Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing to evaluate the her heart disease. Findings:  Three physician reviewers found that she was noted to have a history of vitamin D deficiency and diverticulosis, and she was status post colon resection. She also reported having difficulty absorbing folic acid. Advanced lipoprotein testing, methylene tetrahydrofolate reductase deficiency, factor V Leiden mutation and lipoprotein-A testing were ordered by the provider.  However, he did not provide any justification for this testing nor did he indicate how the data would be used for this patient. The current status of the peer reviewed literature is such that the additional benefits to health outcomes from advanced lipoprotein testing when compared to the use of standard testing has not been definitively proven. In addition, in this patients case the treating provider did not provide an explanation of how the data derived would be used in management of the patient. The medical evidence does not support the use of advanced lipoprotein testing when used to assess or manage the risk for heart disease. Final Result: The reviewer 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 internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested AmniSure testing for evaluation of her pregnancy.  Findings:  Three physician reviewers found that per the records, this patient presented with irregular contractions and uncertainty as to any loss of fluid from her vagina. An AmniSure test was done to determine whether there was any leakage of amniotic fluid.  Based on the submitted documentation, there was no speculum examination done, and no ultrasound performed. Laboratory tests may be used to confirm the clinical diagnosis when there is uncertainty.  In this patients case, there is nothing in the record to suggest that there was clinical confusion as to the presence or absence of ruptured membranes by physical examination, nitrazine testing, or ferning. It does not appear that a speculum examination was performed, nor any ferning or nitrazine testing.  The routine use of AmniSure to diagnose ruptured membranes is not recommended. 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: Reviewer 1, 2, and 3 are board certified in obstetrics and gynecology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested LINX procedure (CPT code 0392T, laparoscopic anti-reflux surgery)for treatment of his gastroesophageal reflux disease (GERD). Findings:  Two physician reviewers found that the LINX device received U.S. Food and Drug Administration (FDA) premarketing approval for four years, effective 3/22/12. The approved indication was for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. As noted by in a study, sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits as demonstrated by reduced esophageal acid exposure, improved GERD-related quality of life, and cessation of dependence on PPIs, with minimal side effects. Patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. This patients records support a diagnosis of GERD based on pH recording off PPI therapy, and per charted comments he has not optimally benefited from acid suppression treatment. Although symptomatic for many years, significantly he has not developed endoscopic evidence of esophagitis. From a symptomatic perspective, the patient may be considered medically refractory to acid blocker drugs. However, implantation of LINX in this patients clinical setting places him at significant risk for dysphagia post-LINX implantation given his known esophageal dysmotility. Final Result: The reviewers determined that the requested procedure 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: Reviewer 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 Repatha SureClick subcutaneous 140 ng/mL injection every two weeks. Findings:  The physician reviewer found that that this patient cannot tolerate high potency statins, she would not be able to use a high potency statin in conjunction with Repatha, which is contraindicated. Stress testing may not detect non-occlusive coronary artery disease (CAD) and may be falsely negative in the setting of balanced ischemia. The records document that the patient had a trial of Praulent, which is another PCSK9 inhibitor, that demonstrated efficacy reducing her LDL to less than 70 mg/dL, further supporting the future use of Repatha given her inability to tolerate statin therapy. Final Result: The reviewer 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Kadian 30 mg. Findings:  The physician reviewer found that the records provided for review document that this patient has failed conservative treatments in an attempt to control her chronic abdominal pain secondary to pancreatitis. In particular, the patient has tried and failed several non-opioid medications, epidural steroid injections, celiac plexus nerve block and has also failed generic MS Contin. Presently, the patient is functional and has good analgesia with Kadian 30 mg twice per day. This is a reasonable dose and the provider has documented the necessary first-line attempts at pain control. 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 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 authorization and coverage for left anterior cruciate ligament reconstruction surgery. Findings:  The physician reviewer found that the patient presents with an approximate six-month history of left knee pain, swelling, instability, and buckling following a twisting event. The patient reported an inability to walk without a hip to ankle brace, as the left knee would bend backwards and was unstable. The patient's comorbidities include Ehlers Danlos syndrome. Clinical examination documented positive Lachmans sign consistent with imaging evidence suggestive of ACL laxity. Reasonable conservative treatment, including bracing and activity modification, has been tried and has failed. 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 physician reviewer is board certified in orthopedic 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 wound vacuum system, ActiVac therapy wound VAC. Findings:  The physician reviewer found that negative pressure wound therapy has been used to promote healing of chronic wounds and pressure ulcers by creating controlled negative pressure over the wound which increases local vascularity and oxygenation of the wound bed, reducing edema by evacuating wound fluid, and removing exudate and bacteria. In this case, the in-network wound vacuum system is appropriate for the treatment of the patients wound. The patients wound is located in an accessible body area that would be expected to respond to proper use of the in-network wound vacuum system. In addition, there are no comorbid medical conditions or other complicating factors in this case. Final Result: The reviewer 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 physician 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 a recliner bath lift. Findings:  The physician reviewer found that based upon the descriptions provided, an automated assisted device is appropriate since her weight of 160 pounds is not easily manageable by a single caregiver. However, a recliner bath lift is inadequate to handle present and future transfer issues. The DME evaluation recommended a tub buddy system which allows the patient to more easily transition into the tub without relying exclusively on hip flexion strength or the caretaker to enter the tub. Based upon the reported assistance required for transfers and mobility, a recliner bath lift is inadequate. A shower tub buddy transfer system is more appropriate based upon the patients reported functional deficits. Final Result: The reviewer 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 with sub-specialty certifications in pain medicine and occupational 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 skilled nursing facility level of care. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the services at issue in this clinical setting. Functional impairments due to acquired brain insults such as stroke can be profound. The role of inpatient rehabilitative care for persons with significant functional deficits, as in this patients case, following stroke is relatively well-established in the medical literature.  In the present case, the patient has had multiple strokes.  The records indicate that she has chronically been at the total assistance level of care since admission to the facility. The records also note that this patient has been unable to participate meaningfully in therapies. While she has chronic skin issues, this patient does not require skilled nursing services. Overall, the record demonstrates that her needs can be met at a custodial level of care.  The need for skilled nursing facility level care has not been established in this patients case. Therefore, the requested services at a skilled nursing facility level of care are not medically necessary.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for revision gastric bypass with lap band removal for sleeve gastrectomy for treatment of her complications related to lap band surgery. Findings:  The physician reviewer found that based on the documentation submitted for review, the request for lap band removal is medically necessary. This patient has negative symptoms related to the lap band. Although there are no anatomic complications noted, intolerance is a medically necessary indication for lap band removal as it is associated with increased risk of secondary complications such as prolapse, obstruction, erosion. However, the request for conversion to sleeve gastrectomy is not medically necessary for this patient. The U.S. Food and Drug Administration (FDA) approved the lap band for use in patients with low BMI of 30-35 kg/m2 and these are not the standard guidelines for patient selection for the sleeve gastrectomy, which require a BMI of 40 kg/m2 or 35 kg/m2 with serious co-morbid conditions such as sleep apnea, diabetes or hypertension. The documentation submitted for review does not show that the patient has any of these co-morbid conditions. In addition, an updated multidisciplinary evaluation that includes dietary, surgical, and psychological assessments is indicated. Final Result: The reviewer determined that a portion of the requested surgery is 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 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 authorization and coverage for Harvoni 90-400 mg tablets for eight weeks for treatment of his chronic hepatitis C virus genotype 1a. 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, and advanced fibrosis is not required for treatment. Per guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with a viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer 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 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 authorization and coverage for continued infertility treatment, (intrauterine insemination (IUI) and all associated services) with injectable medication. Findings:  The physician reviewer found that the patient is with a history of age-related infertility and advanced reproductive age. Women over the age of 40 have a significantly reduced chance for live births from infertility treatment due to age-related diminished ovarian reserve. These live birth rates decrease rapidly as age progresses beyond 40. This negative impact on live birth rates is due to lower pregnancy rates and an increased risk of miscarriage. The Centers for Disease Control and Prevention (CDC) published reproductive outcomes for in vitro fertilization in women by age. The live birth rate for women older than 44 years of age is reported as less than 1%. In this case, the patient has failed three treatment cycles of IUI and her prognosis for a live birth with injectable gonadotropins and donor insemination is not expected. Therefore, continued infertility treatment, (IUI and all associated services) with injectable medication are not medically necessary for treatment of the patients medical condition.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: Physician reviewer is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology 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

Standard Review: A female enrollee has requested authorization and coverage for mental health services at a residential treatment center.  The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health condition. 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. Nature of Statutory Criteria/Case Summary: The documentation submitted does not support the medical necessity of the requested services in this clinical setting. Residential treatment is considered the highest level of psychiatric care available. Medical necessity guidelines and evidence-based practice indicate that psychiatric symptoms must be severe and present to the degree that this level of care is needed. The progress notes indicate that the patient has been clinically stable while in outpatient psychotherapy with the external provider network therapist and intensive case management. The psychiatrist indicated that the patient has been stable and improving with the current treatment plan. The provider indicated that the patient had showed much improvement the last time she was in the alternative options partial hospitalization program (PHP). This PHP program was again being recommended to the patient. Moreover, the patients treatment team noted that residential treatment was not indicated for the patient. The patient has suffered from chronic suicidal ideation for many years but has not verbalized any recent plans to harm.  For the reasons stated above, mental health services at a residential treatment center are not medically necessary for 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program level of care services provided.  Findings:  The physician reviewer found that the level of care was analyzed utilizing the Level of Care Utilization System (LOCUS) for Psychiatric and Addiction Services. This is a nationally accepted system for determining appropriate level of care. Recent gains and/or stabilization in function have been achieved while participating in treatment in a structured setting. Regarding medical, addictive or psychiatric comorbidity, the patient had a significant comorbidity with diagnoses of methamphetamine use disorder and sedative hypnotic use disorder. The patient had a mildly stressful recovery environment, as he had some mild interpersonal conflict with his partner. The records document a supportive environment.  In terms of treatment history, the documentation noted a moderate response to treatment. The patient participated in a 28-day program in 2013 and a 90-day program in 2014. Regarding his engagement and recovery status, the patient has been engaged and motivated for treatment and recovery. Based on LOCUS, the patient would meet criteria for intensive outpatient program level of care.