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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for general anesthesia for magnetic imaging resonance (MRI) of the brain and auditory canal.A review by researchers found that vertigo and claustrophobia were two of the most common symptoms associated with MRI studies. The reviewers also state, The majority of patients should be able to do this without the need for anaesthetic care, but certain population groups are more predisposed to requiring assistance. Medical literature state, Anaesthetic input may be required for those with movement disorders, learning difficulties, claustrophobia or a reduced conscious level, when positioning is limited by pain, and for patients from intensive care unit (ICU). In most cases, general anaesthesia will be required; in some cases, sedation may be used, but consideration must be given to the length of scan and noise level that may make sedation difficult. The American Society of Anesthesiologists guidelines indicate, Observational studies report a high rate of successful imaging in patients receiving deep sedation or light anesthesia, with low rates of motion artifacts. The authors state, Observational studies and case reports also indicate that respiratory depression, oxygen desaturation, bronchospasm, drowsiness, agitation, and vomiting may occur with moderate sedation or light anesthesia. In this case, the patient has been diagnosed with vertigo symptoms and the provider recommended a brain and auditory canal open MRI. The patient reported claustrophobia and ineffectiveness of oral sedation with Valium. The medical literature supports the use of general anesthesia for patients requiring MRI with claustrophobia. Therefore, general anesthesia for MRI of the brain and auditory canal is medically necessary for treatment of the patients medical condition.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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI) with and without contrast (CPT 77049). This patient presents with a family history of breast cancer in her mother and maternal grandmother. The patients provider has recommended breast magnetic resonance imaging (MRI), given her family history and findings of microcalcifications in the right breast and two rounded asymmetries in the left breast. The current peer-reviewed medical literature and guidelines recommend biopsy for a palpable breast mass, even in the setting of negative mammogram and ultrasound findings. However, MRI is indicated for the screening of high risk patients. This patient has one first-degree and one second-degree relative with breast cancer, making her high risk for developing breast cancer. The patients lifetime risk as estimated by a genetic counselor is high, which supports an indication for MRI screening as the appropriate modality. Based on these findings, the requested bilateral breast MRI with and without contrast (CPT 77049) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested bilateral breast MRI with and without contrast (CPT 77049) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in hematology 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: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for implantation of hypoglossal nerve stimulator (CPT codes 0466T and 64568). The records provided for review document that this patient presents with a history of Down syndrome and severe obstructive sleep apnea (OSA) based on an apnea/hypopnea index (AHI) of 10.7 events per hour. The patients provider has recommended treatment with implantation of hypoglossal nerve stimulator. As noted in the medical literature, Down syndrome patients are at higher risk for severe OSA, which is mainly related to the base of the tongue. An AHI of more than 10 events per hour is considered severe OSA in the pediatric population. Treatment with continuous positive airway pressure (CPAP) is challenging in Down syndrome patients, thus CPAP is not considered as first-line of treatment for this patient population with OSA (Diercks, et al.). A recent trial reported excellent benefit in pediatric patients with Down syndrome who underwent implantation of a hypoglossal nerve stimulator (Caloway, et al.). Untreated OSA in patients with Down syndrome can lead to serious medical complications. On review of the available documentation and medical literature, this patient meets the requirements for placement of a hypoglossal nerve stimulator for treatment of severe OSA. Therefore, the requested implantation of hypoglossal nerve stimulator (CPT codes 0466T and 64568) is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested reimbursement for a hysterectomy (CPT 58571). Speer and colleagues note that often no specific etiology can be identified for chronic pelvic pain in women. The authors further note that diagnosis is based on findings from the history and physical examination, a pelvic ultrasonography to rule out anatomic abnormalities, and that referral for diagnostic evaluation of endometriosis by laparoscopy is usually indicated in severe cases. In this case, the indication for the hysterectomy is unclear. If the indication for the hysterectomy was bleeding, the submitted clinical information did not document heavy or abnormal bleeding or of anemia. There was no workup for vaginal bleeding. There was no documentation of an endometrial biopsy to rule out malignancy. An ultrasound showed a possible polyp, indicating that the next step would have been a polypectomy rather than a hysterectomy. The records did not document that the patient had tried and failed conservative options to manage bleeding including nonsteroidal anti-inflammatory drugs (NSAIDs), progestins and oral contraceptive pills, hormonal treatments, a levonorgestrel-releasing intrauterine system, tranexamic acid, or endometrial ablation. If the indication for the hysterectomy was pain, a further workup was needed to evaluate if the cause of the pain was gastrointestinal or genitourinary. Again, the records did not show that the patient had tried and failed pain management with NSAIDs or hormonal treatments. Upon failure of conservative measures, a diagnostic laparoscopy to diagnose and to treat the cause of the pain would have been the next step rather than a hysterectomy. Therefore, a hysterectomy (CPT 58571) was not medically necessary for the treatment of this patient.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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for any or all of the chiropractic services utilizing the Thompsons method and trigger-point therapy provided from beginning of April 2021, and onward for a total of 16 visits over a 12-month period.The medical literature supports the use of chiropractic treatments and trigger point therapy for low back pain. A study by researchers found, compression at myofascial trigger points (MTrPs) is effective to treat acute low back pain compared with compression at non-MTrPs and superficial massage. A study by medical literature found, At 12 weeks, the greatest differences from the no-manipulation control were found for 12 sessions. The authors concluded, 12 visits yielded the most favorable results. In this case, the patient is experiencing ongoing chronic low back pain and has received chiropractic treatments in the past. Additionally, the requested services exceed the number of visits indicated by the medical literature. The medical literature only supports 12 of the 16 requested chiropractic visits. Therefore, the chiropractic services utilizing the Thompsons method and trigger-point therapy provided from beginning of April 2021, and going forward for a total of 12 visits over a 12-month period were and are  medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that some of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in chiropractic 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:  An enrollee has requested authorization and coverage for pembrolizumab (Keytruda) 100 mg/4 ml every three weeks for eight cycles.The U.S. Food and Drug Administration (FDA) states, Pembrolizumab, as a single-agent, is indicated for the treatment of patients with metastatic non-small cell lung cancer (NSCLC) whose tumors express PD-L1 (TPS greater than or equal to 1%) as determined by an FDA-approved test, with disease progression on or after platinum-containing chemotherapy. The National Comprehensive Cancer Network (NCCN) indicates that the combination of carboplatin, pemetrexed, pembrolizumab, and bevacizumab with low dose Tagrisso (osimertinib) is not considered a standard of care. In this case, the patient has progressed after use of Tagrisso and requested use is for combination therapy with carboplatin, pemetrexed, bevacizumab and low dose Tagrisso. The coverage criteria is not met and this combination of drugs is not considered a standard of care with use not supported by major drug compendia or the medical literature. Therefore, pembrolizumab (Keytruda) 100 mg/4 ml every three weeks for eight cycles 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 medical 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for MitraClip transcatheter mitral valve repair (CPT 33418). Armstrong and Foster note that transcatheter mitral valve repair (TMVR) is a minimally invasive technique for treatment of selected patients with symptomatic chronic moderate-severe or severe (3+ or 4+) mitral regurgitation. Other indications for MitraClip include severely symptomatic heart failure despite medical therapy, favorable anatomy for the repair procedure, reasonable life expectancy, and prohibitive surgical risk due to comorbidities. OGara and colleagues note that perioperative mortality rates for selected, low-surgical-risk patients with severe degenerative mitral regurgitation is now less than 1% in major referral centers where a successful repair can be accomplished in over 95% of patients with isolated posterior mitral leaflet pathology. Reduction in mitral regurgitation by TMVR using the MitraClip is associated with improvement in both functional and quality-of-life metrics. Therefore, the requested MitraClip transcatheter mitral valve repair (CPT 33418) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested MitraClip transcatheter mitral valve repair (CPT 33418) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for biomarker and genomic testing FoundationOne CDx. The National Comprehensive Cancer Network (NCCN) guidelines support a role for mutational analysis in this patients stage IIIa left breast multifocal infiltrating lobular carcinoma (Gradishar, et al.). In addition, recent data have demonstrated that the FoundationOne assay can yield useful data in the evaluation and treatment planning of patients with breast cancer (Parker, et al.). BRCA1 and BRCA2 mutational analysis, as well as NTRK fusion analysis, may reveal indications for treatment with Larotrectinib and entrectinib (Alva, et al.). Also, high microsatellite instability tumors or those in which there is a high mutational burden may show responses to pembrolizumab. Furthermore, according to the NCCN guidelines, the patient may also be eligible for a treatment in a clinical trial. For these reasons, the biomarker and genomic testing FoundationOne CDx was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the biomarker and genomic testing FoundationOne CDx was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for 30 days of residential treatment center services or 14 days of inpatient hospitalization.At issue in this case is whether 30 days of residential treatment center services are medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. If not, 14 days of inpatient hospitalization are medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient met the criteria for 30 days for residential treatment center services.With regard to risk of harm, the records support a score of 3. In the last evaluation two weeks ago, the patient had passive suicidal ideation without intent or plan, resulting in a moderate risk for harm.In terms of function, the records support a score of 3. The patient has been primarily in treatment for the last few months. She has not been able to work and has issues with her relationships and fulfilling responsibilities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation with a urogynecologist at a tertiary care center. The records provided for review document that this patient has a diagnosis of pelvic pain and recurrent urinary tract infections (Dason, et al.). As noted in the medical literature, symptoms such as pelvic pain and frequent urinary tract infections are common urologic and gynecologic issues, which can be managed by urologists, gynecologists, and urogynecologists. This patients history and current presentation suggest that she is a candidate for evaluation and treatment with a urologist, gynecologist, or urogynecologist. A recent colonoscopy for recurrent rectal bleed demonstrated trace internal hemorrhoid in a healing phase. However, there is a lack of support for urogynecology services to be provided at a tertiary care center. Therefore, the requested consultation with a urogynecologist at a tertiary care center is not medically necessary 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 urology 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 reimbursement for inpatient hospitalization services. The management of patients with traumatic brain injury (TBI) is primarily contingent on the presence of intracranial hemorrhage. Traumatic intracranial hemorrhage is determined by cranial computed tomography (CT) imaging. In general, patients with traumatic brain injury but without traumatic intracranial hemorrhage are discharged from the emergency department, while patients with traumatic intracranial hemorrhage are admitted to the hospital for further management (Vos, et al.). The standard management of patients with TBI with evidence of intracranial hemorrhage includes admission to the hospital, neurosurgical consultation and evaluation with a repeat head CT scan six to 24 hours after the initial study to evaluate for progression (Cooper, et al.). The disposition of patients with a normal mental status examination and traumatic intracranial hemorrhage that does not require immediate neurosurgical intervention may include admission to the intensive care unit (ICU), admission to hospital in non-ICU setting, or monitoring in the emergency department observation unit. One study across a consortium of trauma centers by Nishijima and colleagues identified wide variability in ICU use within a cohort of similarly injured patients with traumatic intracranial hemorrhage. The authors found that a large portion of patients with traumatic intracranial hemorrhage who are admitted to the ICU never required critical care intervention, which suggests a need to improve the use of the ICU for patients with traumatic intracranial hemorrhage. In this case, the patient presented with head trauma after a fall, and she was found to have a subarachnoid hemorrhage. Based on the current medical literature, the patient was appropriately admitted to the hospital for monitoring. For these reasons, the inpatient hospitalization services were medically necessary for this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.