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 platelet-rich plasma injection (CPT 0232T).Findings:  Two of the three physician reviewers found that this patient presented with persistent left shoulder pain and dysfunction. He was diagnosed with left shoulder impingement syndrome. Imaging demonstrated findings consistent with chronic, severe tendinosis with possible chronic intrasubstance tearing. He underwent left shoulder arthroscopy, debridement of labrum, subacromial decompression with bursectomy, acromioplasty, and Mumford procedure, with insertion of platelet-rich plasma to the left shoulder at the time of surgery. At this time, there is an absence of large well-designed clinical studies to support the safety and efficacy of platelet-rich plasma in the treatment of rotator cuff pathology or to assist in tissue healing. Therefore, platelet-rich plasma injection (CPT 0232T) was not likely to have been more effective than other treatment options. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certification in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne genetic tests.Findings:  Two of the three physician reviewers found Molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network guidelines strongly advise broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. In sum, FoundationOne genetic tests were 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 evaluation 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for CPAP (continuous positive airway pressure) device and supplies. The Health Plan has denied this request indicating that the requested equipment and supplies were not and are not medically necessary for treatment of the enrollees sleep apnea.At issue in this case is whether the CPAP device and supplies were and are medically necessary for treatment of the patients medical condition.Continuous positive airway pressure (CPAP) is considered the treatment of choice for obstructive sleep apnea (OSA), and studies have shown that there is a correlation between patient adherence and treatment outcomes. Generally, a patient is considered `compliant` with the use of a CPAP device; if there is use on greater than or equal to 70 percent of nights for four or more hours. This is based on the threshold the Centers for Medicare and Medicaid Services (CMS) has established within a 30 day window. In this case the patient has not demonstrated compliance as is generally accepted/defined within current standards of practice/care. Rather the patient only used CPAP for four or more hours per night on less than 50 percent of nights (and even then she used CPAP for less than 70 percent of nights in total.) This is otherwise inconsistent with CPAP compliance.  Continued use of CPAP in a non-compliant patient is not otherwise consistent with the standards of medical practice. The records provided for review did not demonstrate that the patient was compliant with CPAP. Therefore, the CPAP device and supplies were not and are not medically necessary.Final Result: The reviewer determined that the requested device and supplies were not and 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 neurology with subspecialty certification in sleep 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: A male enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees alcohol abuse and depression.At issue in this case is whether the requested residential treatment center services were medically necessary for treatment of the patients behavioral health condition.The American Society of Addiction Medicine (ASAM) 2013 guidelines for residential treatment evaluates patient status along six dimensions including acute intoxication; other biomedical conditions; emotional/behavioral/cognitive functions; readiness to change; relapse/continued use potential; and recovery environment. To be eligible for residential treatment care, the patient must meet all six criteria.Documentation provided for this review indicates that the patient was in mild withdrawal although no clinical institute withdrawal assessment (CIWA) scores were provided. He did not have a biomedical condition that would interfere with treatment and was deemed to be medically stable. He was able to participate in therapy, and noted to not have significant functional defects or impulse control. By medical records, he is a recidivist to treatment and was likely to relapse. He was noted to be motivated to change. By this evaluation, this patient did not meet all six ASAM criteria (did not meet emotional/cognitive and biomedical condition requirements) and therefore was not eligible for residential treatment facility. Therefore, the residential treatment services at issue were not medically necessary.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 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

Findings:  The physician reviewer found that the parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin 20mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency. At issue in this case is whether the requested Nutropin AQ Nuspin 20 mg is medically necessary for treatment of the enrollees medical condition.This patient has been growing between the 50th and 25th percentile for height without significant linear deceleration that crosses percentiles. His height was 139.8cm and 134.1cm in the previous year. This gives him an actual growth velocity of 5.7cm in one year, which is great and does not suggest poor growth. The last bone age study was done at 10 years of age, which was read as bone age of 10 to 11 years old, giving him an estimated adult height of 67.5 inches. His mid parental target height is 69.75 inches. He had a growth hormone (GH) stimulation test with clonidine and another one with glucagon, with both values <10ng/m (6.3 with glucagon and 7.2 with clonidine) He had a normal magnetic resonance imaging (MRI) pituitary and later started on growth hormones (GH).The failed GH stimulation tests noted in the records, in the absence of poor growth, do not suggest GH deficiency as there can be false positive tests for the diagnosis of GH, especially in pre-pubertal children. There is not one single test that makes the diagnosis of GH but rather a constellation of clinical and biochemical features, which this patient does not have based on the medical records.There is no documentation of the pubertal state of this child. Pre-pubertal children or children with late puberty can experience small linear decelerations that are temporary and do not require treatment with GH. The estimated predicted adult height of this patient based on the bone age is within the normal range for his mid-parental height. It is also within the normal range for an adult male. Therefore, the requested growth hormone Nutropin AQ Nuspin 20mg is not medically necessary. 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 subspecialty in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services from 11/5/18 through 11/13/18. The Health Plan has denied this request indicating that the requested services were not medically necessary for treatment of the enrollees depression and suicidal ideation. A review of the record indicates that the enrollee has been diagnosed with major depressive disorder, generalized anxiety disorder, and attention-deficit hyperactivity disorder. The enrollee was admitted to a residential treatment program on 10/12/18, following discharge from a six-day inpatient hold. The enrollee was noted to have denied suicidal ideation, with continued feelings of depression, and remaining unmotivated. The provider noted there was little improvement in mood despite increased medication, and expressed concern with the enrollees ability to tolerate everyday stressors due to severity of depression. This appeal concerns denial of stay at a residential treatment center. During the disputed timeframe of 11/5/18 through 11/13/18, the patient showed cooperative behavior and treatment progress. Patient was not noted to have any difficulties with staff. The notes indicated that patient had issues with peers on occasion. Patient followed all treatment programming as she was instructed. The progress notes indicated that patient was open and honest in regards to their feelings about past substance use, mood, and relationship with the family. Patient did not have active suicidal or homicidal ideation and did not engage in self-harm. The patient did not display aggression towards peers or staff during the disputed period. Patient continued to have depression and anxiety as the main issues. Patient's family was very involved with their treatment and appeared to understand their needs. The patient did not express any symptoms of psychosis. This gives the patients presentation a composite score of 18. This score correlates with a treatment intensity level of three which correlates with `Intensive Outpatient Services`. This score is judged by the acuity of the patients symptoms and environment during the period under dispute at the RTC of 11/5/18 through 11/13/18. According to the CALOCUS, the patient would need to have a score of 23-28 in order to require treatment in an RTC. Therefore, the requested treatment was determined as not medically necessary.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent pschiatry 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 the enrolle has requested authorization and coverage for the medication Zomacton. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature and history of delayed puberty. short stature is defined as a height that is 2 standard deviations or more below the mean height; for individuals of the same sex and chronologic age in a given population. This translates to a height that is under the 3rd percentile. The most common causes of short stature beyond the first year or two of life are familial (genetic) short stature and constitutional short stature (also known as constitutional delay of growth and puberty); which are normal nonpathologic variants of growth. This patient has no apparent linear deceleration. She has been growing along the 25th percentile as shown on the growth curve. Therefore, abnormal growth is unlikely when a child is growing along her curve. This child had a delayed bone age, which supports the diagnosis of constitutional delay of growth. The estimated predicted adult height based on the bone age is 66 inches, which is within the normal limits for her genetic potential. It is also within the normal limits for an adult female.  Therefore, the requested medication Zomacton is not medically necessary.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 subspecialty 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a sleep study provided in a facility setting. The Health Plan has denied this request indicating that the service at issue was not medically necessary for treatment of the enrollees obstructive sleep apnea and snoring.At issue in this case is whether the requested sleep study; provided in a facility setting was medically necessary for treatment of the enrollees medical condition.Current literature indicates that there has been a shift from the provision of services in the laboratory setting to the ambulatory setting. Unattended and attended testing has been shown to yield equivalent outcomes to laboratory testing in at least two randomized trials.In this case the patient had an elevated body mass index, a large neck and complaints of snoring which raise the concern of obstructive sleep apnea (OSA). Testing would have been indicated to re-establish a diagnosis of OSA. However, provision of services in the attended/laboratory setting would have exceeded the patient's clinical needs in this setting. The performance of testing and treatment in the home setting has also been shown to produce equivalent outcomes to testing in the attended environment. There were no other extenuating circumstances present in this case; that would have otherwise necessitated or warranted an in-laboratory sleep study, concluding the services could have been completed in the home. The patient had no history of frequent, potentially injurious parasomnia. The enrollee had no other medical conditions that would have been a contraindication to provision of services in the home setting. Therefore, an attended study would not have been medically necessary.Final Result: The reviewer determined that the service at issue was 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 neurology with subspecialty certification in sleep 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: An enrollee has requested reimbursement for DecisionDx-Melanoma Genetic Testing. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. However, there is a lack of peer-reviewed published studies confirming the role of DecisionDx-Melanoma Genetic Testing in this clinical setting. All told, the DecisionDx-Melanoma Genetic Testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Genetic Testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that DecisionDx-Melanoma Genetic Testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prothrombin G20210A (Factor II) mutation testing.Findings: Two of the three physician reviewers found that the prothrombin G20210A (Factor II) mutation testing was likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment. Individuals who are heterozygous for the G20210A mutation in prothrombin are at increased risk for blood clots, with an estimated 2-4 times increased risk for venous thrombosis. Prothrombin thrombophilia is also associated with a somewhat increased risk of pregnancy loss. Such thrombophilia may also increase the risk of other complications during pregnancy, including pregnancy-induced high blood pressure (preeclampsia), slow fetal growth, and early separation of the placenta from the uterine wall (placental abruption). As this patient was known to be at 50% risk for having inherited this mutation, testing was warranted, as it will impact the patients medical management in the near future, if not now. Under these circumstances, the prothrombin G20210A (Factor II) mutation testing performed for the patient was likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: Two of the three reviewers determined that the prothrombin G20210A (Factor II) mutation testing was likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics and in medical genetics and genomics and is actively practicing. Physician reviewer 2 is board certified in pediatrics and in medical genetics and genomics and is actively practicing. Physician reviewer 3 is board certified in medical genetics and genomics 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.