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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the hysterectomy for treatment of the enrollees symptomatic fibroids and left ovarian cyst. Findings:  The physician reviewer found that the hysterectomy performed was medically necessary for treatment of the patients medical condition. Uterine myomas are the most common solid pelvic tumors in women and the leading indications for hysterectomy. The two most common symptoms for which patients seek treatment are abnormal uterine bleeding and pelvic pressure. The most common kind of abnormal bleeding is hypermenorrhea which often results in significant disruption of activities of daily living (ADL). Adenomyosis refers to a disorder in which endometrial glands and stroma are present within the uterine musculature. This gynecologic condition likewise causes heavy menstrual bleeding and often painful periods. Patients with adenomyosis often have other associated gynecologic problems such as endometriosis or leiomyomas, such as in this case. Because there are no standard diagnostic imaging criteria to make the diagnosis preoperatively, choosing the optimal treatment for this particular condition is challenging. Currently, hysterectomy remains the standard of care for surgical treatment for leiomyomas because it is the only definitive treatment and eliminates the possibility of recurrence. In addition, the management options for adenomyosis is a hysterectomy. Final Result: The reviewer determined that the surgery 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center level of care services. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records noted mild post-acute withdrawals.  She was not a danger to herself or others, and she was not showing self-injurious behavior. She was medically and psychiatrically stable. Lexapro and trazodone could have continued to be monitored on an outpatient basis.  There were no emotional, behavioral, or cognitive issues that would have prevented her from receiving continued treatment at an ambulatory level of care.  She was motivated and aware of triggers, actions to take, and the impact her behaviors had on her family, relationships, and employment situations. She was an active participant in treatment and demonstrated insight and the development of coping skills.  Although she did remain at risk, she indicated that she knew what she must do to prevent relapse. The records indicate that the patient could have continued her treatment at a lower level of care during the dates of service at issue. She no longer required the restrictive setting of residential treatment, and could have been released to the ambulatory setting, in conjunction with a 12-step program, substance abuse counseling, and a sponsor. All told, residential treatment center level of care services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 hydrocodone/acetaminophen (Norco) 10-325 mg, quantity 120, and carisoprodol (Soma), quantity 120. Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. Applying this guideline, not all non-opioid and narcotic treatment options have been utilized in this patients case. There is no documentation of the completion of behavior therapy despite much research to support its use. Furthermore, no objective treatment goals for pain and function are noted for the requested medications . The Centers for Disease Control and Prevention (CDC) also state that when opioids are started, providers should prescribe the lowest effective dosage. Finally, not all non-opioid and non-narcotic medications classes have been optimized or tried . For these reasons, the requested hydrocodone/acetaminophen (Norco) 10-325 mg, quantity 120, and carisoprodol (Soma), quantity 120 are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nerve block. Findings:  The physician reviewer found that the request for nerve block is not medically necessary for treatment of the patients medical condition. There is a lack of medical literature supporting the requested service in this clinical setting. A study reported that sympathetic blocks may be medically useful for diagnostic and treatment considerations of peripheral neuropathy with findings of sympathetic mediated pain. In the absence of sympathetic pain symptoms or physical findings, sympathetic nerve blocks are not beneficial. The medical records submitted for review fail to demonstrate findings of sympathetic pain. There is no indication of hyperpathia, peripheral skin changes, hair growth abnormalities or temperature changes consistent with sympathetic mediated pain. As the records do not indicate such findings, a nerve block is not supported as medically necessary for treatment of the patients medical condition.  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 neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine sulfate 200 mg extended-release tablets, three times daily for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patient is taking a high dose of morphine. The risk of opioid-related overdose is dose dependent, and this patient is at increased risk of overdose. There is no documentation submitted that demonstrates a multidisciplinary approach to dealing with this patients pain. There is a lack of documentation of nonsteroidal anti-inflammatory drugs or anticonvulsant medication trials, cognitive behavioral therapy, physical therapy, chiropractic therapy, epidural steroid injections or surgery consultation. There is no documentation of urine toxicology screening in the submitted documents.  The evidence supporting the use of this high dose of opiates for non-malignant chronic pain is weak, and the medical evidence supports tapering the medication in this setting. The current medical evidence does not support the requested medication in this patients case. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the FoundationOne gene testing for evaluation of the enrollees sarcomatoid carcinoma. Findings:  The physician reviewer found that FoundationOne is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the FoundationOne assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment. A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the FoundationOne test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in 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 patient has requested authorization and coverage for maxillomandibular advancement surgery for treatment of the enrollees obstructive sleep apnea (OSA). Findings:  The physician reviewer found that this patient has been diagnosed with severe OSA. Surgical intervention focused at site specific obstructions is ideal. Maxillomandibular advancement has been shown to improve posterior airway space and also to increase the stability of the lateral pharyngeal wall, countering its tendency to collapse. A study reported a 100% success when maxillomandibular advancement was combined with a genial advancement. The author concluded that maxillomandibular advancement is highly successful and safe. Maxillomandibular advancement has also been reported to be an effective first-line treatment for severe OSA. Final Result: The reviewer determined that the requested surgery 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 oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a hysterectomy for treatment of the enrollees uterine prolapse. Findings:  The physician reviewer found that the services at issue were medically necessary in this clinical setting. The patient had a complete workup for the etiology of her symptoms. The provider recommended surgical management for treatment of this patients uterine prolapse after the workup was completed and the physiologic/pathologic changes that were contributing to her symptoms were more clearly defined. Based on the records, the degree of rectoenterocele prolapse at the time of this patients surgery would not have been resolved with medical management or pelvic floor physical therapy. The use of a pessary may have helped alleviate some of her symptoms temporarily, but it would not have resolved all of her symptoms completely. The American College of Obstetrics and Gynecology (ACOG) supports a hysterectomy in patients who decline the use of a pessary or in patients whose pelvic organ prolapse would not have reached a resolution of their symptoms through conservative management. This patient is postmenopausal, hypoestrogenic state, and not currently sexually active. This patients uterine prolapse would have likely continued beyond the current stage 1. Repair of the cystocele and rectoenterocele without addressing the uterus would have progressively prolapsed further. Addressing her pelvic organ prolapse in totality was clinically indicated for this specific 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery (CPT code 43775-laparscopy, surgical gastric restrictive procedure, longitudinal gastrectomy (i.e. sleeve gastrectomy)) with two day stay for treatment of the enrollee's morbid obesity and hip pain. Findings:  The physician reviewer found that there is support in the medical literature as well as in the documentation provided for review to support the requested services in this clinical setting. Based on the records, this patient meets the criteria for bariatric surgery from the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines. The patient is morbidly obese. The patient has failed dietary efforts without success and completed a comprehensive multidisciplinary evaluation that did not reveal any obvious dietary or behavioral barriers to surgery. The patient has obtained medical clearance as well as clinical support for surgery. The patients record supports the presence of comorbid conditions. The patient is not able to undergo treatment of his hip secondary to increased risks of surgery given his high BMI. Therefore, six months of supervised weight loss efforts is not supported by published literature and would delay necessary treatment and care. 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 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 authorization and coverage for Synvisc One injection in both knees. Findings:  The physician reviewer found that there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. A study conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The study  reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Synvisc One injections in both knees are supported as medically necessary for treatment of this patients knee osteoarthritis. Final Result: The reviewer determined that the requested service 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for the water circulating cold pad with pump for treatment of the enrollees medical condition status post knee surgery. Findings:  Two physician reviewers found that the water circulating cold pad with pump provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The use of icepacks is the standard of care in this clinical setting. A researcher performed a meta-analysis on the use of cryotherapy following anterior cruciate ligament reconstruction. Six studies were reviewed. Some individual studies reported significant benefit. However, pooled analysis did not support a significant impact compared to traditional methods of delivering cold, such as icepacks. A study provide support for reduction in pain levels at 48 hours but does not provide sufficient evidence for efficacy of cryotherapy for other outcomes such as analgesic medication use, range of motion, blood loss, hospital stay or quality of life. The authors concluded that there was a need for additional studies with randomized trials before the ambiguity as to the efficacy of cryotherapy can be resolved. In summary, while cold therapy may be beneficial, there is a lack of sufficient support in the peer-reviewed literature for its use in this clinical setting. Final Result: The reviewers determined that the equipment at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test. Findings:  The physician reviewer found that while FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered indeterminate. Until recently, studies have shown that the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma gene classifier analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is suggestive of a benign nodule and can therefore preclude such surgical procedures. For the reasons stated above, the gene test was likely to have been more beneficial for the evaluation of this patient than any available standard therapy. Final Result: Two of the three  reviewers determined that the services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.