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 magnetic resonance imaging (MRI) of the left elbow. The submitted documentation supports the requested services in this clinical setting. This patient has requested coverage for MRI of the left elbow, and the Health Plan noted that an ultrasound should be performed prior to MRI. This patient has indications for additional imaging given her continued symptoms despite conservative treatment. MRI is the procedure of choice in this patients case. This modality is not as dependent on operator skill, and the MRI images can depict chronic tendinosis and micro-tears of the extensor tendon. All told, MRI of the left elbow is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for liposuction of the trunk (CPT 15877) and neck (CPT 15876). This patient presents with evidence of severe lipodystrophy of the neck and back as a likely complication of her treatment for congenital HIV. Liposuction is supported in the medical literature for use to treat deformities in a reconstructive fashion, as is the case for this patient. Colleagues noted that the standard treatment for HIV is a combination of protease inhibitors and reverse transcriptase inhibitors. Although these medications have greatly improved morbidity and mortality rates in HIV patients, they have also been found to cause significant side effects, most commonly hypertriglyceridemia in approximately three-quarters of patients, hyperglycemia, insulin resistance, and abnormal fat distribution. Colleagues reported that suction-assisted liposuction is appropriate to treat the deformities causes by HIV treatment. Given this support, the requested liposuction of the trunk (CPT 15877) and neck (CPT 15876) is medically necessary for treatment of this 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 testing. Findings:  Two of the three physician reviewers found non-small cell lung cancer should be tested for specific mutations, such as EGFR, ALK, ROS-1, as well as PDL-1. Each of these has a specific therapeutic implication. This testing should preferentially be done on a tissue sample, but can be done on liquid assay. Patients with an EGFR mutation who are treated with Tarceva and experience progression should be tested for a secondary mutation, T790M, as this also has a therapeutic implication. If these molecular profiles cannot be done on tissue, then Guardant360 assay may be indicated. However, in this patients case, it appears that there was appropriate testing on the cytology specimens. Therefore, further broad testing with Guardant360 testing was not likely to have been clinically beneficial. In sum, Guardant360 testing was not 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Njx platelet rich plasma (CPT code 0232T). After careful review of the enclosed information and the pertinent literature and guidelines concerning platelet rich plasma injections, the Njx platelet rich plasma (CPT code 0232T) provided on 5/25/18 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Most of the studies on platelet rich plasma injections have been performed for the treatment of lateral epicondylitis. Platelet rich plasma injections may improve healing of tendons, but the treatment is not considered standard of care. Given these findings, the Njx platelet rich plasma (CPT code 0232T) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the Njx platelet rich plasma (CPT code 0232T) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the Njx platelet rich plasma (CPT code 0232T) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Medical professional reviewers 1, 2 and 3 are board certified in podiatry 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees dyslipidemia. Findings:  The physician reviewer found that this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including apolipoprotein B, lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. In sum, advanced lipoprotein testing was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Two of three 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 cardiovascular disease 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: A patient has requested reimbursement for the residential treatment center services provided. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. Studies recommends residential treatment for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, lack sufficient social and vocational skills, and drug-free social supports to maintain abstinence in an outpatient setting. This patient was using large amounts of nitrous oxide every day and was unable to stop using despite treatment in a lower level of care. The patient was unable to function at work, school, or socially despite lower levels of care. A standard rehabilitation program of a 30-day residential treatment was in accordance with generally accepted standards of medical practice and was clinically appropriate for this patients illness. Therefore, the residential treatment center services provided were medically necessary for the treatment of 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for the psychiatric residential treatment center for treatment of her behavioral health issues.  Findings:  The physician reviewer found that initial psychiatric evaluation showed no evidence that there was an emergency mental health problem that would justify admission to a psychiatric residential treatment center. Psychotropic medication was not started until more than two months after admission. The patients social history and psychiatric evaluation revealed that a major factor in patients depression, suicidal behavior, feelings of abandonment, and loneliness were likely indications of reactive attachment disorder (RAD), which was one of the diagnoses initially considered. The diagnosis of reactive attachment disorder had been considered in the patients previous treatment and in the patients discharge summary. The American Psychiatric Publishing Textbook of Psychiatry states that RAD is best treated with dialectical behavior therapy that involves both the adolescent and the parent. The patients discharge treatment plan recommended essentially the kinds of outpatient treatment that would have been appropriate prior to the patients admission to the RTC. The services at issue were not necessary for treatment of a psychiatric emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services on the dates of service at issue. Final Result: The reviewer determined the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica. This patient has been diagnosed with cervical radiculopathy and fibromyalgia. He has been treated with both duloxetine and gabapentin. The documentation notes that he had dizziness with duloxetine. The records do not document adverse reactions to gabapentin.  Fibromyalgia is a complicated chronic pain syndrome that requires both nonpharmacologic and pharmacologic therapies for optimal treatment. Patient education is a key part of treatment, and treatment recommendations include exercise. If education and exercise do not resolve symptoms, a tricyclic antidepressant may be appropriate. If a tricyclic antidepressant does not improve symptoms, Duloxetine is recommended. If these treatments fail to resolve symptoms, pregabalin (Lyrica) is recommended with gabapentin as an alternative. In this case, the patient has not failed treatment with a tricyclic antidepressant, and there is no documentation that he has attempted a home exercise program. Therefore, Lyrica is not medically necessary for the treatment of this patient.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 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 fulvestrant injection and Zometa infusion. This patient has progressed on first-line therapy with Letrozole and Ibrance as part of a clinical trial. She is now being treated with second-line therapy with Zometa and fulvestrant in combination with Verzenio. Fulvestrant is indicated for treatment of HER2 negative advanced or metastatic breast cancer, in combination with Ibrance or Verzenio, in patients with disease progression following endocrine therapy. Zometa is standard therapy for patient with bone metastases. Given this support, the requested fulvestrant injection and Zometa infusion are medically necessary for treatment of this patients medical condition. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for revision sacroiliac (SI) joint fusion surgery. Based on the submitted information and review of the North American Spine Society (NASS) guidelines, the revision SI joint fusion surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. SI fusion may be appropriate for treatment of SI joint infection, tumor involving the sacrum, disabling pain due to sacroiliitis due to spondyloarthropathy, or SI pain due to severe traumatic injury or for multisegmental spinal constructs. However, SI joint fusion is not recommended for mechanical low back pain, non-specific low back pain, SI joint disruption in the absence of major pelvic fracture, degenerative sacroiliitis, SI joint osteoarthritis, or SI joint-mediated pain. In this patients case, there is a lack of indication that the patient received adequate relief from the initial surgery, as the patient reported a recurrence of symptoms when the patient initiated weight bearing within one month of the procedure. The provider noted the CT scan showed minimal bridging. However, this imaging study was only two months after the surgery, and a robust fusion mass would not be expected at that time. The recent MRI of the left hip seems to indicate progression of the left SI fusion. All told, the requested revision SI joint fusion surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer found that the requested revision SI joint fusion surgery is 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 services are 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP). The progress notes indicate that since she started IOP level of care, the patient has made some improvements behaviorally as well as psychiatrically. She was noted to continue to have a stressful relationship with her family. Thus, continued group, individual, and family therapy will likely be beneficial for the patient. She has reported episodes of self-harm behavior in the last several weeks. Applying the Child and adolescent level of care utilization system (CALOCUS), the patient continues to require the IOP level of care in order to manage her impulsivity and suicidal ideation. Current literature indicates that effective self-harm reduction can occur with therapy available on an outpatient basis such as dialectical behavioral therapy (DBT). As indicated by colleagues, a stronger long-term reduction in self-harm and a more rapid recovery in suicidal ideation, depression, and borderline symptoms suggest that DBT-A may be a favorable treatment alternative for adolescents with repetitive self-harming behavior. Given the patients continued need for continued group, individual, and family therapy, the IOP at Insight Treatment Program was and is medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zohydro ER. The provider recommended continuation of long-term opiate therapy for this patient but there is a lack of support for use of Zohyrdo ER in lieu of standard formulary alternatives. The patient underwent pharmacogenetic testing and there are several extended release alternatives noted as potential treatment options that are on the Health Plans formulary. The use of chronic opiate therapy for non-malignant pain is not recommended by the current clinical practice guidelines. The patient can be treated with a medication that is available on the Health Plans formulary. Thus, the requested Zohydro ER is not medically necessary for treatment of this patients medical condition. One reviewer found that the requested Zohydro ER is medically necessary for treatment of this patients medical condition.Final Result: Two of the three reviewers determined that the requested medication 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:  One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. One Reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  One Reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for incontinence supplies (adult diapers). This patients medical records document the presence of urinary incontinence, both stress and functional. Thus, the use of certain incontinence supplies including adult diapers is medically necessary to manage the patients urinary incontinence. There is no report of any skin changes or complications related to incontinence. Thus, additional items would be for convenience. All told, the incontinence supplies (adult diapers) are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested supplies 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 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.