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

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for prenatal screening for microdeletions using cell-free fetal DNA that she received. The Health Plan has denied the service at issue as investigational for evaluation of the enrollees fetus.Findings:  Two out of three physician reviewers found that according to the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) joint practice bulletin, cell-free DNA screening tests for microdeletions have not been validated clinically and are not recommended at this time. In a study, the positive predictive value of microdeletion testing does not support its routine use. One physician reviewer found that researchers conducted a study with an extended range of chromosomal anomalies. The authors reportedly obtained an incremental diagnostic yield of 50%, with rare autosomal trisomies and duplication copy-number variations found to be significant causes of fetal pathology.Final Result: The reviewers determined that the service 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: Physician reviewers 1, 2 and 3 are board certified in genetics 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 enrollee is requesting Adderall for relief of her fatigue as well as improved focus and motivation.  Findings:  The physician reviewer found that Adderall has improved her fatigue and concentration symptoms in the past. Therefore, Adderall is medically necessary for the treatment of this patient.The enrollee was diagnosed with major depressive disorder (MDD), obstructive sleep apnea, and systemic lupus erythematosus. The enrollee reported having depression since her teens. The enrollee reported she was on Adderall with adequate relief of her fatigue as well as improved focus and motivation in the past.  Recently, the enrollee endorsed poor memory and concentration, anhedonia, appetite changes, insomnia, decreased energy, excessive worry, and restlessness. Examination findings included that the patient had an anxious, irritable, and sad mood. The patient was being treated with Pristiq, Wellbutrin, and Abilify. At issue in this case is whether Adderall is medically necessary for the treatment of this enrollees medical condition. One nationally reputable association reports that augmentation of antidepressants with low doses of stimulants such as methylphenidate or dextroamphetamine may help ameliorate otherwise suboptimally responsive depression. The enrollee has a history of a single seizure in the context of medication change. The records report that Adderall has improved her fatigue and concentration symptoms in the past. Therefore, Adderall is medically necessary for the treatment of this enrollee.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication regimen Dupixent 300 mg/2 ml subcutaneous injection administered twice on day 1 (600 mg/4 ml) followed by once (300 mg/2 ml) every two weeks thereafter. This patient has a chronic history of moderate to severe atopic dermatitis and is requesting coverage for Dupixent. The records document that he has failed therapy with topical steroids and topical immunomodulators. Dupixent has been approved by the U.S. Food and Drug Administration for the treatment of moderate to severe atopic dermatitis in adolescents and adults.  This patient has a lifelong history of this condition. Given the chronicity and severity of disease in this patients case, the requested medication regimen is medically indicated. Therefore, the medication regimen Dupixent 300 mg/2 ml subcutaneous injection administered twice on day 1 (600 mg/4 ml) followed by once (300 mg/2 ml) every two weeks thereafter is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 dermatology 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 patient has requested authorization and coverage for esophagogastroduodenoscopy (EGD) procedure (CPT code 43239) and colonoscopy procedure (CPT code 45380). The American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that EGD is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful. In this case, the patient has failed proton pump inhibitor therapy, with persistent heartburn. Thus, the patient meets the ASGE criteria for evaluation with EGD. In addition, the ASGE supports the use of colonoscopy for evaluation of this patients symptoms. The ASGE guidelines state that a colonoscopy is appropriate as the initial method for evaluation, as an alternative to radiographic studies for unexplained abdominal pain to rule out disease. Diseases such as colon cancer can present with lower abdominal pain in patients younger than age 50. Further, if irritable bowel syndrome is suspected, diagnosis requires other causes, such as inflammatory bowel disease and malignancy to be ruled out, using a method such as colonoscopy. For these reasons, both EGD and colonoscopy are supported for the evaluation of this patients heartburn and left lower quadrant abdominal pain. Accordingly, the requested EGD procedure (CPT code 43239) and colonoscopy procedure (CPT code 45380) are medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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

The patient is a male who was diagnosed with bilateral lower extremity paresthesia. An x-ray of the cervical spine was noted to be a normal. The patient reported leg paresthesia and weakness. No upper extremity symptoms were noted. At issue in this case is whether a MRI of the cervical spine without contrast is medically necessary for evaluation of the patients medical condition. Neural injury may be associated with denervation of the muscles supplied by the nerve. Electromyography (EMG) remains the gold standard for diagnosis of denervation. The most recent neurology evaluation noted a diagnosis of peripheral neuropathy and no recommendation for advanced imaging. EMG results were not provided for review. The medical evidence does not support the request in this clinical setting. Therefore, a MRI of the cervical spine without contrast is not medically necessary for the evaluation of this patient.  Final Result: The reviewer determined that the requested service 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 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

The patient is a female who was diagnosed with an incarcerated umbilical hernia. The patient underwent an emergent incarcerated ventral hernia repair in December. The patient developed recurrence of her hernia in January with an associated small bowel incarceration, requiring a second hernia repair. Mesh was not used in either of the hernia repairs. The patient's body mass index (BMI) was noted to be. At issue in this case is whether hernia repair surgery with mesh is medically necessary for the treatment of this patients medical condition. The incidence of complications with ventral hernia repairs (VHR) increase in obese patients. Elective VHR is not recommended for patients with a BMI of or more. Liang and colleagues noted that mesh reinforcement is recommended for repair of hernias measuring two cm or larger. Further, the authors concluded that there were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients. There is no evidence that the patient currently has a hernia to support an indication for placing mesh at the site of the previous hernia repair. Therefore, hernia repair surgery with mesh is not medically necessary for 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 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: The patient has requested Synvisc injections. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of these injections. The current medical literature pertaining to viscosupplementation reveals mixed results. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is inconclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited.  In this patients case, there is known benefit from prior injections. This patient's options are limited, with the alternative being a total knee arthroplasty. Therefore, Synvisc injections were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: At issue in this case is whether the request for reduction mammaplasty is medically necessary for treatment of the patients medical condition. In addition, does the patients condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital abnormalities, developmental abnormalities, trauma, infection, tumors or disease? If so, is the requested surgery performed to do either of the following: improve function, create a normal appearance to the extent possible or restore symmetry? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?American Society of Plastic Surgeons (ASPS) guidelines report reduction mammaplasty is supported when it provides a measurable benefit and improvement in such things as symptomatology and quality of life in patients. The ASPS guidelines also identify a list of criteria that when at least two are identified, the procedure is considered medically necessary.  The patient demonstrates meeting at least two of these criteria. The records support that there is a developmental abnormality of the body in the form of a Type I tuberous breast deformity and associated breast asymmetry. Reduction mammaplasty would be expected to provide more than a minimal improvement in the appearance.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for laboratory test (CPT 82725) for their medical condition of hair loss. Findings:  The physician reviewer found that Hair loss is common as women get older. In a peer-reviewed article that patients presenting with hair loss should be screened by medical history, dietary history and physical examination for risk factors for nutrient deficiency. If warranted, laboratory studies may be performed. In patients with no risk factors, further laboratory evaluation searching for nutritional deficiencies is not recommended. For patients with nutritional deficiencies, these deficiencies should be corrected. Further research is required to determine whether any benefit exists for nutrient supplementation in the absence of documented deficiency. In this case, the patient has a history of chronic hair loss. She is underweight and had a significant weight loss of 18 pounds from March 2018 to October 2018. However, the record does not address a work-up for malabsorption or other major medical problem to rule out a cause for the patients symptoms. Thus, the laboratory test (CPT 82725) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the laboratory test (CPT 82725) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 63-year-old female diagnosed with hemorrhoids. Findings:  The physician reviewer found that he patient underwent a screening colonoscopy for malignant neoplasm. The pre-anesthesia assessment documented an American Society of Anesthesiologists (ASA) risk score of one, and a Mallampati class two airway score. The patient was provided with monitored anesthesia care and propofol. At issue in this case is whether monitored anesthesia care that was provided during a colonoscopy on 12/4/18 was medically necessary for treatment of the patients medical condition. The guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) note that the combination of an opioid and benzodiazepine is safe and effective for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. Minimal and/or moderate sedation can be delivered safely to patients who are ASA class I, II, or III. The use of anesthesia is associated with a 13% increase in the risk of complications within 30 days and was associated with an increased risk of perforation, hemorrhage, abdominal pain. The medical records noted the patient had a previous colonoscopy without complications. In addition, preoperatively, the patients ASA risk score was rated as one. Therefore, monitored anesthesia care that was provided during a colonoscopy was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 66-year-old female who was diagnosed with fibromyalgia, cervical spondylosis, and chronic pain syndrome is requesting authorization and coverage for morphine. Findings:  The physician reviewer found that e patients sensation, strength, and reflexes were reported to be intact. The patients provider noted that the patient was involved in a car accident due to falling asleep while driving. The provider noted safety concerns for the patient and recommended tapering off morphine. A pain management specialist did not recommend opioids for the patients chronic pain and agreed with the plan to taper off opioid medications. Non-opioid therapy was recommended to treat the patients fibromyalgia. At issue in this case is whether morphine is medically necessary for treatment of this patients medical condition. The use of strong opioids in patients with fibromyalgia is not recommended due to a lack of efficacy, and the high risk of side effects and/or addiction. Strong opioid use is discouraged, and patients who continue to use opioids should show improved pain and function. Further, the Federation of State Medical Boards states that continuation, modification, or termination of opioid therapy for pain is contingent on the patients progress toward treatment objectives, and the absence of risks or adverse events. Behaviors that require modification or termination of opioid therapy include patient intoxication and impairment. In this case, the patient was diagnosed with fibromyalgia and chronic pain syndrome. The records indicate that she was treated with morphine and was involved in a motor vehicle accident due to falling asleep while driving. The provider noted safety concerns and recommended tapering the patient off morphine. Since the records do not report that the patient has progressed toward treatment objectives and there is a risk of adverse events, morphine is not supported as medically necessary for 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 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.