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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a hysterectomy for treatment of the enrollees pelvic pain. Findings:  The physician reviewer found that this patient presents with a history of chronic left lower quadrant abdominal pain. Initial examination findings were suggestive of neuropathic pain especially in the absence of significant pelvic findings on examination and imaging. After an MRI revealed some prominent pelvic veins, a CT described them as mildly prominent bilateral adnexal veins, which is not a rare incidental finding. As noted in the medical literature, it can be difficult to establish the true incidence of PCS, given the lack of definitive diagnostic criteria. The authors reported that ovarian vein dilatation, stasis, and/or reflux on pelvic venography are common findings in multiparous premenopausal women, and most of these women are asymptomatic. The authors commented that in patients with characteristic symptoms, the diagnosis is supported by bimanual examination showing marked ovarian tenderness, cervical motion tenderness, and uterine tenderness with direct palpation. Until the providers last note, there was an absence of uterine or adnexal tenderness on multiple physical examinations for this patient. Overall, this patients findings and descriptions of her pain are not typical of PCS. Although bilateral salpingo-oophorectomy can be an option for patients who have failed other treatment modalities, this patients records do not demonstrate that standard therapies have been exhausted such as physical therapy. In addition, there are many non-gynecologic conditions that can be the cause of this patients abdominal pain, since there is a significant likelihood that there is a neurologic component to her pain. Final Result: The reviewer determined that the requested surgery 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 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: The patient has requested reimbursement for a breast pump for treatment of the enrollees lactation. Findings:  The physician reviewer found that based on current guidelines, a hospital grade electric pump is not medically necessary for most patients. While this infant was hospitalized for one night on day four of life, this was actually before the patient rented the hospital grade breast pump. The American College of Obstetricians and Gynecologists (ACOG) states that maintaining milk supply depends largely on frequency of milk removal through breastfeeding and through expressing milk (breast pumping or manual expression) when the woman and her infant are separated. However, there is no data to support the need for a specific type of breast pump. Similarly, the U.S. Breastfeeding Committee states that an electric pump is needed to maintain lactation when the mother is separated on a regular basis, or for a prolonged period of time, from her infant, as with returning to work. Similarly, a hospital-grade or rental-grade pump is needed to support initiation of lactation for mothers and infants who are separated due to illness, or who are unable to feed directly from the breast. In this patients case, neither of these circumstances existed during the pump rental period. Thus, the breast pump at issue was not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the device at issue was 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 obstetrics and gynecology with sub-specialty certification in maternal and fetal 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 DecisionDx-Melanoma gene testing. Findings:  The physician reviewer found that The DecisionDx-Melanoma has shown some accuracy determining risk of metastasis in thin melanomas, however treatment of this patient would not change based on the results of the examination. The testing at issue is not considered routine standard of care. There is a lack of peer-reviewed literature to support its use in patients with thin melanomas to effect health outcomes. Therefore, the DecisionDx-Melanoma gene testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three of the 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: Physician reviewers 1, 2, & 3 are  board certified in dermatology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the intensity modulated radiation therapy (IMRT) for treatment of the enrollees rectal adenocarcinoma. Findings:  The physician reviewer found that currently, there is a lack of clinical data in the medical literature to demonstrate that treatment with IMRT offers a clinical benefit compared to conventional radiation therapy techniques for patients with rectal cancer. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using three-dimensional (3D) conformal radiation. The plan comparison submitted by the provider shows no clinically significant difference between standard 3D conformal planning and the IMRT plan. In addition, the National Comprehensive Cancer Network (NCCN) guidelines indicate that IMRT should not be done for patients with rectal cancer because a recent phase II study examining this issue did not reveal positive health outcomes. 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 radiation 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency medical service. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of a psychiatric emergency medical condition. On admission the patient was not a danger to self or others, and was not gravely disabled. The patient showed no self-harming behavior. The patient had no auditory hallucinations, visual hallucinations, delusions, or mania. The patient had no comorbid medical conditions, and the seizure experienced was 10 years prior to admission.  The patients vital signs were stable and the patient was not in an altered state of consciousness. The patients CIWA of 13 indicates moderate level of withdrawals, and does not constitute a life threatening condition. The patient was placed on a Valium protocol, which is commonly done in an ambulatory setting. The patient did not have a psychiatric emergency medical condition during the dates in dispute. For the reasons provided, the patient did not receive psychiatric emergency medical services on the dates of service at issue. 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 authorization and coverage for Radicava.Findings:  The physician reviewer found that there is limited peer reviewed studies demonstrating the efficacy of the proposed treatment in patients with ALS.  Double blinded placebo controlled trials of Radicava in ALS have not demonstrated a change of motor scores relative to strength compared to placebo.  There is only one study demonstrating efficacy of the proposed treatment in a small subgroup of patients with ALS.  At this time, the efficacy of Radicava has not been well established. All told, Radicava is not likely to be more effective than the other methods of treating this patients medical condition Final Result: Two of the three he reviewers determined that the requested medication 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: Physician reviewers are  board certified in neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for capsule endoscopy for evaluation of bloating and constipation. Findings:  Two physician reviewers found that there is a lack of support for the requested services in this clinical setting. Community-accepted indications for capsule endoscopy include obscure gastrointestinal bleeding, small bowel Crohns disease, assessment of celiac disease, screening and surveillance for polyps in familial polyposis syndromes, and evaluation of the small bowel for tumors such as lymphoma, carcinomas or carcinoids. In this patients case, the records support possible irritable bowel syndrome. The results of her serology (even after dietary gluten challenge), HLA typing, and endoscopic biopsy do not warrant further studies for celiac disease. Final Result: The reviewers determined that the requested services are 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 gastroenterology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the Guardant360 testing for evaluation of the enrollees stage 1 adenocarcinoma of the right upper lung.  Findings:  Two physician reviewers found that there are non-randomized studies exploring the value of molecular profiling, however the results have not demonstrated the efficacy of such an approach to treatment. One 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. Final Result: The 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: 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the gene panel testing. Findings:  The physician reviewer found that the gene panel testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Genotype testing for genetic polymorphisms to determine psychotropic drug metabolizer status holds promise for improving the treatment of individuals with autism spectrum disorder who could benefit from pharmacotherapy. However, at present time there are insufficient controlled, adequately powered published studies to support its general adaptation . Variables such as age, sex, precision of diagnosis and environmental influences have not been addressed in currently available published studies. For the reasons provided, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: All three of the 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: Physician reviewers 1,2 & 3 are board certified in pediatrics and neurology with special qualification in child neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Botox. Findings:  The physician reviewer found that The Botox provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although trials evaluating the effect of intrapyloric Botox injection on gastroparesis have been reported, there is no definitive agreement whether Botox can effectively relieve the symptoms and improve the results of gastric emptying study in patients with gastroparesis. Bai and colleagues performed a systemic review on intrapyloric Botox injection for gastroparesis. The authors concluded that there is no evidence to recommend Botox injection for the treatment of gastroparesis. Moreover, the American College of Gastroenterology clinical guideline on the management of gastroparesis states Second-line approaches include venting gastrostomy or feeding jejunostomy; intrapyloric botulinum toxin injection was not effective in randomized controlled trials. All told, the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three of the reviewers determined that the service 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: Physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intradialytic parenteral nutrition (IDPN) therapy. Findings:  The physician reviewer found that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of published data demonstrating meaningful clinical outcomes are improved with IDPN therapy. A two-year multicenter, prospective, randomized study  demonstrated that IDPN provided to malnourished patients on dialysis did not improve patient outcomes. A study performed a prospective controlled study involving 113 dialysis patients receiving IDPN. The study demonstrated an improvement in albumin but no significant improvement in subjective local nutritional assessment. In addition, four subjects in the study developed uncontrolled hyperglycemia. A multicenter randomized controlled trial of 107 patients on hemodialysis demonstrated a statistically significant improvement in pre-albumin levels with intradialytic parenteral nutrition. However, the study was only 16 weeks in duration and did not assess mortality. In this case, the records do not show that the patient has contraindication to use of intradural nutritional supplements such as protein shakes provided by oral intake or via a gastrostomy or jejunostomy tube. In sum, IDPN therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested service 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: Physician reviewers 1, 2 & 3 are  board certified in internal medicine with sub-specialty certification in nephrology and  are actively practicing. The reviewers are an 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 reimbursement for residential treatment center services and partial hospitalization program (PHP) services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the services at issue were not medically necessary for treatment of the patients medical condition. The patients post-acute withdrawal symptoms were mild in nature. The patient was not a danger to self or others, nor was the patient aggressive or violent. The patient was cognitively intact and not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms present. The patient had no comorbid medical or psychiatric conditions. The patient was not psychotic or manic, and did not have any other symptom that would appear to interfere with care. The patient was motivated and appeared to be working the program. The patient was cooperative and participating in the treatment plan. The patient was not on medically assisted treatment. The patient had completed an uneventful detoxification, and had not been treated at a lower level of care. The patient did not require the restrictive setting of residential treatment. In addition, the PHP services could have been provided at an intensive outpatient program (IOP) level of care. Although the patient remained at risk for relapse, this is not sufficient rationale to remain at higher levels of care. For the reasons provided, the residential treatment center services provided and PHP services provided were not medically necessary for treatment of the patients medical condition. 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 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: The enrollee has requested reimbursement for the DecisionDx-Melanoma Assay for evaluation of the enrollees cutaneous melanoma.  Findings:  Three physician reviewers found that the DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Assay has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma Assay provided 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 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 dermatology 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.