Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for an implantable electrical bone stimulator for the right ankle.The submitted documentation supports that the requested device is medically necessary. Medical literature support the efficacy of bone growth stimulation as a fracture healing modality in the appropriate clinical situation. In this case, the patient remains symptomatic four and a half months after sustaining a fracture and has pain over the medial malleolus in addition to MRI evidence of the absence of a healing reaction. Use of a bone growth stimulator for the treatment of the ununited fracture of the medial malleolus is reasonable and appropriate in this clinical situation. Accordingly, the requested implantable electrical bone stimulator for the right ankle is medically necessary to treat the medical condition.Final Result: The reviewer determined that the requested device 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 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: Overturned Decision of Health Plan

The patient has requested reimbursement for OxyContin 20 mg (one tablet every 12 hours; #28 tablets for two week supply). The guidelines from the American Pain Society and American Society of Regional Anesthesia and Pain medicine support acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia for management of postoperative pain in patients without contraindications. In this case, the patient was treated with OxyContin following L4-5 interbody fusion for lumbar spondylolisthesis with lumbar spinal stenosis and neurogenic claudication. The provider noted that the spinal fusion was a contraindication for the use of NSAIDs due to healing of the bone fusion. The provider noted that other modes of analgesia were unsuitable. The provider recommended postoperative pain management with OxyContin 20 mg for two weeks. This short course of a long-acting pain medication to assist with the patients increased levels of pain in the immediate postoperative period was reasonable and individualized to the patients medical condition. Given these findings, the OxyContin 20 mg (one tablet every 12 hours; #28 tablets for two week supply) was medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was 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 anesthesiology with subspecialty certification in pain management 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

An enrollee has requested reimbursement for breast Cancer Index (BCI) testing. Hormone receptor-positive breast cancer responds to adjuvant anti-estrogen therapies such as aromatase inhibitors and tamoxifen. These drugs are usually administered for five years after mastectomy. However, patients are at risk for recurrence for nearly 15 years after diagnosis and initial surgical resection. A biomarker may help providers identify those patients at higher risk and making them candidates for extended anti-estrogen therapy. BCI is a gene expression test that generates a risk for five-year recurrence for use in this clinical setting. In one well-controlled clinical study, the BCI was a good prognostic marker of breast cancer recurrence and performed better than the OncotypeDX gene expression test. Given this support, the BCI testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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

The patients parent has requested authorization and coverage for group speech therapy for an hour, once a week and after school hours. Researchers recommend that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism. The authors noted that further development of therapy plans and interventions targeting pragmatics is lacking. At present, per the description by the patients speech provider of his behavior, the requested group speech therapy is not medically necessary. While he should benefit from continued individual speech therapy, his behavior is not conducive to him benefitting from group speech therapy. The patients behavior is also likely to be disruptive to other children in the group speech therapy session. The provider reports that the patient has limited joint attention and his inability to be present prevent him from participating and being successful in a social learning group. The patient has also demonstrated grabbing behaviors that interfered with the therapy process. For these reasons, the requested group speech therapy for an hour, once a week and after school hours, is 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. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology 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 patient has requested authorization and coverage for acupuncture treatment. Researchers concluded that acupuncture is is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Currently, there is a paucity of peer-reviewed medical literature supporting acupuncture for the treatment of hand osteoarthritis. This patient reported that prior five acupuncture sessions were beneficial in reducing her symptoms. However, the records provided for review do not include documentation of specific measurable, progressive, objective functional improvement to support an indication for additional acupuncture. The continuation of acupuncture should only occur based on progressively greater objective gains. For these reasons, the requested acupuncture treatment is 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. Credentials/Qualifications: The reviewer is board certified in oriental 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:  The enrollee is requesting authorization and coverage for Aimovig auto-injectors. The enrollee has a history of chronic migraines. She has had recurrent headaches for 12 years. The enrollee reports headache durations of one to two days, and they are associated with nausea, vomiting, auras, and photophobia. A computed tomography scan of the head was negative. She has tried Topamax, but experienced cognitive problems. She has also tried nortriptyline, sumatriptan, rizatriptan, baclofen, and dicyclomine. She is requesting coverage for Aimovig injections for migraines. Medical records show the enrollee tried and failed Topamax and nortriptyline, which is nearly identical to amitriptyline, along with other medications approved governmental bodies for migraine headache.  Literature reports Aimovig is effective for migraine prophylaxis and is approved by governmental bodies for this purpose.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for a power scooter. The enrollee has a history of degenerative disc disease, osteoarthritis of the spine, arthritis of both hips, and bilateral rotator cuff syndrome. She has had a right hip replacement, left knee replacement, carpal tunnel release, and hernia repair. She has a 4-wheeled walker with a seat, but reports she can only ambulate short distances without resting. The enrollee reports she requires a scooter to enable movement inside and outside of her home. Her orthopedic physician reports the enrollee is unable to use her upper extremities to push a standard wheelchair. Motorized scooters are only recommended for a very specific category of individuals; those with severe mobility impairments, an inability to ambulate with the assistance of a cane, walker, or other assistive device, and an inability to propel a manual wheelchair. These individuals must also have shown an inadequate response to multiple other treatments, including medications, aerobic exercise, strengthening exercise, weight loss, aquatic therapy, injections, joint replacement, and other surgeries. Reliance on a motorized scooter can increase the risk of further deconditioning and worsening of a enrollees condition if used inappropriately. A physical therapy evaluation shows the enrollee is able to ambulate under her own power in the house and uses a 4-wheeled walker, with a seat for community ambulation.  She has limited, but functional, use of both arms.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement for fertility preservation services. The American Society of Clinical Oncology and the American Society for Reproductive Medicine consider sperm and embryo as well as oocyte cryopreservation are considered standard practice for patients with cancer planned to undergo treatment with chemotherapy. This patient has a history of Hodgkins lymphoma. Treatment planning included chemotherapy. The provider referred the patient for fertility preservation services. With current technology, fertility preservation services have been shown to be successful. In this case, the patients fertility status after treatment for Hodgkins lymphoma with chemotherapy is uncertain. Given the treatment plan outlined for the treatment of her Hodgkins lymphoma, her fertility will be suboptimal. All told, the fertility preservation services were medically necessary for 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 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

The enrollees parent is requesting reimbursement for the final seven hours of neuropsychological testing. The enrollee has social anxiety. His mother reports the enrollees behavioral, social, and communication issues began causing significant problems at home and in school. The enrollee underwent neuropsychological testing. The enrollees psychologist reports the assessment was necessary to his mental and physical health, as it greatly informed treatment options and clarified differential diagnoses. Literature indicates neuropsychological assessments are often used to provide additional information about a variety of developmental disorders. The most common questions concern medical disorders, such as genetic disorders, brain injury, and neurologic concerns such as epilepsy and movement disorders. Disorders such as dyslexia, attention deficit hyperactivity disorder, autism spectrum disorder, and fetal alcohol spectrum disorder are common reasons for referral for assessment. Psychiatric disorders such as obsessive-compulsive disorder, anxiety and depression, are referred for evaluation in order to understand the child's difficulty and to provide recommendations for treatment at home and at school. As a result of the neuropsychological assessment, this enrollee was diagnosed with social anxiety. Depending on the age of the child, level of tolerance and numbers of tests, the assessment may require multiple days.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested reimbursement for the DecisionDx-Melanoma assay. The enrollee has a malignant melanoma on her left foot. Pathology showed a Breslow depth of at least 0.3 millimeters. The Castle Biosciences report indicates the Decision Dx-Melanoma class was 1 and sub-class was 1A. A class 1A signature is associated with the lowest risk of recurrence within 5 years. The risk classification provided by the DecisionDX-Melanoma test is used to better estimate an individuals risk of recurrence. This result helps determine appropriate surveillance, clinical follow-up and specialty referral. The DecisionDx-Melanoma gene panel is not currently recommended by any standard treatment guidelines. Providers may suggest that those who are shown to be at high risk for metastasis as a result of this test undergo more frequent clinical evaluations and imaging. However, if additional therapies are either contraindicated or not available, this categorization may increase anxiety without real benefit to the individual.Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in dermatology and are 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: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for biofeedback training, perineal muscles, anorectal or urethral sphincter. The enrollee has chronic constipation, overflow fecal incontinence, and pelvic floor muscle coordination problems. A colonoscopy was normal, and there is no known family history of colon cancer. A pelvic ultrasound was normal. During an office visit, records show the enrollees symptoms have persisted for a long period of time, but have worsened in the past few months. He also reports some urinary incontinence. The physician documented the enrollee would benefit from biofeedback therapy for retraining of his pelvic floor muscles. The enrollee reports he has difficulty controlling his bowel movements long enough to make it to a toilet. The enrollees physician reports this is the only available treatment for this functional disorder. A systematic review of 21 studies (with a total of 1525 enrollees) on the use of biofeedback for fecal incontinence concluded that biofeedback and electrical stimulation may offer an advantage over electrical stimulation alone or exercises alone, but larger, well-designed trials are needed before definitive conclusions can be made. Literature reports a specialty society guideline recommends biofeedback therapy as a first-line treatment for symptomatic constipation due to pelvic floor muscle coordination problems; however, this was based on a single randomized controlled trial with 77 enrollees.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in general 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollees parent requested reimbursement for the tryptase blood test. The enrollee has a reported food allergy to corn and corn derivatives. He underwent a tryptase blood test. Records indicate the tryptase test measures both the alpha and beta forms of tryptase, and measuring both forms increases the sensitivity for the diagnosis of mastocytosis, and mast cell degranulation as a cause of anaphylaxis. Literature reports serum tryptase is useful in diagnosing drug and venom anaphylaxis.  Its use in food anaphylaxis is unknown.  For this enrollee, there is no data to support the utility of a tryptase level, unless the enrollee is undergoing a food challenge or has a documented history of anaphylaxis to the known food. The scientific evidence and peer-reviewed literature does not support a result of improvement in health outcomes. This enrollee is not a good candidate for the tryptase blood test.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in allergy and immunology and are 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

The enrollee is requesting reimbursement for inpatient hospitalization. The enrollee has a history of depression and eating disorder. She was admitted to the inpatient psychiatric level of care after presenting to the emergency department for a progressive decline in function. The enrollees composite LOCUS score corresponds with Level IV; however, due to the enrollees score in the dimension of Functional Status, Level V care is warranted. The inpatient level of care is beneficial to this enrollees condition. Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.