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 inpatient residential treatment for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medical necessity of the services at issue in this clinical setting. There was no evidence of post-acute withdrawal symptoms, or danger to self or others. She was cognitively intact and was not gravely disabled.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  She was medically and psychiatrically stable to the extent that she did not need a 24 hour per day/seven day per week facility to render the remainder of her care.  Her medication regimen did not require a residential setting.  She had a history of an extended period of sobriety with Alcoholics Anonymous exposure.  She demonstrated insight and motivation. There was no evidence that she would relapse if returned to her home environment, which was sober and supportive.  She could have been stepped down to an ambulatory level of care at that point, such as intensive outpatient services. 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic anti-reflux surgery utilizing the LINX Reflux Management System for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  Two of the three physician reviewers found that the an endoscopy showed a normal esophagus, a very small hiatal hernia, normal stomach, and normal duodenum. A 48-hour Bravo pH study showed elevated DeMeester score of 19.3. Per the provider note, the patient was having severe symptoms despite maximal medical therapy (including Prilosec and Nexium), behavioral changes, and dietary changes. His symptoms include reflux, severe and debilitating episodes of coughing, and regurgitation (but not dysphagia).  The patient has requested coverage for the LINX Reflux Management System.  The Health Plan has denied the requested services as investigational for treatment of the patients GERD. There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. In the Current Opinion in Gastroenterology, concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best-evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial than standard treatment, surgical fundoplication. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 computed tomography (CT)-guided ablation microwave renal right procedure for treatment of the enrollee, who presented with right renal tumor. Findings:  Two of the three physician reviewers found that the patient was evaluated for abdominal pain by contrast enhanced computed tomography (CT) scan. This scan revealed a small enhancing right renal mass approximately 13 mm. The lesion was highly suspicious for small renal neoplasm. After discussion with her provider, the patient elected to proceed with ablative therapy. The patient requested reimbursement for the CT-guided ablation microwave renal right procedure. The Health Plan denied the reimbursement. Per the Health Plan, the services at issue were investigational for treatment of this patients medical condition. The medical evidence does not support the superior efficacy of CT-guided microwave ablation in this clinical setting. The gold standard treatment option of small enhancing renal masses in otherwise healthy patients is partial nephrectomy. Other options include active surveillance and ablative therapies. There are multiple options for ablative therapies. However, microwave thermal ablation is relatively recent. While the limited studies appear to support this treatment as safe and effective, there is a lack of long-term follow-up to evaluate oncologic outcomes. 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: Reviewers 1, 2, and 3 are board certified in urology 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: An enrollee has requested authorization and coverage for Tresiba Flextouch U-20-200/ml for treatment of the enrollees type 1 diabetes. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Hypoglycemia is a frequent byproduct of tight glycemic control for diabetic patients, and may impact a patients quality of life. Despite advances made with basal insulin analogs, many patient using these insulins achieve less than optimal glycemic control or are at risk for hypoglycemia. Until recently, the available basal insulin analogues have failed to deliver steady, peakless, continuous insulin for greater than 24 hours and were associated with frequent hypoglycemia.  Newer insulin products have recently become available for use in the United States, including the ultra-long-acting insulin degludec (Tresiba).   These new insulins demonstrate different pharmacokinetic/pharmacodynamic profiles and longer durations of action in comparison to earlier insulins, which may lead to potential benefits, including decreased frequency of hypoglycemic episodes. Per the records, this patient has responded well to a trial of Tresiba and has experienced a decrease in his frequency of overnight hypoglycemia.  The medical evidence supports the requested medication in this clinical setting. Final Result: The reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 endoluminal ablation of varicose veins for treatment of his varicose veins. Findings:  The physician reviewer found that the documentation submitted for review supports the medical necessity of endoluminal ablation of varicose veins in this clinical setting. The patient has significant symptoms in the area of the varicose veins that have persisted despite significant weight loss and palpable pedal pulses. While there is no documentation of use of compression stockings, it is unlikely that compression stockings would be a successful plan considering the patients body habitus. The duplex demonstrates reflux in the symptomatic segments of the left GSV. For a morbidly obese patient to have obvious, visible varicose veins, the tributary veins would be expected to be quite large. The recommendation for left lower extremity stab phlebectomies along with ablation of the left GSV is both reasonable and medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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 vascular 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 a positron emission tomography (PET) scan for evaluation of her ovarian cancer. Findings:  Three physician reviewers found that the current medical evidence supports the requested services in this patients case.  The patient has had sequential PET/CT scans, and it is easier to compare the same imaging modality as opposed to starting with a different cross-sectional examination.  There are other advantages to PET as well.  PET/CT scans image the entire body, as opposed to CT scans.  To perform a comprehensive CT scan for this patient, one would need to do a CT scan of her neck, chest, abdomen, and pelvis.  A PET/CT scan would image all of these areas as well as her skeleton and spine.  In addition, PET offers the advantage of imaging activity of the tumor.  On occasion, especially with regards to lymphoma, a CT scan will demonstrate residual enlarged lymph nodes, but a PET scan will show that these nodes are not fluorodeoxyglucose (FDG) avid.  This patient was started on a new therapy, and it is important to assess whether there has been a therapeutic response.  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: Reviewer 1, 2, and 3 are board certified in diagnostic radiology 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: The parent of an enrollee has requested reimbursement for inpatient detoxification services for treatment of his alcohol dependence and alcohol withdrawal. Findings:  The physician reviewer found that on admission, the patients physical examination was essentially within normal limits. The patient had an intact neurological examination, review of systems was described as unremarkable, and he was noted to be medically stable. Nursing notes indicate that he was fully oriented, neat and clean, and had no suicidal or homicidal ideation. He was described as anxious and cooperative. Group notes document that he described himself as happy and relaxed. Other progress notes indicate that he slept seven hours per night and ate all of his meals. He was described as coping well. He was able to manage his own activities of daily living, and there is no description of delirium tremens, seizures, blackouts, or disorientation. The patient did not have any significant alcohol withdrawal symptoms and was a candidate for treatment in a less restrictive setting. 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 certifications in child and adolescent psychiatry and 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested for a standard manual wheelchair. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Physical activity and exercise are generally appropriate and recommended for conditions such as obesity and diabetes.  In this case, the patient uses a power wheelchair for mobility.  The records do not establish that the patient is capable of safely propelling a manual wheelchair or why a manual wheelchair is specifically being requested with respect to the patients functional needs, given that he has a power wheelchair that meets his mobility-related activities of daily living needs.  This type of information is necessary for prescribing any mobility device, including a manual wheelchair.  A detailed physical examination and functional evaluation, moreover, is important for properly prescribing a manual wheelchair that is not going to cause injury to a user.  This information is also not documented in the available records.  Final Result: The reviewers determined that the requested equipment 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 physical medicine and rehabilitation 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 gastric sleeve bariatric surgery for treatment of the enrollees obesity. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient does not meet standard definition of morbid obesity at this time.  The records do not document a body mass index of 40 or 35 with a serious comorbid condition such as a diabetes, sleep apnea or hypertension.  In this patients case, the records document a body mass index which is less than 40, without an associated comorbid condition.  The current medical evidence does not support the requested services in this clinical setting. Final Result: The reviewers 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 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 authorization and coverage for abdominoplasty to repair diastasis recti and placement of acellular dermal matrix. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient complains of an abdominal bulge, back and pelvic pain attributed to a documented diastasis recti of the abdomen.  Conservative management had not been documented, including the use of an abdominal binder or abdominal conditioning. In addition, work-up of other potential causes of her back and pelvic pain has not been adequately documented.  Although the patient has lower back and pelvic pain, it is not clear if abdominal muscle plication and biologic implant for reinforcement would likely correct her functional deficit of pain and weakness. The repair of diastasis recti is not generally considered to be a functional treatment, but can be an integral part to cosmetic procedures, namely abdominoplasty. Researchers noted 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, sufficient work-up of the pain and conservative management have not been adequately documented. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the positron emission tomography (PET) scan for evaluation of the enrollees Crohns disease. Findings: The physician reviewer found that Elevated C-reactive protein correlates well with disease activity in patients with inflammatory bowel disease. In this case, the patient had ongoing elevation of C-reactive protein, and disease activity seen in the jejunum during surgery in the past, but the location of current disease activity was not clearly elucidated by other testing. In patients with Crohns disease, treatment decisions depend on the extent and severity of disease activity, as certain therapies are more effective in certain portions of the gastrointestinal tract, and more extensive disease may require medications which have more severe side effects. FDG PET in Crohns disease shows good correlation with the clinical, endoscopic and biological activity of the disease. FDG PET allows reliable detection of moderate to severe inflammation in bowel segments involved by Crohns disease. Another study support PET as an excellent method for the noninvasive quantification of bowel inflammation in patients with IBD. Given that the patient had failed multiple medications, was on a high dose of Entyvio with the addition of Entocort, had ongoing clinical disease symptoms, and had negative testing with magnetic resonance enterography and capsule endoscopy, the FDG PET scan had the potential to provide useful diagnostic information to manage the patients Crohns disease. Final Result: The reviewer determined that the diagnostic procedure at issue was 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 36 hours per week of direct applied behavioral analysis (ABA) therapy, 15 hours per month of supervision and two hours per month of parent training for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that continued ABA therapy has been authorized by the Health Plan, but at a reduced rate. The correlation between treatment outcomes and treatment intensity is well documented in the peer-reviewed literature. One study found a strong relationship between treatment intensity and mastery of learning objectives. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, the patient demonstrates high levels of stereotypic hilarity, inappropriate coping, and vocal stereotypy (level 2) along with delays in adaptive skillsets as measured across multiple domains. The patient also requires a high level of support to complete activities of daily living. While the patient has met his behavior goals, he continues to demonstrate stereotypical hilarity up to 3.5 times per hour, and inappropriate coping up to 100% of the times measured. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.