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

Nature of Statutory Criteria/Case Summary: An enrollee has requested prospective authorization and coverage for ablation and Atria without bypass for treatment of his history of atrial fibrillation.Findings: Three physician reviewers found that the Society of Thoracic Surgeons 2017 guidelines summary states the following, In the treatment of atrial fibrillation (AF), multidisciplinary heart team assessment, treatment planning, and long term follow up can be useful and beneficial to optimize outcomes (class 1, Level C expert opinion). Surgical ablation for symptomatic AF in the absence of heart disease that is refractory to class I/3 antiarrhythmic drugs or catheter based therapy is reasonable as a primary stand-alone procedure (class 2A, Level B randomized). Surgical ablation for symptomatic persistent AF is reasonable stand-alone using full lesion set compared to pulmonary vein isolation alone (class 2A, level 3 nonrandomized). As such, it is the consensus of the 2017 international experts in cardiology and thoracic surgery that stand alone AF surgery should be considered for the symptomatic AF patients who prefer a surgical approach or have failed one or more attempts at catheter ablation, such as in this patients case. This patient has had a longstanding history of AF and failed therapies. Therefore, this patient is a good candidate for the requested procedure. In sum, ablation and Atria without bypass is likely to be more effective than the other standard modalities for treatment of this patient. Final Result: The three 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: All three physician reviewers are board certified in thoracic 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient behavioral health services for her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The medical record does not demonstrate that psychiatric services provided in a less restrictive setting would have been unsafe or inadequate during the dates of service in dispute. Upon admission, the psychiatrist described the patient as dramatic with chronic suicidal ideation. The nursing assessment documented positive suicidal ideation, although the patient reported that she had fleeting thoughts to harm herself, but would never do that. She expressed a desire to live and identified her family as her primary protective factors. The following day, the patient was euthymic and denied suicidal thoughts. There was no evidence of psychosis, grave disability or an unsupportive home environment. The patient wanted to be hospitalized for the first Electroconvulsive Therapy (ECT) treatment. However, this practice is not consistent with typical community practice standards. Thus, admitting a patient to the hospital solely for purposes of initiating Electroconvulsive Therapy (ECT) is not medically indicated. In sum, although symptomatic and in need of specialty care, the patient was not experiencing an acute psychiatric syndrome. Service delivery in a less restrictive setting would have been safe, appropriate and reasonably expected to improve her condition. Thus, inpatient behavioral health services provided 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the durable medical equipment (DME) devices provided for treatment of the enrollees bilateral articular cartilage disorder, bilateral capsulitis of the temporomandibular joint and temporomandibular sounds on opening and closing of the jaw. Findings: The physician reviewer found that there are multiple types of orthopedic devices used for treatment of temporomandibular disorders (TMD). The medical literature demonstrates that the use of orthopedic appliances reduces TMD symptoms. Anterior positioning appliances or anterior repositioning appliances are used to treat joint pain and noise and any associated muscle pain. According to Leeuw and Klasser, The primary indication for anterior positioning appliance therapy is acute joint pain associated with disk displacement with reduction. In general, these devices should be used on a short-term basis and their use reduced once symptoms have improved, as long-term mandibular repositioning can result in irreversible changes to occlusion and possible internal temporomandibular joint changes. In this case, the documentation supports that the use of an anterior repositioning appliance as it is likely to improve the patients symptoms. While two devices may be more convenient for the patient, there is a lack of consensus in the medical literature that supports two devices are superior to one device. As such, two devices are not clinically indicated. Therefore, one DME device provided was medically necessary for treatment of the patients symptoms. Final Result: The reviewer determined that a portion of the devices at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in dentistry 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 MoPath procedure level 7 test provided for evaluation of her pregnancy. Findings:  Three physician reviewers found that as noted by the American College of Obstetricians and Gynecologists (ACOG), a patient should be provided aneuploidy screening or diagnostic testing for fetal genetic disorders, regardless of maternal age. The testing should be tailored to the most common conditions, those specific to the patient based on personal and family history, and those that are present in a higher rate in their specific ethnic group. It is not recommended that the patients are pan-tested for all possible genetic disorders. In this case, the provider found the patient to be at high risk for conditions including spinal muscular atrophy (SMA), glucose-6-phosphate dehydrogenase (G6PD), and methyltetrahydrofolate reductase (MTMHR) deficiency. Thus, testing for these conditions was therefore indicated. However, the MoPath 7 also includes rare conditions that this patient did not have an elevated risk for carrying. As such, the SMA, G6PD, MTMHR deficiency testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the MoPath procedure level 7 test provided was not likely to be more beneficial for evaluation of the patients medical condition than any standard testing.Final Review: All three reviewers determined that a portion of 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 partially overturned.Credentials/Qualifications: Two physician reviewers are board certified in obstetrics and gynecology and are actively practicing. One physician reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal fetal medicine 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 testing provided for evaluation of the enrollees lung cancer. Findings: All three physician reviewers found that the treatment administered to this patient is consistent with the current standard of care as recommended in current guidelines (Ettinger, et al). This patient was initially treated with afatinib for the EGFR mutation found on the initial tissue biopsy. Disease progression prompted the provider to evaluate the patient for the T790 mutation. Options include biopsy of the progressing areas or a liquid plasma biopsy. The progressing areas to biopsy are difficult to access and potentially risky. The technology of a liquid biopsy may be used as a non-invasive biopsy-free alternative to conventional sequencing using tumor biopsy (Kim, et al). This patient tested positive for the T790 mutation and was therefore switched to osimertinib, which is U.S. Food and Drug Administration (FDA) approved for the T790 mutation. All told, the Guardant360 testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: All three physician 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewer 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 authorization and coverage for Epclusa for 12 weeks for treatment of her hepatitis C virus.  Findings: The physician reviewer has found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies to all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98% (Foster, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, treatment is needed at this time, and the requested treatment with Epclusa for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for services as recommended by Jonathan Goldman, MD including hold osimertinib, start carboplatin/pemetrexed with or without pembrolizumab followed by maintenance pemetrexed with or without pembrolizumab, dexamethasone prior to initiation, folic acid 1 mg tablet, megestrol 40 mg/mL suspension, cyanocobalamin 1000 mcg/mL inject 1000 mcg, and central nervous system (CNS) involvement, including a complete metabolic work-up for treatment of the enrollees epidermal growth factor receptor (EGFR) positive metastatic adenocarcinoma of the lung.  Findings:  The physician reviewer found that this is a patient with metastatic NSCLC who has been treated with chemotherapy and radiation therapy. Several studies have shown that systemic chemotherapy can prolong survival compared to best supportive care. Pemetrexed has also been shown to prolong survival in this clinical setting and is approved for use in advanced NSCLC by the U.S. Food and Drug Administration (FDA). All the recommendations provided by Dr. Goldman are medically necessary and appropriate. Thus, the requested services as recommended by Jonathan Goldman, MD including hold osimertinib, start carboplatin/pemetrexed with or without pembrolizumab followed by maintenance pemetrexed with or without pembrolizumab, dexamethasone prior to initiation, folic acid 1 mg tablet, megestrol 40 mg/mL suspension, cyanocobalamin 1000 mcg/mL; inject 1000 mcg, and CNS involvement, including a complete metabolic work-up are medically necessary for evaluation and treatment of this patients NSCLC. 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 internal medicine with sub-specialty certification in medical 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: 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) services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the Level of Care Utilization System (LOCUS) criteria, are commonly used measure for determining appropriate levels of care. The patients risk of harm was moderate (score 3) since the patient denied suicidal ideation on admission, has a history of overdosing without clarity regarding his intention, excessive use of substances, and cutting himself. The patients functional status demonstrated moderate impairment (score 3) as he has a conflictual relationship with his parents, is unable to fulfill responsibilities, and he had an episode where he broke a chair and damaged property at his IOP. The patient demonstrates significant co-morbidity (score 3) with a co-existing alcohol use disorder, cannabis use disorder, borderline personality disorder, social anxiety disorder, body dysmorphic disorder, and major depressive disorder. The patient has a mildly stressful recovery environment (score 3) with interpersonal conflicts with his biological father, and supportive environment with his mother who is willing to participate in treatment and provide aid in times of need (score 2). The treatment history shows the patient has had an equivocal response to treatment (score 3) with one year of IOP treatment with partial recovery maintained for moderate periods of time with strong professional support and in structured settings. The patient has demonstrated limited engagement and recovery (score 3) with difficulty engaging in treatment. This provides a total score of 20, which is consistent with partial hospitalization program (PHP) level of care. Further, the patient stated that he did not want to be in an RTC and preferred to be in a lower level of care. It the standard of care to treat all patients in the least restrictive environment to effectively and adequately address their condition. Given these findings, 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 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 the residential treatment level of care services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that The progress notes indicate that the patient had continued withdrawal symptoms during the admission. He had constant verbal outbursts toward staff and peers and was minimally invested in his treatment. He had previously failed PHP and IOP levels of care recently and had no significant period of sobriety outside of a controlled environment. Applying the American Society of Addiction Medicine (ASAM) criteria to determine level of placement, this patient had continued withdrawal symptoms (score 3), no co-morbid serious medical problems (score 0), emotional, behavioral or cognitive conditions and complications were serious given the patients mood and paranoia issues that were unstable (score 3), and the patient demonstrated a lack of motivation to change and minimal if no investment in treatment (score 3). The patients continued use or continued use potential was severe as the patient did not demonstrate any history of sobriety outside of a controlled setting within the past several years (score 3), and his recovery and living environment was noted to be stressful (score 2). Overall the patients presentation suggests risk rating scores in the range of above 3 in several categories. This overall risk rating recommends the patient be treated with residential services, 24-hour care with more intense milieu anger treatment. Due to the fact that the patient was preoccupied with substance use, had no job or social skills to maintain sobriety, had little insight and a longstanding history of substance abuse, he met the criteria for RTC level of care admission and treatment. Thus, the RTC services were medically necessary for treatment of this patients medical condition. 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 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: An enrollee has requested reimbursement for residential treatment center services provided for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer has found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Based upon the records provided, there was no evidence of post-acute withdrawal symptoms, nor was there any evidence of danger to self or others. The patient was medically and psychiatrically stable. Although carrying the diagnosis of depressive disorder, he was on no medications for this diagnosis.  He reported mild cravings.  He was motivated, engaged, and working actively towards recovery and relapse prevention. He had a stable, sober support network. He was developing insight. In individual psychotherapy, he was working on personal issues including grief, loss, anger, self-criticism and acceptance; all of which were triggers. However, these issues did not require the structure of the residential setting. All told, residential treatment center services provided 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 enrollee has requested reimbursement for residential treatment center services provided for treatment of his behavioral health condition.  Findings:  The physician reviewer found that residential treatment center services provided were not medically necessary for treatment of the patients behavioral health condition. According to the documentation submitted for review, there is a lack of evidence demonstrating acute withdrawal symptoms, or evidence showing the patient to be a danger to himself or others. He had no comorbid psychiatric or medical conditions. He was not psychotic or manic. There were no emotional, behavioral, cognitive, or impulsive symptoms to warrant this level of care. He presented for admission volitionally, demonstrating a degree of motivation for change and level of awareness. Although he smoked cannabis daily he was willing to relinquish his medical cannabis card. He was a binge user, his last use was two days prior to admission. He participated in his treatment plan. He planned to go to a sober living environment. Based on the documentation submitted for review, the patient could have been treated at a lower level of care such as intensive outpatient program (IOP), in conjunction with community support in the form of a 12-step program along with a sponsor and counseling. For the reasons provided, the services at issue 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.