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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement of the subacute detoxification treatment provided. Her diagnoses are alcohol use disorder and depressive disorder unspecified. On admission, the patient was not a danger to herself or others. The history given was consistent with daily alcohol consumption however her clinical presentation did not reach the severity of that consistent with the need for a medically intense 24/7 managed detoxification. There were no emotional, behavioral, or cognitive factors, which would warrant this level of care for her detox. Although described as having poor impulse control, there were no clear examples of this described. She was not manic, psychotic, or aggressive. She showed a pattern of difficulty remaining sober however that on its own is not reason for an inpatient detox setting, especially as the patient herself expressed motivation. She was medically and psychiatrically stable. There is no established history of delirium tremens (DTs).Final Result: The reviewer determined that the requested services 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: Overturned Decision of Health Plan

Case Summary: The patient is a male with sickle cell trait and a sibling diagnosed with renal medullary carcinoma. He was last seen in August and was complaining of stomach aching. A renal ultrasound was ordered by the physician due to risk for renal medullary carcinoma. No other treatments or testing were done. MD Analysis: Renal medullary carcinoma (RMC) is a highly aggressive rare cancer seen primarily in patients with sickle cell trait. Often presenting symptoms include pain and hematuria. RMC is often diagnosed in late stages, and most patients succumb to the disease. Alvarez et al reported the crude unadjusted prevalence of RMC among individuals with sickle cell trait is around 1/39,000. If we take all patients reported with RMC and sickle cell trait from the United States (N = 149) since 1995, then the crude unadjusted prevalence of RMC among individuals with sickle cell trait is 1/20,000. Currently there are no guidelines for screening for RMC; however, a study discuss this in their conclusions given the high incidence of advanced stage RMC in patients with sickle cell trait. Therefore, in a child with abdominal pain with sickle cell trait, it is medically necessary to perform a renal ultrasound. Final Result: The reviewer determined that the requested service 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 pediatrics with subspecialty certification in pediatric hematology-oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee with a diagnosis of  history of bilateral hand osteoarthritis. X-rays of the bilateral hands, demonstrates mild osteoarthritis of the right first carpometacarpal joint with osteophytes, mild osteoarthritis of the bilateral thumb interphalangeal joints with small osteophytes, mild osteoarthritis of the left third proximal interphalangeal (PIP) joint with small osteophytes. She cannot tolerate non-steroidal anti-inflammatory drugs and Tylenol has had lack of efficacy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees osteoarthritis.This is a case of a patient with hand osteoarthritis and trigger finger. A recent systemic review found that for non-pharmacological treatment of chronic pain, `For acupuncture, there was no difference in pain at intermediate term, but a slight improvement at long term.. A recent review did not demonstrate efficacy of acupuncture for peripheral joint osteoarthritis. Acupuncture as an adjuvant to an exercise based physiotherapy program did not result in any greater improvements than the exercise program alone. Researchers noted Sham-controlled trials show statistically significant benefits; however, these benefits are small, do not meet our pre-defined thresholds for clinical relevance, and are probably due at least partially to placebo effects from incomplete blinding. Waiting list-controlled trials of acupuncture for peripheral joint osteoarthritis suggest statistically significant and clinically relevant benefits, much of which may be due to expectation or placebo effects.` The guidelines do not recommend acupuncture for the treatment of osteoarthritis. As such, the request for acupuncture services is 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 internal medicine, with subspecialty certification in allergy, rheumatology, and immunology, 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 gene testing, DecisionDx-Melanoma Gene Assay. Findings:  Three physician reviewers found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. Therefore, gene testing, DecisionDx-Melanoma Gene Assay was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant gene test. Findings: Three physician reviewers found that 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, Guardant gene test was likely to have been more effective 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: Case Summary: An enrollee with a diagnosis of an enlargement of the right labia minora that is causing functional impairment. She complains of pain with activity and pain with wearing clothes. Examination documents asymmetric significant labia hypertrophy, supported by both her primary care physician and requesting surgeon. This has been a chronic problem. The health plan states that this is considered cosmetic surgery.MD Analysis: Based on the reviewed medical documentation, there is sufficient evidence that this is a functional concern for this patient and that surgical correction can likely be successful. Thus, this is not a cosmetic procedure for this patient. Cosmetic surgery improves on relatively normal structures. Reconstructive surgery addresses functional concerns and/or on relatively abnormal structures. As the planned procedure is to address the patient's functional deficit of pain, it is reconstructive surgery and medically necessary. 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 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 gene panel testing (CPT codes 81200, 81209, 81240, 81241, 81242, 81251, 81255, 81257, 81260, 81290 and 81330). Findings:  Two of the three physician reviewers found that there is sufficient support for the services at issue in this patients case. Genetic testing technology has evolved rapidly over the past decade, and it is now possible to screen for a large number of conditions simultaneously. This testing strategy is known as expanded carrier screening. Per the medical evidence, expanded carrier screening is an acceptable strategies for prenatal carrier screening. Therefore, gene panel testing (CPT codes 81200, 81209, 81240, 81241, 81242, 81251, 81255, 81257, 81260, 81290 and 81330) was 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 reviewer 1 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 3 is board certified in clinical biochemical genetics and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a dermatology referral. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees hypertrophic skin disorder.At issue in this case is whether the requested dermatology referral is medically necessary for treatment of the patients medical condition.Individuals may acquire a multitude of benign skin lesions over the course of a lifetime. Many of these lesions are easily visible, and patients often ask clinicians to confirm that new growths on the skin are benign. Most benign skin lesions are diagnosed on the basis of clinical appearance and history. If the diagnosis of a lesion is uncertain, or if a lesion has exhibited unexpected changes in appearance or symptoms, a diagnostic procedure (eg, biopsy, excision) is indicated to confirm the diagnosis. Family physicians should be able to distinguish potentially malignant from benign skin tumors.A dermatology referral is not medically necessary for a hypertrophic skin condition; such as the diagnosed skin tag, when there is no documentation of size; bleeding; or recent changes. The medical documentation describes a benign skin condition, a skin tag, and provides no other information regarding the size or recent changes (e.g. growth; pain; bleeding; etc.). Therefore, the requested dermatology referral is not medically necessary.Final Result: The reviewer determined that the requested service 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 family 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Cosentyx. Pityriasis rubra pilaris is an inflammatory dermatosis of unknown etiology. The typical morphologic features of pityriasis rubra pilaris are erythematous squamous salmon-colored plaques with well demarcated islands of unaffected skin. Disease management of pityriasis rubra pilaris includes systemic retinoids, methotrexate, and other immunosuppressive agents, as well as ultraviolet (UV) light therapy. Cosentyx has been demonstrated to provide positive results in the treatment of pityriasis rubra pilaris in recent case reports. The records indicate that this patient has tried and failed treatment with current first-line therapies including topical steroids, prednisone, and acitretin. Thus, the requested Cosentyx is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that Cosentyx is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication is 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:  One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in dermatology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing.Findings: Three of the three physician reviewers found that the advanced lipoprotein testing provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. There is a lack of studies in the peer-reviewed medical literature which demonstrate that strategies to correct the residual risk potentially identified by novel lipoprotein testing such as the advanced lipoprotein analysis will further reduce cardiovascular risk. Currently, clinical trial data do not support that advanced lipoprotein testing adds significant information to what is already known from a fasting lipid panel. Although assessment of advanced lipoprotein analysis parameters such as Apo B, LDL particle number and Lp(a) have been advocated by some as reasonable for many intermediate and high risk patients, clinical trial data do not support the superiority of treatment strategies incorporating non-statin lipid modifying agents compared with intensive statin therapy. Additionally, the patient has a low 10 year atherosclerotic cardiovascular disease (ASCVD) coronary risk of 0.3%, for which modifying certain lipid parameters such as LDL particle size or number would not be expected to significantly impact her already existing low risk, despite an elevated CRP. There is insufficient evidence to support the use of advanced lipoprotein analysis in this clinical scenario. Accordingly, the advanced lipoprotein testing performed for the patient was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: Three of the three reviewers determined that the advanced lipoprotein testing provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in internal medicine, with subspecialty certification in cardiovascular disease, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia service rendered during the flexible sigmoidoscopy with biopsies on 5/23/17. The Health Plan has denied this request indicating that the requested service was not medically necessary for treatment of the enrollees Crohns disease.At issue in this case is whether the anesthesia service rendered during the flexible sigmoidoscopy with biopsies on 5/23/17; was medically necessary for treatment of this patients medical condition.The patient was given an ASA preoperative physical status classification score of two. 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. This level would be appropriate in this case given the low ASA score. Therefore, the requested anesthesia service rendered during the EGD with flexible sigmoidoscopy along with biopsies on 5/23/17, was not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 anesthesiology 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 coverage for the durable medical equipment device, Eneura Transcranial Magnetic Stimulation. Findings: Two of the three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested device. There are several tools used in the treatment of migraine. These tools include Botox, oral medications, and pain relieving devices. One of those devices is the Eneura device. The ESPOUSE trial demonstrated some benefit for migraine therapy. Despite positive results, the Eneura device has not been compared to other available standard therapies. While the patient has tried several migraines therapies, the records do not document that the patient has exhausted standard available options. Therefore, the requested durable medical equipment device, Eneura Transcranial Magnetic Stimulation, is not likely to be superior over other treatment options. Final Result: The reviewers determined that the requested device 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 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.