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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 60 days of intensive outpatient program (IOP) services for treatment of the enrollees autism spectrum disorder and anxiety. Findings:  The physician reviewer found that the request for 60 days of IOP services is medically necessary for treatment of the patients medical condition. There is sufficient peer-reviewed literature supporting the medical necessity of early intervention services for children diagnosed with an autism spectrum disorder. Estes and colleagues examined children enrolled in a multidisciplinary team approach such as the proposed IOP program in this case. The authors noted that significant gains were demonstrated in overall functioning that was sustained on follow evaluations two years later. Occupational therapy has also shown to be beneficial in the treatment of autism, addressing postural control and adaptive skills for long term independence. In addition, the use of cognitive behavioral therapy has been shown to be beneficial in the care of children with autism, successfully addressing common problems such as feeding difficulties. Given the support in the medical literature demonstrating benefit of early intervention for children with autism, coupled with the aforementioned efficacy of speech, occupational and cognitive therapies the request for IOP is medical necessity for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 a positron emission tomography (PET) scan for evaluation of the enrollees newly diagnosed leiomyosarcoma. Findings:  Two physician reviewers found that patients who have underwent routine hysterectomy with the incidental finding of uterine sarcoma such as in this case, the National Comprehensive Cancer Network (NCCN) recommend that those patients have CT scans of the chest, abdomen, pelvis or abdominal/pelvic magnetic resonance imaging (MRI) and chest CT to evaluate for metastases. For patients who have had their tumors morcellated such as in this case, the NCCN indicate that pelvic MRI should be considered. The NCCN further states that PET/CT scanning should be considered for ambiguous findings. Considering the propensity for leiomyosarcomas to metastasize distally, it is reasonable to obtain one imaging study that can image the entire body. As noted by the NCCN, to adequately stage this patient, separate CT or MRI studies would have to be performed for every anatomic region. According to research In a staging procedure, whole body FDG PET/CT discloses the presence of both local recurrence and remote metastases at widespread musculocutaneous sites, liver, and femur. With its advantage of scanning the whole body in a single procedure, we propose the use of PET/CT imaging for the evaluation of patients with uterine leiomyosarcomas, a tumor with propensity for widespread hematongenous spread to unusual sites. Further, peritoneal implants are not at all unusual in these patients (similar to ovarian cancer).  Peritoneal implants can be very difficult to detect at an early stage on routine CT scanning. In this case, there was no initial indication that the patients suspected fibroid would turn out to be a leiomyosarcoma. For this reason, the surgery performed did not adequately stage the patient. Nodal sampling was not performed, and clear margins cannot be evaluated. Final Result: The reviewers determined that the diagnostic procedure 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: Reviewers 1, 2 and 3 are board certified in diagnostic radiology 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 cervical/thoracic facet joint block. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The medical records do not document that the patient has responded with a 50% or greater reduction of pain following medial branch block of the cervical facet joints. Furthermore, the data concerning long-term pain relief using the requested procedure are conflicting and fall short of level I evidence. The current medical evidence does not support the requested services in this clinical setting. All told, the requested cervical/thoracic facet joint block 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 neurology 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 duodenal switch procedure with hiatal hernia repair.Findings:  The physician reviewer found that the request for the duodenal switch procedure is not medically necessary at this time. The completion and documentation of a thorough multidisciplinary evaluation is required. Both a psychological and dietary evaluation is clinically indicated. The patient underwent a psychological evaluation, however a dietary evaluation specifically in regards to the duodenal switch procedure and review of fat and water soluble micronutrient intake deficiency is not documented. Although the patient attended an in-Plan nutrition class, it is not documented that the effects of the duodenal switch procedure were discussed. While the patients surgeon indicates he has counseled the patient regarding the potential nutritional deficiencies associated with the duodenal switch procedure, there is a lack of sufficient objective documentation demonstrating the patients understanding of the nutritional needs unique to duodenal switch such as a dietary evaluation by trained, licensed registered dietician as recommended by published standard primary and re-operative guidelines. In regards to the request for hiatal hernia, it is generally recommended that a hiatal hernia be repaired when performing bariatric surgery, as it is considered part of the overall bariatric procedure. As such, repair of hiatal hernia alone without duodenal switch is not medically necessary. If a dietary evaluation documenting patient understanding of the dietary restrictions associated with the duodenal switch procedure as well as anticipated patient compliance is obtained, the requested procedure would be considered medically necessary. For the reasons provided, the request for duodenal switch procedure with hiatal hernia repair is not medically necessary for treatment of the patients medical condition at this time. Final Result: The reviewer determined that the requested procedure is not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found, and Zepatier with ribavirin for 16 weeks when NS5A resistance is present.  However, the guidelines state that lack of NS5A resistance testing should not be an impediment to coverage, and recommend 12 weeks of Zepatier when NS5A resistance testing is not available.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier 50-100 mg for 12 weeks is medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) of the abdomen for evaluation of the enrollees epigastric pain and chronic pain syndrome. Findings:  The physician reviewer found that the records provided for review document that this patient has a history of epigastric pain with prior surgery for hiatal hernia repair. Her abdominal pain is concerning as well as the declining hemoglobin and hematocrit levels. The persistent pain and dropping hemoglobin and hematocrit values in a patient with prior hiatal hernia repair require investigation and computed tomography (CT) scan is the most useful test for this indication. Final Result: The reviewer determined that the requested diagnostic procedure is 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cerefolin NAC. Findings:  The physician reviewer found that Cerefolin NAC contains L-methylfolate (as Metafolin) 5.6 mg, methylcobalamin 2 mg, and N-acetylcysteine 600 mg. Cerefolin NAC has been approved by the U.S. Food and Drug Administration (FDA) for the treatment or prevention of vitamin deficiencies as a medical food. However, Cerefolin NAC has not been approved for the treatment of mild cognitive impairment, primary progressive aphasia, or memory loss. Overall, there is a lack of data in the peer-reviewed medical literature demonstrating that treatment with Cerefolin in patients with primary progressive aphasia results in improved health outcomes. There are case reports about use of Cerefolin in mild cognitive impairment, but no randomized and controlled studies. All told, the requested Cerefolin NAC is not medically necessary for 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 neurology 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 Vicodin (hydrocodone 5 mg and acetaminophen 325 mg) for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. In this patients case, all non-opioid treatment options have not been utilized. The records do not document the completion of behavior therapy despite much research to support its use. It is reasonable to consider alternatives to opioids and to wean the patient off opioids. Furthermore, no objective treatment goals for pain and function are noted for the requested medication. Epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. Multiple minimal requirements for opioid prescribing have not been done, and the need to use them as the primary medication treatment strategy for pain has not been established. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for spinal surgery. Findings:  The physician reviewer found that evidence based medical guidelines recommend lumbar decompression surgery for patients with spinal stenosis secondary to degenerative processes exhibiting ligamentous hypertrophy, facet hypertrophy, and disc protrusion. Surgical indications include symptoms or findings that confirm the presence of radiculopathy and correlate with clinical examination and imaging findings. Guideline criteria include evidence of nerve root compression, imaging findings of nerve root compression, lateral disc rupture, or lateral recess stenosis, and completion of comprehensive conservative treatment. A study reported that their systematic review of the recent literature demonstrates that decompressive surgery is more effective than land based exercise in the management of lumbar spinal stenosis. However, given the slowly progressive nature and the potential for known surgical complications, they recommended that a trial of conservative management with land based exercise be considered prior to consideration of surgical intervention. A study concluded that decompressive surgery, with or without fusion, was more effective for patients with symptomatic lumbar spinal stenosis than continued conservative treatment when the latter had failed for three to six months. This patient presents with chronic low back pain radiating into the bilateral lower extremities, with numbness into the anterior lateral thighs to the feet. Signs and symptoms have been consistent with neurogenic claudication. Clinical examination findings have not demonstrated a focal neurologic deficit correlated with imaging evidence of nerve root compression. There is imaging evidence of mild to moderate bilateral neuroforaminal narrowing at L5-S1 due to facet hypertrophy. Evidence of long-term conservative treatment has been reported without sustained improvement. He has improved with multiple epidural steroid injections at the L5-S1 level. He has been diagnosed with bilateral meralgia paresthetica. There are no electrodiagnostic studies documented in the submitted medical records. Further, there is no documentation of a surgical consultation prior to consideration of surgery. Given these findings, the requested services are 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 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 authorization and coverage for bilateral breast mastectomy with male chest reconstruction for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that the documentation provided supports the requested procedure in this clinical setting. This patient has gender dysphoria and is transitioning to a male. This patient has evidence of abnormal breasts for a male despite the use of hormonal therapy. Additionally, this medical condition would not likely resolve with continued hormonal therapy. While the Health Plan criteria provides that the patient should be 18 prior to undergoing surgical intervention, chronological age is not as important as the level of pubertal development. In this patients case, his breasts appear to be consistent with a teenage female. Hormone therapy will unlikely resolve this patients breast enlargement.  Since the condition will not resolve even with hormone therapy, surgical intervention to treat this patients dysphoria is medically reasonable and appropriate.  In sum, this patient has evidence of abnormal breasts for a male and his medical condition will not likely improve with continued hormonal therapy. Therefore, bilateral breast mastectomy with male chest reconstruction is medically necessary for the treatment of this patients gender dysphoria. With regard to whether the requested surgery is considered reconstructive in nature, the submitted documentation reveals that the patients breasts constitute an abnormal structure of a male body. According to the definition and significance of gender dysphoria, abnormal breasts can be considered a developmental abnormality in a male. Reconstructive surgery in this clinical setting is generally performed to improve function, but may also be performed to approximate a normal appearance. In this patients case, the breasts should be more consistent with male breasts. Based on the patients gender dysphoria and his identification as a male, a normal appearance of the breasts for a male is the ultimate goal. In this patients case, he has evidence of abnormal breasts for a male. The goal of the surgery is to create a more normal appearing male chest and offer a more than minimal improvement in the appearance of this patient. Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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 the gene testing for evaluation of the enrollee who has a history lymphoma. Findings:  The physician reviewers found that Follicular helper like T cell lymphoma is a newly described entity seen mostly in elderly males. It is rare and treatment has not been clearly defined. Currently, there is a lack of standard therapies that exist. Although the precise events driving angioimmunoblastic T cell lymphoma (AITL) oncogenesis are not fully understood, several molecular anomalies have been described in AITL. These molecular anomalies can help further characterize the tumor as well as guide therapy. Multiplexed genotype testing, such as with FoundationOne Heme, allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially one by one. This is the most tissue efficient approach, particularly when dealing with small tumor samples. For these reasons, genetic testing was likely to be more beneficial than any available treatment option for the evaluation of this patients medical condition. Final Result: Two of three reviewers determined that the services at issue were likely to have been 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.