF-1 level for pubertal stage and his adult height prediction of 68-68.5 inches is normal for US adult males. He is not known to have any morphological abnormalities of his pituitary gland and does not have evidence of pituitary dysfunction. The most likely cause of his fall-off in growth and delayed bone age is constitutional delay, not GH deficiency. His height velocity is expected to accelerate spontaneously with progression in pubertal development. All told, the requested Nutropin AQ NuSpin 20 mg is not supported as medically necessary for treatment of this patients idiopathic short stature. 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 pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for upper arm and breast lift procedures for treatment of the enrollee who has a history of excess skin due to weight loss. Findings:  The physician reviewer found that the requested services are not medically necessary and are not reconstructive in nature. Overall, there has been insufficient documentation to support that there is a functional deficit related to this patients excess soft tissue.  As such, the requested services are not medically necessary. Based on the submitted records, the patient has generalized skin laxity consistent with her history of massive weight loss. Correction of skin laxity following massive weight loss is not medically necessary in the absence of clear and compelling documentation of specific signs and symptoms. The medical literature states that the requested services must clearly be related to the excess skin, are health threatening or cause significant functional disability and have failed to improve despite reasonable attempts at conservative therapy. The submitted medical records do not include, over time, documentation of a series of office notes, dermatology consultations, pharmacy prescription records of skin fold, and photographs documenting cellulitis, ulcerations or rashes.  In addition, the medical records do not provide any documentation in the form of a primary care provider or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either never responded to topical therapy given or despite initial response, have recurred and caused significant functional impairment. With regards to whether the proposed surgeries are to correct an abnormal body structure, the records do not support that this patients loose arm skin and breast ptosis are abnormal body structures. Skin laxity and breast ptosis are findings with aging, breastfeeding and weight fluctuation. As such, these proposed procedures do not meet the criteria for reconstructive surgery. Therefore, upper arm and breast lift procedures are not medically necessary for treatment of this patients medical condition and are not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for wireless capsule endoscopy for evaluation of the enrollees abdominal pain. Findings:  2/3 of the physician reviewers found that the physician reviewer found this patient has had symptoms and biopsy findings suggestive of possible Crohns disease. Capsule endoscopy is useful for the diagnosis of Crohns disease or determination of the extent of disease activity, and has been demonstrated to be superior to radiographic imaging tests such as small bowel follow through. Capsule endoscopy has proven superior to current forms of radiological testing of the small intestine in detecting the mucosal abnormalities of non-stricturing Crohns disease. Per the study by colleagues, the frequency of small intestinal Crohns disease activity found by capsule endoscopy in a consecutive series was approximately double that detected by computed tomography enteroclysis, leading to change in management in a significant number of patients. In this patients case, wireless capsule endoscopy was likely to have been more effective than other available modalities for evaluating this patient.  Final Result: 2/3 of the 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 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.Physician reviewer number two 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.Physician reviewer number three 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services. Findings:  The physician reviewer found that the medical services provided were necessary for treatment of an emergency medical condition. In this case, the patient presented to the emergency department and was diagnosed with a potentially malignant, life threatening large abdominal tumor. Due to his emergent presentation, he underwent partial bowel resection. Based on the clinical documentation submitted for review, the patient received emergency medical services for an emergency medical condition on the date of service in dispute. Final Result: The reviewer determined that the patient receives 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 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: An enrollee has requested authorization and coverage for total bilateral ankle replacement. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Total ankle arthroplasty or tibiotalar arthrodesis is indicated for surgical management of end-stage ankle arthritis. Although the complication rate of the total ankle arthroplasty is higher than ankle arthrodesis, it is more widely requested by patients. In this patients case, x-rays revealed no tibiotalar arthritis on the left side and narrowing of the joint space and slight irregularity of the tibiotalar joint on the right side, with no bone destruction. These radiology findings do not support the request for total ankle arthroplasty, which is indicated as an option for end-stage arthritis. The current medical evidence does not support the requested services in this clinical setting. Therefore, total bilateral ankle replacement is 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 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.