Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. The patient was diagnosed with descending aortic intramural hematoma. The follow up chest CT scan performed was not indicated for an emergency medical condition. The patient had already been diagnosed one month earlier and the follow up chest CT scan was performed to monitor that condition. There is no documentation to support new or recurrent chest pain to suggest an acute or potentially emergent medical condition.  Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided.Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. In this case, the patient presented with eye redness and irritation that commenced the night prior. The patients condition was not sudden. The patient denied any sudden or serious symptoms such as trauma or decreased vision that would indicate complications such as kerato-conjunctivitis or corneal ulcer . The patients vital signs were normal without fever. The patient had a normal visual acuity. Other than conjunctival injection, the remainder of the patients eye exam was normal. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of serviceFinal Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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: The patient has requested authorization and coverage for brand name Lexapro for treatment of the enrollees depression and bipolar disorder. Findings:  The physician reviewer found that Escitalopram is a potent and highly selective serotonin reuptake inhibitor that acts by binding directly to the serotonin transporter. Escitalopram was first approved by the U.S. Food and Drug Administration (FDA) in 2002 for treatment of major depressive disorder, and a year later for generalized anxiety disorder. As noted by researchers, bioequivalence testing ensures that the generic product performs the same as its respective brand-name product. This standard applies to all generic drugs, whether immediate or controlled release. A particular compound associated with a specific brand name medication, or generic preparation, may be necessary for an individual patient in the instance of ineffectiveness or intolerance to one type of preparation. However, the brand name Lexapro is not supported for this patient as there is no evidence in the records that the generic medicine has been poorly tolerated or was inefficacious. This patient has been diagnosed with bipolar illness and is prescribed four antidepressants, in addition to an anxiolytic and mood stabilizer. Although medication adjustments may be indicated, the brand name medication Lexapro is not supported as medically necessary for treatment of the patients medical condition. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for percutaneous tibial nerve stimulation (PTNS) for treatment of the enrollee who has a history of overactive bladder. Findings:  Two physician reviewers found that this patient is symptomatic with overactive bladder symptoms including urgency incontinence. There is evidence of the effectiveness of short term PTNS in treatment of OAB. According to the American Urological Association (AUA) incontinence guidelines, percutaneous tibial nerve stimulation is considered an appropriate salvage therapy for patients with intractable irritative lower urinary tract symptoms including urgency incontinence.  This patient has failed multimodal therapy. Furthermore, she has urinary retention most likely related to diabetes mellitus. The records note that she has exhausted most of her treatment options for her condition. The patient is not a candidate for Botox injections secondary to urinary retention. Final Result: The reviewers determined that the requested services are 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: Reviewers 1, 2 and 3 are board certified in urology 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 authorization and coverage for a colonoscopy for evaluation of the enrollees polyp. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this case. The American Cancer Society guidelines for colorectal cancer screening states that in patients with average risk, colon cancer screening such as colonoscopy is recommended at age 50, and then every 10 years. These recommendations do not apply if there is a personal history of colorectal cancer or adenomatous polyps, a personal history of inflammatory bowel disease, a strong family history of colorectal cancer or polyps, or a known family history of a hereditary colorectal cancer syndrome. None of these are documented in this patients case. The joint guidelines issued by the American College of Gastroenterology (ACG), American Gastroenterological Association Institute (AGA), and American Society for Gastrointestinal Endoscopy (ASGE) for surveillance after a screening colonoscopy state that the recommended interval for repeat screening should be 10 years unless an adenomatous polyp or sessile serrated lesion is found, which indicates a 10-year repeat interval in this case based on the pathology results provided.  The finding of a single hamartomatous polyp does not meet the criteria for a high risk polyposis syndrome. Based on the family history and personal history information provided for this case, the colonoscopy findings, the pathology results, and the national guidelines do not support a repeat colonoscopy at five years after the first colonoscopy.  Final Result: The reviewer determined that the requested procedure 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for denosumab (Prolia) treatment of the enrollees osteoporosis. Findings:  The physician reviewer found that the medical records fail to demonstrate the medical necessity of the requested medication. Although the patient has tried Fosamax, the documentation do not show that she has tried intravenous bisphosphonate in the form of Reclast. The submitted records do not indicate that this patient has a contraindication to or an inability to tolerate bisphosphonate therapy. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for thermal radiofrequency ablation (RFA) of the nerves in the sacroiliac (SI) joint, also known as Sinergy. Findings:  The physician reviewer found that Sacroiliac (SI) joint pain is a well-documented syndrome, which can generally involve infection, malignancy, pregnancy, and acute or repetitive trauma. Symptoms include low back, buttock and thigh pain and sometimes sciatic-like radiating pain. Along with conservative measures like anti-inflammatories, heat, ice and some manipulation, SI joint injections have shown some merit in regards to fluoroscopic guidance with local and steroid with inter-articular placement of the medication. In a study, radiofrequency neurotomy was reviewed noting limited evidence. The author cited variability with nerve patterns studied as well as variations in electrode positioning with many of the studies. Hansen and colleagues reported that controlled double confirmative blocks with a long acting and short acting local anesthetic was found to be the gold standard for diagnosis of SI joint pain. In light of the current reviews, the requested radiofrequency ablation (RFA) of the nerves in the SI joint, also known as Sinergy, is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested service is 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 are board certified in anesthesiology with sub-specialty certification in pain medicine 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 authorization and coverage for Ingrezza for treatment of the enrollees tardive dyskinesia. Findings:  The physician reviewer found that there is a lack of support in the documentation for the medical necessity of the requested medication in this clinical setting. It is unclear if this patients involuntary movements are tardive dyskinesia. Tardive dyskinesia is one differential for involuntary movements. However, other treatment options should be explored prior to prescribing Ingrezza. For example, amphetamines are known to cause involuntary movements. Discontinuation of amphetamines would be considered a first step. Subsequent urine toxicologists should be performed to rule out amphetamine and other substance of abuse. Additionally, the chart notes indicate that the patient has memory problems. However, there is no explanation in the notes for the memory loss. In combination with involuntary movements and absence of stimulants, the differential remains wide including Parkinsons disease, Huntingtons disease or other neurological syndromes. As such, the medical records do not support the use of Ingrezza as medically necessary for the treatment of this patients medical condition. 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 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 enrollee has requested reimbursement for the anesthesia for the colonoscopy. Findings:  The physician reviewer found that The patient has an ASA preoperative physical status classification score of 2. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the research given a low preoperative physical status classification score. Thus, monitored anesthesia care services were not appropriate. Final Result: The reviewer determined that the service at issue was not medically necessary for evaluation of the patients medical condition. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Trulance tablet for treatment of the enrollees Crohns disease. Findings:  The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. Trulance has been proven effective in a multicenter, randomized, double-blinded, placebo-controlled Phase III clinical trial.  In this case, the patient reports failure of three formulary alternatives and a failure of Amitiza. The patient reported a good response to Trulance, which is an effective alternative.  For these reasons, the request for Trulance tablet is supported as medically necessary for the treatment of the patients medical condition.  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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for dopamine transporter (DaT) scan of the brain for evaluation of the enrollees tremors. Findings:  Two physician reviewers found that the diagnostic accuracy of DaT scans to detect abnormalities of dopamine metabolism in patients with Parkinsons disease is in excess of 95%. However, this test cannot distinguish between various parkinsonian syndromes. This modality can differentiate benign essential tremor from parkinsonian type tremor. In this patients case, she has already been treated for the presumed diagnosis of benign essential tremor, without a response. Therefore, the test is not supported for therapeutic decision making in this clinical setting. All told, the requested DaT scan of the brain is not likely to be more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT) with image guided radiation therapy (IGRT). Findings:  The physician reviewer found that there is sufficient support in the medical literature for the efficacy of requested services in this clinical setting. In general, IMRT is not an experimental technique, but rather a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution, and therefore minimize the dose to normal structures. IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. IGRT is a means of using daily image guidance to help localize the target so as to minimize normal tissue dosing. IGRT allows accuracy of treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume of normal tissues exposed to radiation. IGRT images can be obtained prior to treatment on a daily basis (interfraction IGRT), and/or before and during radiation (intrafraction IGRT). The data that supports pelvic/prostate therapy is not for routine use in patients with metastatic disease, but something that could be considered in select patients. For this patient who has a single oligometastasis to be treated with SBRT, IMRT may maintain acceptable radiation exposure to the bowel, bladder and rectum. It is plausible that without IMRT, the patient would be at a significant risk of toxicity from radiation, and that IMRT would appreciably reduce the toxicity risks. The clinical records support that this patient is well selected for radiation. This patient would benefit and would better tolerate IMRT therapy to the prostate and pelvic nodes. Therefore, IMRT with IGRT is likely to be more efficacious than the available modalities for the treatment of this patients medical condition.Final Result: The reviewers  two of the three  determined that the requested services are 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H.P. Acthar gel for treatment of the enrollees sarcoidosis. Findings:  The physician reviewer found that the request for H.P. Acthar gel is not medically necessary for treatment of the patients medical condition. There is a lack of peer-reviewed literature supporting the use of H.P. Acthar gel for the treatment of sarcoidosis. Given the lack of peer-reviewed literature and the medical documentation submitted for review, the request for H.P. Acthar gel is not medically necessary for treatment of the patients medical condition. 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 internal medicine with sub-specialty certification in rheumatology 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 referral to a bariatric surgeon and gastric sleeve or gastric band surgery for treatment of the enrollees obesity. Findings:  The physician reviewer found that based on the documentation submitted for review, the request for referral to a bariatric surgeon and gastric sleeve or gastric band surgery are not medically necessary. The patient does not have documented morbid obesity or clinically severe obesity with a BMI of 40 or 35 with serious co-morbid conditions such as diabetes, hypertension or sleep apnea. In addition, the patient does not have BMI of 30-34.9 with type 2 diabetes on medication. The patient does not meet standard BMI metric criteria for consideration for bariatric surgery at this time. The medical necessity for referral to a bariatric surgeon or to undergo bariatric surgery is not supported for 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 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.