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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for duodenal switch procedure with hiatal hernia repair for treatment of the enrollees obesity. Findings:  The physician reviewer found that the request for duodenal switch procedure with hiatal hernia repair is medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has a known complication of sleeve gastrectomy with new and worsening GERD and persistent morbid obesity. The patient underwent re-evaluation with an updated multidisciplinary evaluation and was determined to be an appropriate candidate for duodenal switch procedure. The patient meets all standard primary and re-operative bariatric guidelines from the American Society of Metabolic and Bariatric Surgery at this time. Therefore, the medical necessity of the requested for duodenal switch procedure with hiatal hernia repair has been established as medically necessary for treatment of the 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 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 authorization and coverage for Actemra (tocilizumab) injections. Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested medication in this clinical setting. Intervention with tocilizumab is medically indicated in this patients case. The records demonstrate that this patient has increased risk for reduced allograft chronic rejection. There is morbidity risk associated with allograft failure. The presence of DSAs are a negative long term predictor for allograft survival. Treatment with tocilizumab has been used with ABO-incompatible transplantation. Tocilizumab is indicated in that its pro-inflammatory mechanism of action has benefits in reducing DSAs. Therefore, in this patients case, Actemra (tocilizumab) injections are medically necessary for the treatment of this patients medical condition. 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 nephrology 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 Cologuard stool testing for evaluation of the enrollee, who underwent routine colon cancer screening.   Findings:  2/3 of the physician reviewers found that the physician reviewer found colorectal neoplasms shed DNA in the stool. The DNA can be isolated and tested for the presence of mutations and epigenetic changes acquired during carcinogenesis. Cologuard is a second generation stool DNA test. Cologuard has been approved by the U.S. Food and Drug Administration as a screening test for colorectal carcinoma to be followed, when abnormal, by diagnostic colonoscopy. This test may be appropriate for asymptomatic patients, 50 to 84 years of age, who are at average risk for colorectal cancer. This patient is a high risk for sedated colonoscopy due to her extensive neurologic history. Therefore, Cologuard stool testing provided was likely to have been of greater benefit than other modalities for 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 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Botox injections for treatment of the enrollees cricopharyngeus dysfunction. Findings:  The physician reviewers found that In the peer-reviewed medical literature, motor events allow esophagopharyngeal air movement by promoting retrograde airflow and opening of the upper esophageal sphincter. The transport phase, possibly activated secondary to diaphragmatic contraction, consists of a retrograde contraction of the striated muscle esophagus that transports the air from the thoracic esophagus to the pharynx. The esophageal reverse peristalsis is mediated by elementary reflexes, rather than a coordinated peristaltic response like secondary peristalsis. The phases of eructation can be activated independently of one another or in a different manner to participate in physiological events other than eructation that cause gastroesophageal or esophagogastric reflux. Given these physiologic mechanisms, the Botox injections in this patients case were not anticipated to have therapeutic benefit in alleviating her described symptoms. Accordingly, the Botox injections were not likely to be more beneficial for treatment of the patient than any available standard therapy. Final Result: Two of three 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in gastroenterology and 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 authorization and coverage for services with an infectious disease specialist for treatment of the enrollees medical condition. Findings:  The physician reviewer found that This patient presents with multiple symptoms and has undergone extensive evaluation. Overall, on physical examination he has no positive findings except for a defect at L5 that may be associated with his complaint of back pain and he is profoundly anxious. However, he has no complaints suggestive of an infectious process. He has not reportedly traveled outside of the U.S. and all of the screening tests for infection have been negative. For these reasons, the requested services with an infectious disease specialist are not medically necessary for evaluation and treatment of the patients medical condition. 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. In this case, there was no emergent medical condition noted in the records submitted for review. The patients treatment received on the dates in dispute were necessary and appropriate, however there is a lack of documentation demonstrating the services were for emergency care. Therefore, the services provided were not considered emergency medical services. Thus, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for peripheral nerve block injections and lateral branch radiofrequency ablation. Findings:  The physician reviewer found that in the documentation available for review, the provider states the patient had 95% pain relief and improvement in function after doing a diagnostic block to the lateral branches of S1, S2, and S3. However, no pain diary for a diagnostic block is available for review. The literature states that radiofrequency ablation requires a diagnostic block with only local anesthetic and a pain diary with notations of medication usage. A pain diary is not present in the documentation available for review and the duration of the pain relief lasted longer than the duration of the local anesthetic. Therefore, the requested peripheral nerve block injections and lateral branch radiofrequency ablation are not supported as medically necessary for treatment of the patients medical condition. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lyrica for treatment of the enrollees severe nerve pain from small fiber neuropathy. Findings:  The physician reviewer found that The records indicate that this patient developed a neuropathic pain related to a small fiber neuropathy that failed to respond to several medications including gabapentin, tramadol, Celebrex, pramipexole, low dose naltrexone and amitriptyline. Several studies have demonstrated the efficacy of Lyrica in neuropathic pain. Although most of the current studies have focused on the efficacy of Lyrica in diabetic neuropathy, the data suggests that Lyrica would also be effective in non-diabetic neuropathy. Other studies demonstrated that Lyrica is effective in toxic neuropathy and neuropathy in the orthopedic setting. Given this support, the requested Lyrica is supported as medically necessary for treatment of this patients severe nerve pain from small fiber neuropathy. 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 neurology with sub-specialty certification in neuromuscular 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: An enrollee has requested authorization and coverage for an electrical osteogenesis stimulator for treatment of the enrollees medical condition status post multilevel fusion surgery of the neck.  Findings:  The physician reviewer found that the requested electrical osteogenesis stimulator is medically necessary for treatment of the patients medical condition. Successful fusion surgery of the spine necessitates the formation of bridging bone between segments where surgery occurred. Failure of this bone formation can potentially result in pain and spinal instability. Bone growth (osteogenesis) stimulators are externally worn devices that use electromagnetic fields to enhance bone formation. The use of bone growth stimulators after surgery in the lumbar spine is well accepted in the peer-reviewed literature. A large prospective study by colleagues demonstrated that electromagnetic field stimulation for cervical fusion significantly increased the rate of healing. In this case, the providers recommendation for the requested device are in accordance with the North American Spine Society (NASS) policy recommendations. NASS supports the use of electrical stimulation for spinal fusion healing in all regions of the spine including cervical and lumbar regions. Additionally, NASS policy is consistent with community standard of care. Given the support in the peer-reviewed literature, the requested device has been established as medically necessary for treatment of the patients 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 neurological 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 requested authorization and coverage for sacroiliac joint fusion surgery for treatment of the enrollees right sacroiliac joint pain. Findings:  The 3 physician reviewers found that in this case, the patient has mechanical low back pain with evidence of degenerative sacroiliitis and a positive response to sacroiliac (SI) joint injection. SI joint fusion is recommended on a case-by-case basis as a last line of therapy, as treatment for SI joint infection, tumor involving the sacrum, disabling pain due to sacroiliitis due to spondyloarthropathy, SI pain due to severe traumatic injury, and the procedure may be required for multisegmental spinal constructs. SI joint fusion is not recommended for mechanical low back pain, non-specific low back pain, SI joint disruption, degenerative sacroiliitis, SI joint osteoarthritis, or SI joint mediated pain. For these reasons, the requested SI joint fusion surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested surgery 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for the residential treatment center (RTC) services provided for treatment of the enrollees suicidal ideation, self-harm and depression.Findings: The physician reviewer found that progress notes indicate the patient denied symptoms of depression and reported anxiety that was mild to moderate. During the remainder of his stay, the patient had oppositional behaviors, but was primarily cooperative in treatment. The progress notes did not indicate the patient had any active suicidal ideation or attempted suicide. In cases such as this, an evidence based instrument such as the child and adolescent level of care utilization system (CALOCUS) is indispensable in determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible. Applying the CALOCUS, this patient had some risk of harm (score 2) due to his history of impulsive actions and aggression. However, the medical records indicate that the patient was not actively suicidal and only expressed intermittent suicidal ideation with no intent or plan to harm himself. The patient experienced moderate functional challenges (score 3) due to some school disruption. Since the patient did not have active serious medical problems or any significant substance use issues, his co-morbidity was mild (score 2). The patients recovery environment was mildly stressful (score 2) with a positive recovery environment and a stable housing situation, and the patients parents were involved with treatment and supportive (score 2). The patient has demonstrated some resiliency in treatment (score 3) due to no significant and noted treatment successes. The patient was overall constructive in treatment (score 2), and was noted to participate in therapy and use coping skills learned in therapy. Moreover, his parents constructively work with the patients providers (score 2). This gives the patients presentation a composite score of 18 which correlates with intensive outpatient (IOP) services. Thus, the patient could have been safely and effectively treated in a less restrictive setting. In summary, the RTC services provided were not medically necessary for treatment of this patients behavioral health issues.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 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 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 ConfirmMDx test for evaluation of the enrollee who has a history of elevated prostate specific antigen (PSA). Findings:  The 3 physician reviewers found that there is a lack of support in the current literature as to the superior efficacy of the services at issue in this patients case. Given the PSA rising in a short course and the equivocal but declining free PSA, a biopsy of the prostate was an appropriate choice to rule out prostate cancer. However, while the ConfirmMDx testing might affect a decision for repeat biopsy, there is a lack of medical evidence from the literature or clinical forum to indicate that there would have been an added benefit to the evaluation of this patient. As such, ConfirmMDx test was not likely to have been more effective for the evaluation of this patients medical condition than the available standard therapy. Final Result: The 3 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 number one is board certified in urology 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 urology 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 urology 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.