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 for a stress echocardiogram for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that this patient presented with coronary risk but no documented chest discomfort, a normal cardiovascular physical examination and a normal electrocardiogram.  The letter from the provider is not consistent with the medical records provided.  In the absence of documented chest discomfort, cardiac physical examination abnormalities or electrocardiographic abnormalities in the medical records, the medical necessity of the services at issue cannot be established.  Current guidelines that are endorsed by several national organizations do not consider stress echocardiography appropriate in the absence of documented chest discomfort or other findings concerning for coronary ischemia in the medical records.  Screening stress testing, even in patients with increased coronary risk, has not been demonstrated to improve cardiac outcomes.  Final Result: The reviewer determined that the services at issue were 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an abdominoplasty for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the patient has a history of chronic abdominal pain/discomfort.  In addition, the patient has a questionable umbilical hernia and a rectus diastasis.  The patients pain has been attributed to the rectus diastasis.  Conservative management attempted by the patient includes binder clothes.  There is some indication that muscle plication may affect intractable lower back pain.  However, the authors noted that nonoperative therapy and significant work-up for other reasons of the pain should be evaluated prior to abdominoplasty with muscle plication.  In this patients case, the records do not document sufficient work-up of the pain, and conservative management has not been exhausted.  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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services provided during an endoscopy for evaluation of the enrollees change in bowel habits. Findings:  The physician reviewer found that the patient has an American Society of Anesthesiology (ASA) preoperative physical status classification score of 1. In this clinical setting, 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. Final Result: The reviewer determined that the services at issue were 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 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 reimbursement for inpatient liver ablation treatment stay for treatment of the enrollees liver cancer. Findings:  The physician reviewer found that Large clinical trials of radiofrequency ablation of hepatocellular carcinoma have included inpatient admission as standard of care.  Patients with cirrhosis have almost twice the rate of early complications, some fatal, after this procedure.  These include pneumonia, sepsis, liver failure, bleeding, and bile leak, all of which can be diagnosed and addressed in an inpatient setting.  Some of these complications, such as retroperitoneal bleeding, can manifest hours after the procedure or the next day.  Additionally, when lesions are near the liver capsule as in this case, there is an increased risk for injury to adjacent organs during the procedure. 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: Physician reviewer number one 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 reimbursement for the Zoll LifeVest for treatment of the enrollees medical condition.  Findings:  The physician reviewers found the patient presented with congestive heart failure and a newly recognized cardiomyopathy with ejection fraction of less than 35%. In this circumstance there is potential for recovery of left ventricular function over time with medical therapy. In addition, there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time at least 90 days have elapsed where continued left ventricular dysfunction with an ejection fraction of 35% or less is documented to persist despite appropriate treatment. A prophylactic wearable defibrillator before this time has not been demonstrated to improve outcomes. The studies evaluating wearable cardioverter defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. A prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explanation.  Final Result: All three reviewers determined that the device at issue was 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewer 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 air ambulance and associated ground ambulance transportation services for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the air ambulance and associated ground ambulance transportation services was medically necessary for treatment of the patients medical condition. There is sufficient support in the peer-reviewed literature to support the services at issue in this clinical setting. Herzer and colleagues found an association between time to rehabilitation after a spinal cord injury (SCI) and lower functional level, concluding that Earlier rehabilitation following traumatic SCI may improve patients functional status at discharge. In this case, the patient sustained a cervical spinal cord injury some distance from home. Timely rehabilitation can minimize health risks and improve functional outcomes. Transport home by air ambulance was medically necessary for the patient to receive early specialized rehabilitation in close proximity to his support network. As such, the air ambulance and associated ground ambulance transportation services have been established as medically necessary for treatment of the patients medical condition.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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 surgery of the upper part of the throat for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has been diagnosed with mild obstructive sleep apnea as well as nasal congestion.  Physical examination revealed septal deviation, turbinate hypertrophy, redundant soft palate and elongated uvula.  Polysomnography demonstrated an AHI of 6.0 and oxygen saturation nadir of 73%.  Nasonex has been used for nasal congestion.  The records do not document that prior treatment has been instituted for sleep apnea.  CPT code 30465 is for repair of vestibular stenosis, which is most commonly done with placement of spreader grafts.  In this patients case, there is no documentation on physical examination to support the presence of nasal vestibular stenosis.  The provider has also recommended uvulopalatopharyngoplasty and tonsillectomy.  As standard of care, uvulopalatopharyngoplasty and tonsillectomy are surgical procedures that come under consideration for patients who have been diagnosed as having obstructive sleep apnea and have failed a trial of CPAP therapy.  The records do not indicate a CPAP trial in this patients case.  There is a lack of support for the requested services in this patients case.  In sum, the requested surgery of the upper part of the throat is not medically indicated 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 physician reviewer is board certified in otolaryngology 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 intensity modulated radiation therapy for treatment of the enrollees prostate cancer.  Findings: Three reviewers found that in this clinical setting, consensus group guidelines support the use of intensity modulated radiation therapy (IMRT) for prostate cancer. IMRT therapy is considered effective in the treatment of prostate cancer.  In this case, the patients pathologic specimen revealed T3a disease. This is a clear indication for the use of post-operative radiation to decrease the loco-regional risk of recurrence according to the National Comprehensive Cancer Network guidelines. Randomized trials have demonstrated a clear benefit for the use of radiation therapy in this setting. Intensity modulated radiation therapy is an accepted modality for treatment of prostate cancer in order to spare the rectum and bladder. Therefore, the requested therapy is likely to be more effective than any conventional therapy for treatment of this patient.  Final Result: Three reviewers determined that the requested therapy is 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: All three 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 MetaNeb system and percussion treatment for the enrollees medical condition status post subdural hematoma.  Findings: The physician reviewer found that the records do not indicate that this patient does has cystic fibrosis or bronchiectasis. He does have neuromuscular disease but there is no documentation that the use of the requested device in this patient with paralysis would improve his long-term health outcome. As noted by the provider, the patient cannot move his extremities. Chest physical therapy with suctioning through the tracheostomy is considered the standard of care for this patients treatment given these findings. Accordingly, the requested MetaNeb system and percussion treatment in a long-term acute care facility is not medically necessary for treatment of this patients medical condition.  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 physician reviewer is board certified in internal medicine with sub-specialty certification in pulmonary 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 Lexapro for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the FDA provides medication dose recommendations based on scientific data. The interpretation and application of these recommendations falls upon clinicians working directly with the patient population. This process allows for consideration of additional factors, such as physician experience, emerging treatment trends and clinical issues unique to individual cases, in the delivery of evidence-based, patient-centric care. As such, it is not uncommon for providers to dose medications in excess of FDA recommendations. Systematic medication titration is a core element of the art of medical practice and a key component to patient-centered care. Lexapro is a potent and highly selective serotonin reuptake inhibitor (SSRI) that acts by binding directly to the serotonin transporter. Lexapro is indicated for depression and generalized anxiety disorder. Additionally, about one-third of individuals diagnosed with autism spectrum disorder are prescribed a serotonin-enhancing medication such as Lexapro. Further, like other SSRI medications, Lexapro is a trusted intervention in the treatment armamentarium for those suffering from OCD. Clinicians in the field have long recognized that the treatment of OCD often requires supra-therapeutic SSRI dosing. This is supported by the American Psychiatric Association (APA) clinical practice guidelines for OCD which state occasionally prescribed maximum dose of Lexapro is 60 mg per day.  In this case, considering the patients diagnoses, medical records, community standards, endorsement from the APA and the peer-reviewed literature base, Lexapro 20 mg, 45 tablets per 30 days represents a safe, appropriate treatment consistent with good medical practice. The therapy has been well tolerated and at least partially efficacious. The therapy remains reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, Lexapro 20 mg, 45 tablets per 30 days has been established as medically necessary for treatment of the patients behavioral health condition.Final Result: The reviewer determined that the requested medication dosage 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of the enrollees chronic hepatitis C virus genotype 2b.  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 applies regardless of fibrosis stage or viral load. The guidelines recommend Sovaldi and Daklinza for 12 weeks in treatment-naive genotype 2 patients (Sulkowski, et al). The guidelines no longer support the use of Sovaldi with ribavirin for treatment-naive genotype 2 patients. The guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, treatments of hepatitis C with Sovaldi and Daklinza for 12 weeks are supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications 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 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: An enrollee has requested Sovaldi and Daklinza for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that the current medical evidence supports the requested medications in this clinical setting.  According to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. In treatment-naive, genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks.  Delay in treatment may result in decreased survival.  All told, Sovaldi and Daklinza in the requested dosage and duration are medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician 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 residential treatment center (RTC) services for treatment of the enrollees alcohol dependence. Findings: The physician reviewer found that the records document that this patient had no post-acute withdrawal symptoms, although he continued to experience cravings. The patient was not a danger to himself or others. Although initially medically unstable, the patient was deemed to be medically stable and not in need of 24-hour care. Moreover, he was psychiatrically stable. The depression he was experiencing did not need to be managed at the RTC level of care. There were no emotional, behavioral, or acute cognitive conditions that warranted RTC treatment. He had improved cognitively, he was motivated, insightful, and appeared to be working the program. Although he continued to struggle with his emotions and required further treatment to help develop and solidify coping skills, this did not require the structured environment of a RTC setting and could have continued at a lower level of care. For these reasons, the RTC services provided were not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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.