Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency medical services.Findings:  The physician reviewer found that the patient was admitted to detoxification. He was stepped down to residential treatment center level of care. Based on the documentation submitted for review, the patient did not receive psychiatric emergency medical services during the dates of service at issue. On admission the patients withdrawal symptoms were mild in nature. There was no Clinical Opiate Withdrawal Scale (COWS) on admission, or thereafter. The course of detoxification was not provided for review, and there is no documentation showing the patient was placed on a detoxification protocol. He was not a danger to himself or others. He was medically and psychiatrically stable. He reported that he was highly motivated, and staff reported that he was open and engaged in treatment. There was no evidence of emotional, behavioral, cognitive, impulsive issues. He was not manic or psychotic. There is no evidence showing that the patient had a psychiatric emergency medical condition that required emergency medical services, or that he received emergency medical services. Final Result: The reviewer determined that 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene hypermethylation testing provided for evaluation of the enrollees elevated prostate specific antigen (PSA). Findings: All three physician reviewers found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Confirm MDx is a multiplex polymerase chain reaction (PCR) assay measuring DNA methylation of three biomarkers associated with prostate cancer: GSTP1, APC and RASSF1. In this case, the patient does not have any risk factors in the form of rising PSA, changing digital rectal exam, or family history of prostate cancer. The medical literature available suggests that Confirm MDx can accurately predict the need for repeat biopsy in a patient with negative biopsy results. However, these studies were recently published and need continued validation from widespread clinical use. While Confirm MDx may have a role in making treatment decision about patients with prostate cancer risk, there is limited data on clinical outcomes to currently support routine use. As such, the gene hypermethylation testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: All three physician reviewers determined that the testing at issue was 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: All three physician reviewers are board certified in urology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging of the spine for evaluation of the enrollees low back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the requested service. The medical literature supports an imaging study if it will change the course of therapy. In this patient, who has a relatively new onset of low back pain and who has an absence of preexisting conditions, such as a tumor or indications of an acute infection, the general practice is to proceed conservatively. The American College of Radiology (ACR) has established appropriateness criteria to evaluate various clinical presentations, including low back pain.  The guidelines indicate that imaging patients with acute low back pain, of less than six weeks duration and no red-flag symptoms provides no clinical benefit (ACR Appropriateness Criteria).  The ACR criteria also recommends that in patients with chronic low back pain, who do not present with red flags, first-line treatment remains conservative therapy with both pharmacologic and nonpharmacologic (eg, exercise, remaining active) therapy without imaging. In this patients case, there is no indication that she has specific neurological signs or radiculopathy. There is no information submitted that she has undergone a course of conservative anti-inflammatory medications or physical therapy.  There is also no information submitted that the patient has had any prior imaging studies including plain x-rays. The medical literature and the guidelines recommend conservative therapy, both pharmacologic and nonpharmacologic, prior to initiating further diagnostic therapies. In this case, the documentation does not show that she has exhausted conservative management. All told, conservative management is warranted, prior to undergoing MRI of the spine.  For these reasons, MRI of the spine is not medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested service is 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cell-free fetal DNA-based prenatal testing for fetal sex chromosome aneuploidies and microdeletion syndromes for evaluation of the enrollees pregnancy.  Findings:  The physician reviewers found that Fetal aneuploidy screening is supported for all pregnant patients by the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine. Cell-free DNA testing has been validated as having a high detection rate for fetal chromosomal abnormalities, including sex chromosomes. This patients age places her at increased risk for all fetal chromosomal abnormalities. Currently, the screening test of choice is cell-free DNA testing. Part of the commercial testing includes an analysis of fetal sex chromosomes. Fetal sex chromosomal abnormalities are common. Sex chromosome abnormalities such as Turners syndrome include significant associated medical morbidities. There is sufficient support for the services at issue in this patients case. This technique has been highly validated and shown to have a high detection rate.  Therefore, cell-free fetal DNA-based prenatal testing for fetal sex chromosome aneuploidies and microdeletion syndromes provided was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: 2/3 of the reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in obstetrics and gynecology 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.Physician reviewer number two is board certified in obstetrics and gynecology 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.Physician reviewer number three is board certified in obstetrics and gynecology 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 a three-dimensional (3D) mammogram for evaluation of her breast cancer.  Findings:  The physician reviewer found that although tomosynthesis is not routinely used as a part of screening mammography, this patient has unique circumstances. First, the patients breast tissue has been described as heterogeneously dense which limits the utility of standard mammography. Second, the patient has known Lobular Carcinoma In Situ in the remaining left breast as well as a family history of breast cancer. Since Lobular Carcinoma In Situ is more difficult to visualize on mammography, and in light of the patients circumstances, the addition of tomosynthesis is appropriate in this case. All told, the requested 3D mammogram is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested service is 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mepron for treatment of the enrollees diagnosis of Lyme disease. Findings: The physician reviewer found that this patient was being treated for non-specific complaints and was found to have some improvement on current therapy. The consideration of Babesia was made and testing was negative. While it is possible that the patient may have an infection for which no test is available, this patients clinical scenario does not merit Mepron as there does not seem to be evidence of Babesia infection. Accordingly, the requested Mepron is not medically necessary for 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 with sub-specialty certification in infectious 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for Decision DX UM melanoma assay for evaluation of the enrollees uveal melanoma (UM).Findings:  Two physician reviewers found that Uveal melanomas arise from melanocytes in the uvea, as was the situation in this case. Uveal melanomas tend to present with visual symptoms and are diagnosed upon funduscopic evaluation. The literature reports that local treatment is effective in preventing local recurrence in over 95% of cases, but 50% treated with enucleation developed metastatic disease over a five year follow up period. Clinical factors associated with poor prognosis include large tumor size, involvement of the ciliary body, increased age, and extrascleral extension. DecisionDX UM is a 15 gene panel expression assay which classifies genes based on a calculation from the gene expression and comparison with a training set of known outcomes. Multiple studies have been performed to validate its use, and these small studies indicate that the score generated permits clinicians to individualize the patients surveillance plan. Although DecisionDX may provide an additional risk assessment tool, the current treatment and surveillance options (post-surgical) available have shown to have limited effect on overall survival. Due to the high risk of metastatic recurrence, evaluation of clinical and molecular characteristics is encouraged to guide surveillance care after local therapy, as there is very limited definitive data on the optimal follow up after initial treatment. Surveillance plans appear to be clinician and cancer center dependent and involve blood work, clinical examination and imaging at regular intervals. There are few guidelines to suggest change in frequency of follow up based on prognostic characteristics and thus, the utility of the score remains of limited value. Final Result: Two reviewers determined that the testing was 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: All three physician reviewers 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 12-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of direct one-on-one applied behavioral analysis (ABA) therapy, 16 hours per month of supervision and four hours per month of parent training for treatment of the autism. Findings:  The physician reviewer found that ABA is a medically necessary intervention for the treatment of autism and remains one of the most evidence based interventions available. In this case, continued ABA therapy is medically necessary to address the patients emotional regulation, impulse control, perspective taking and compliance. There is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. In this case, the patient has made great progress, but he continues to engage in maladaptive behaviors of aggression and self-injury. The Health Plan has authorized 10.8 hours per week of direct one-on-one ABA, along with 8.7 hours per month of supervision and 8.7 hours per month of caregiving, which is less than what has been provided in the past. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Based on the clinical documentation provided for review, 40 hours per week of direct one-on-one ABA therapy, 16 hours per month of supervision and four hours per month of parent training have been established as medically necessary for treatment of the patients medical condition.  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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.Findings: The physician reviewer found that according to the 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Epclusa for 12 weeks, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Feld, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, treatment of hepatitis C is needed, and the requested treatment with Epclusa is medically necessary for the treatment of the patients hepatitis C infection.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the treatment plan recommended for the treatment of the enrollees metastatic breast cancer. Findings:  The physician reviewer found that the first line therapy for patients who have been diagnosed with metastatic breast cancer is chemotherapy. The choice of chemotherapy is dependent upon the presence or absence of estrogen/progesterone receptors and/or HER2. The guidelines summary suggest the following: (1) There are reports that suggest that 15% of recurrent lesions may have discordant ER status and therefore biopsy is recommended. (2) If ER status is positive, then current treatment guidelines suggest hormone/endocrine based therapy and reserving chemotherapy for patients who appear to be refractory to estrogen therapy. (3) If greater than 12 months from the conclusion of hormone based therapy, then hormone therapy is indicated. If less than 12 months, then an alternative hormone therapy should be considered. (4) If recurrent disease is local, then surgery or radiation should be considered. (5) If recurrence is hormone receptor negative and associated with symptomatic visceral metastasis, then chemotherapy should be considered. In this patients case, she has developed recurrent disease three years into her adjuvant treatment.  Accordingly, the guidelines would suggest that alternate endocrine based therapy should be considered. The medical record provided by the in network oncologist indicates that they are recommending chemotherapy. On the other hand, the out of network oncologist is recommending an alternate endocrine based therapy which has less side effects. Recommended treatment plan is in line with current treatment guidelines. Therefore, the treatment plan specifically recommended 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Edarbi 80 mg for treatment of the enrollees hypertension. Findings:  The physician reviewer found that the records document that this patient has hypertension which is effectively controlled by treatment with an angiotensin receptor blocker, Edarbi. In this circumstance of treatment for hypertension, there is no single angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker that has proven outcomes benefit compared to other agents in the same class.  Current guidelines for the treatment of hypertension do not support the use of one specific ACE inhibitor or angiotensin receptor blocker over another.  In this patients case, the records do not support a trial or intolerance of any of the specified medication alternatives.  Finally, generic alternatives in general contain the same active ingredients as their brand name counterparts and are within an acceptable bioequivalent range to the brand name drugs with respect to pharmacokinetic properties. All told, Edarbi 80 mg 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 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.