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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) level of care services for treatment of his alcohol abuse. Findings:  The physician reviewer found that  on admission, the patient was not suicidal, homicidal, manic, or psychotic. His medical conditions were stable and managed on medications. He had no prior treatment at a lower level of care such as partial hospital program (PHP) or intensive outpatient program (IOP). No Clinical Institute Withdrawal Assessment (CIWA) was provided on admission, but his vital signs were stable and the withdrawal symptoms reported were not severe in nature. The medication changes that occurred did not require residential monitoring. The tremor reported was trace, he had no sweating, nausea, vomiting, diarrhea, or other gastrointestinal symptoms. There were no emotional, behavioral, or cognitive issues to warrant 24-hour level of care with medical and nursing supervision. The patient was motivated and he had sober supports in place. He could have received treatment at PHP level of care along with community supports in the form of a 12-step program with a sponsor, and continuation of care with his outpatient psychologist and psychiatrist. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the corneal cross-linking for treatment of his keratoconus. Findings:  Two physician reviewers found that Corneal cross-linking is a U.S. Food and Drug Administration (FDA) approved procedure for corneal ectasia and post-refractive ectasia. The primary purpose of cross-linking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus. The procedure involves soaking the cornea with riboflavin and the using ultraviolet (UV) light to create chemical bonds between collagen fibrils within the corneal stroma. This stiffens the cornea and halts the thinning that is seen with corneal ectasias. Prior to this treatment, patients with keratoconus who failed medical treatment and whose disease continued to progress would require surgical management with corneal transplantation. Multiple studies have demonstrated that patients who underwent corneal cross-linking showed an improvement in keratometry values, uncorrected visual acuity and best corrected visual acuity. In addition, further studies have shown an overall decrease in the number of penetrating keratoplasties performed since the introduction of crosslinking. Given this patients intolerance to contact lenses, high astigmatism, and topography, as well as the progressive disease in the contralateral eye, corneal cross-linking was an appropriate treatment to halt the progression of his keratoconus prior to a more invasive procedure such as penetrating keratoplasty. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in ophthalmology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program services for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that according to the American Society of Addiction Medicine (ASAM), placement should be based on a complex, individual, clinical assessment rather than reimbursement limitations, program ideology, or utilization reviewers. Further, the American Psychiatric Association (APA) noted that IOP treatment that graduates used fewer psychiatric inpatient bed days in comparison with both program non-completers and their own prior use. In this case, the patients substance use disorder dominated all elements of his functionality and was complicated by anxiety and affective illness. Despite his tenuous sobriety, he remained symptomatic with depressive symptoms and anxiety. The patient was prescribed complex pharmacotherapy including a mood stabilizer with divalproex, anti-depressant with bupropion, anxiolytic with buspirone, anti-hypertensive often used for nightmares and hyperarousal with prazosin and an anti-psychotic with aripiprazole. He had been using many substances including fentanyl which is a synthetic opioid 100 times more potent than morphine. He had a serious overdose that reportedly required a reversal agent. The patient was tired, unmotivated and depressed. His provider recommended specialty care at the IOP level of care. His fledgling sobriety is jeopardized by his addictive disease, psychiatric illness burden, personality organization, and external stressors. He will more than likely relapse in the absence of IOP programming until he consolidates the treatment gains necessary to succeed independently in the outpatient setting. Considering the relevant peer-reviewed literature, current practice guidelines and the case in its entirety, service at the IOP level of care is safe, appropriate and consistent with good medical practice, and reasonably expected to improve the patients condition, bolster relapse prevention efforts and prevent a more serious episode of illness. Final Result: The reviewer determined that the services at issue were and 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 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 gene test for evaluation of the enrollees pineal pilocytic astrocytoma with aggressive features. Findings: All three physician reviewers found that there is a lack of support in the medical literature as to the superior efficacy of the services at issue in this clinical setting. Prospective randomized clinical trials, which compare the strategy of targeted treatment to standard of care therapies, are needed in order to demonstrate the clinical utility of this gene test. The available medical literature, as to its clinical utility, consists of a small number of uncontrolled studies, and nonrandomized controlled trials. The evidence is not sufficient to make conclusions as to its efficacy and clinical utility when compared to standard options. Final Result: The reviewers determined that the service at issue was not likely to have been 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: An enrollee has requested reimbursement for cell-free fetal DNA based prenatal testing for fetal sex chromosome aneuploidies and microdeletion syndromes for evaluation of the enrollee, who presented for fetal DNA testing. Findings: Two of the three physician reviewers found that this patient underwent noninvasive cell-free fetal DNA testing for aneuploidy including optional testing for sex chromosome anomalies and microdeletion syndromes at 12 weeks gestation. There is no reported family history of sex chromosome abnormalities, x-linked disorders or other genetic disorders. The patient requested reimbursement for cell-free fetal DNA based prenatal testing for fetal sex chromosome aneuploidies and microdeletion syndromes. The Health Plan denied reimbursement indicating that the services at issue were investigational for the evaluation of this patient. The American College of Obstetricians and Gynecologists and the Society for MaternalFetal Medicine recommends cell-free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. There are three parts to this test, aneuploidy testing for chromosomes 13, 18 and 21, testing for sex chromosome abnormalities, and testing for microdeletions. For the patient's age, the the aneuploidy risk for this patient in this pregnancy warrants cell-free DNA testing for aneuploidy. However, the superior efficacy of the tests for sex chromosome abnormalities and microdeletion syndromes are not supported in the medical literature. Final Result: The reviewers determined that the services 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: Reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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 the gene test. Findings:  The physician reviewers found that while the patient does not have a personal history of cancer, she meets the National Comprehensive Cancer Network (NCCN) criteria for BRCA1 and BRCA2 testing given her family history. Individuals who are BRCA mutation carriers have a very high risk of breast and ovarian cancer by age 70. Women with BRCA mutations are also at elevated risk of other or secondary malignancies. It is therefore important to identify patients who may have a mutation in order to ensure the appropriate genetic counseling, testing, screening and prevention strategies are performed. Accordingly, the gene testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the testing at issue was 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: Two physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One physician reviewer is certified in clinical genetics 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: An enrollee has requested authorization and coverage for bariatric surgery for treatment of the enrollees morbid obesity. Findings: The physician reviewer found that although this patient is morbidly obese and may benefit from bariatric surgery with a BMI of 59 kg/m2, the medical necessity of bariatric surgery has not been met. Specifically, there is no documentation of completion of a multidisciplinary evaluation documenting that this patient has completed dietary and behavioral education and evaluation demonstrating that the patient is an appropriate candidate for bariatric surgery. In addition, dietary and psychological evaluations were not available for review. The patient has reportedly failed dietary efforts in the past. However, without a multidisciplinary evaluation, the medical necessity of the requested bariatric surgery has not been established for treatment of this patients medical condition. 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 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: An enrollee has requested authorization and coverage for knee surgery for treatment of the enrollees right knee pain. Findings: The physician reviewer found that this patient has a degenerative tear of the medial meniscus, a high BMI, and unremarkable radiographs or evidence of mild osteoarthritis. In the medical literature, one study noted that higher BMI in middle aged patients with isolated medial meniscal tears and unremarkable radiographs may predict more advanced chondral lesions at arthroscopy. The literature advises against partial medial meniscectomy in the presence of chondral lesions because of adverse outcomes. In this case, the patients pain is anterior, across the patella radiating in a transverse fashion and is more likely to be due to the MRI evidence of patellofemoral chondromalacia that was noted three years ago. This has likely advanced and the outcome of any surgical procedure will not be favorable. According to another study, degenerative medial meniscal tears, in the presence of osteoarthritis, can only marginally benefit from arthroscopic debridement over intraarticular steroid injections in short-term follow up. In patients with posterior horn degenerative tears in the presence of obesity and osteoarthritis, surgical interventions are not recommended. Weight loss should receive primary consideration. 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 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: An enrollee has requested reimbursement for skilled nursing facility services including occupational therapy, physical therapy and speech therapy for treatment of status post cerebrovascular accident. Findings:  The physician reviewer found that in the present case, the patient has had major functional deficits following his stroke.  He was transferred to a skilled nursing facility.  He remained medically stable.  He made slow, but relatively steady, functional progress.  He had progressed sufficiently to have been transitioned to the community to continue his rehabilitation and convalescence.  He was on a modified oral diet as well as bolus tube feeds to cover his nutritional needs.  He was mobile in a wheelchair at the independent level.  He was ambulating with a walker at the contact guard to stand by assistance level.  He was performing his basic self-care at the contact guard assistance level.  He would have been expected to continue to make functional progress, but this could have been overseen in the community setting. He was not making progress at the rate where he would have been expected to no longer require supervision and assistance from caregivers due to persistent balance issues.  Ongoing rehabilitative services could have been provided in the community setting, with custodial level services at his residence or at a custodial facility. There were otherwise no documented ongoing medical or skilled nursing needs (e.g., complex wound care, initiation of self-care related to enteral feeding or ostomy care) requiring ongoing inpatient care in the available records. 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or 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 proton beam radiation therapy for treatment of her breast cancer. Findings:  Two physician reviewers found that there is a lack of medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for breast cancer. A plan comparison was run between standard three-dimensional conformal techniques with photons versus intensity modulated proton therapy, and this showed a decrease in the heart dose. However, this comparison is not valid because the standard techniques to use in this setting when the heart dose cannot be achieved with three-dimensional conformal techniques is to utilize intensity modulated radiation therapy with photons (instead of protons). There is a lack of data submitted that suggests that treatment with proton techniques will be able to improve sparing of the skin, heart, and/or lungs compared to standard intensity modulated breast radiation with photon techniques. Consensus group guidelines do not support the use of proton therapy in this setting. In the vast majority of cases, intensity modulated radiation with photons is able to achieve an acceptable cardiac dose in left sided breast cancer compared to three-dimensional conformal techniques. Final Result: The reviewers determined that the requested services are 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 radiation oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive outpatient treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes indicate that the patient transitioned from a partial hospital program to an intensive outpatient program with success. The progress notes do not indicate that the patient was suffering from suicidal or homicidal ideation, and she was not experiencing any psychosis.  The records document some anxiety symptoms in regards to her eating disorder, but primarily due to a potential move to another state and employment issues.  There were no other severe psychiatric symptoms noted. The records indicated that she was open in treatment and receptive to feedback from her providers. It appears that she was able to follow her meal plan for a majority of the time. The literature indicates that therapy on a consistent basis along with medication treatment is the most successful for eating disorder treatment overall.  Due to the fact that the patient was cooperative in treatment, not using substances, medically stable, and not suffering from severe psychiatric symptoms, regular outpatient therapy would have been safe and effective.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 1-30 mg twice per day for treatment of the enrollees plaque psoriasis. Findings: The physician reviewer found that this patient has widespread plaque psoriasis affecting more than 40% of his body surface area. He has tried and failed therapy with topical steroids and ultraviolet B treatment. He has a history of untreated latent tuberculosis. Injectable biologic agents including Enbrel, Humira, and Stelara carry risks of infection and reactivation of latent tuberculosis, which this patient has been shown to have. Moreover, Otezla is considered to be a first-line oral agent for the treatment of plaque psoriasis for use in this clinical setting. 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 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.