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 Zetia (ezetimibe) 10 mg. Findings:  The physician reviewer found that the documentation provided supports the requested medication in this clinical setting. Based on the records, the patient has known coronary disease, elevated LDL cholesterol greater than 100 mg/dl and documented intolerance to at least two statin medications.  In this circumstance, treatment with Zetia has been shown to be safe and effective at lowering cholesterol.  In addition, there is evidence of improved outcome with the addition of Zetia. Therefore, treatment with Zetia is reasonable, appropriate and considered standard accepted practice in the medical community in this patient population with known coronary disease, elevated cholesterol and documented statin intolerance. All told, coverage for Zetia (ezetimibe) 10 mg is medically necessary for treatment of this patient. 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 cardiovascular 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: An enrollee has requested authorization and coverage for panniculectomy for treatment of her excess skin. Findings:  The physician reviewer found that based on the documentation provided for this review, the patient does not have typical symptoms associated with functional impairment related to the abdominal pannus. There are no complaints of pain, chronic rashes, infections or other difficulties associated with her pannus. The submitted photographs demonstrated that she has a relatively mild excess skin. Researchers noted that the abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms However, there is insufficient detail in the medical documentation to support that there are functional problems related to this patients lower abdominal overhang. Thus, panniculectomy for this patient is not supported as medically necessary. With regard to whether the requested surgery is reconstructive in nature, there is evidence of mild abnormality of the lower abdomen. This condition was the result of treatment of obesity, which is a form of disease. However, there is no evidence of functional impairment. Further, although the appearance is abnormal, panniculectomy would only provide a minimal improvement in the appearance of the patient. Final Result: The reviewer determined that the requested surgery is not reconstructive in nature and 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services, who underwent esophagogastroduodenoscopy and colonoscopy. Findings:  The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting. The decision making process for determining use of monitored anesthesia care versus sedation is nuanced and complex. Important factors to consider include anticipated procedure length, gastrointestinal provider skill, and anticipated need for additional maneuvering/moving of the patient to facilitate the procedure.  Additional factors include the patients American Society of Anesthesiologists (ASA) classification, the potential need to convert to a general anesthetic, and the level of a patients anxiety, especially if it interferes with his or her willingness to undergo a colonoscopy.  Although the utilization of short-acting sedatives and pain medications, such as midazolam and fentanyl, may be appropriate for some patients, this is not appropriate for all patients.  There is sufficient support for the anesthesia services provided on this patients case.  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 anesthesiology 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 parent of an enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that the treatment plan addressed multiple symptoms and diagnoses and presented a reasonable expectation of improvement. The patient was cooperative with treatment and continued to meet goals, resulting in a successful outcome from this treatment intervention. The medical evidence supports the medical necessity of residential treatment during the dates of service in dispute. Children and adolescents often display multiple symptoms following abuse experiences and do not easily reveal trauma in treatment situations. The facility treatment plan recognized the importance of this history, and it appears that intervention was tailored differently in this facility, resulting in more successful intervention. There is ample evidence from psychiatric evaluations, progress notes, and group participation to indicate that the patient made steady progress toward goals throughout the duration of treatment and was discharged with much improved prognosis.  All told, residential treatment center services were medically necessary for the treatment of this patient. Final Result: The reviewers 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: Physician 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for services rendered at a residential treatment center for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that Per the submitted documentation, the patient does not meet the criteria for treatment in a residential 24-hour facility. Prior to admission, the patient was reportedly suicidal with a plan. At that point, she would have met criteria for an acute psychiatric hospital admission. There is no evidence that this was considered.  The letter from the residential treatment facility does not describe her as being suicidal upon her admission. The letter describes her as having some suicidal thoughts only in week four of treatment and not recurring. The patient does not have any comorbid medical problems or substance abuse. She does not live in an environment that would prevent her from progressing in treatment. The records do not indicate that she has tried and failed less restrictive treatment other than individual therapy and medication. She has not been treated and failed at the intensive outpatient program or partial hospitalization program level of care. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of her behavioral health condition. Findings:  The physician reviewer found that There is sufficient support for the medical necessity for the services at issue in this clinical setting. Although the patient had no ideas of self-harm, and was euthymic, cooperative and sleeping well, service delivery in a less restrictive setting would have been inadequate and potentially unsafe at the time.  The records demonstrate that this patient remained symptomatic and had not consolidated the treatment gains necessary to succeed in an outpatient based program. The co-occurrence of major depression and anxiety is of particular relevance since it has been well established in both clinical practice and the medical literature, such as the definitive Sequenced Treatment Alternatives to Relieve Depression (STAR-D) study, that anxiety ridden mood disorders are difficult to treat and in general have poorer outcomes.  Further, the patient had failed treatment in a lower level of care during the episode of illness.  She lived alone.  She was unable to work.  She was negotiating complex bereavement in context of problematic sibling dynamics, emotional dysregulation, self defeating personality traits and clinical depression.  According to the records provided, the patient remained actively engaged in treatment throughout the entire admission.  For example, she continued mindfulness and dialectical behavioral therapy groups, in addition to individual counseling.  She started a new antidepressant, bupropion.  She completed family therapy sessions.  Her mother was referred to National Alliance on Mental Illness (NAMI) for additional support. Aftercare services were established.The services provided were reasonably expected to improve her condition and prevent a more serious episode of illness. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for genetic testing (whole exome and mitochondrial DNA sequencing). Findings:  The physician reviewer found that : the patient with seizures and history of hypoglycemia. The patient has also been diagnosed with hypotonia and developmental delays. She has had an extensive work-up, including metabolic testing, with no definitive answer. There is a likely pathogenic duplication of chromosome Xp11.3p11.23, which overlaps partially with a duplication Xp11.22p11.23 that causes intellectual disability, speech delay, electroencephalogram abnormalities and seizures. The patients parent has requested coverage genetic testing (whole exome and mitochondrial DNA sequencing). The Health Plan denied the requested services noting that the requested services are investigational for the evaluation of this patients medical condition. There is sufficient support in the medical literature for the requested services in this clinical setting. WES is a technology whereby the portion of the genome consisting of coding sequences is analyzed to look for variants that may explain the patients phenotype.  Clinical indications for WES are a suspected genetic disorder based on signs and symptoms, with no known single gene condition fitting the phenotype.  The utility of WES for gene discovery (to identify the genetic cause of well-characterized specific phenotypes) has been demonstrated.  The utility of WES in the clinical arena is becoming clear, showing a diagnosis is made by exome sequencing in approximately 25% of patients referred for this testing. The evidence shows that a diagnosis can be made more expediently using newer genetic technologies such as exome sequencing rather than embarking upon a diagnostic odyssey that includes invasive procedures ). Moreover, there is evidence that exome sequencing results assist with management . For these reasons, genetic testing (whole exome and mitochondrial DNA sequencing) is likely to be more effective than other methods for evaluating this patients medical condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturnedCredentials/Qualifications: Physician reviewer1, 2 & 3 are board certified in pediatrics and genetics and  are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for residential treatment services provided. Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  In this particular case, the patients addictive illness was impairing her daily routine and contributing to significant impairment across multiple domains of functionality. She reported an early age of first use for multiple substances that steadily progressed and jeopardized her well-being. Her motivation was undermined by poor self-worth, dependent personality traits and a dysfunctional marriage with a spouse who reportedly was actively using substances in the home.  The patient also had co-occurring depression, chronic suicidality, anxiety and trigeminal neuralgia, conditions that were more than likely negatively impacted by her substance use.  Finally, despite efforts to quit on her own and attendance at community meetings, the patient was unable to achieve meaningful sobriety in her environment.Per the records, this patient had not consolidated the treatment gains necessary to succeed in the outpatient setting by date of dispute was likely to have relapsed in a community-based setting if discharged that day.  Although she opened up in group to an extent that had yet to be seen during the admission, she was described by the therapist that day as anxious, hypervigilant, tearful and depressed. The patient feared her addictive tendencies and broached her underlying poor self-esteem.  Further, she had not yet found a sponsor.  On date of dispute , she was labile. Moreover, she had not completed family week, which was a particularly critical element of care critical in this case. Thereafter, the records indicate that the patient was actively engaged in treatment until the day of discharge, which included completing a contentious family week, securing a sponsor and developing an aftercare program consisting of an alternative residence and intensive outpatient programming. The services and setting were safe, appropriate and consistent with good practice in the United States, while the duration of treatment aligned with community standards and ultimately facilitated a transition of service delivery to a less restrictive setting. All told, residential treatment services provided were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 gene test performed on date A and date B. Findings:  The physician reviewer found that Circulating tumor DNA (ctDNA) is shed into the blood stream by tumor cells. The detection of ctDNA in a patients bloodstream depends on many factors including stage, tumor burden, cancer type and rate of cell turnover. The National Comprehensive Cancer Network (NCCN) guidelines for non-small cell lung cancer (NSCLC) recommend measurement of genomic alterations in seven different genes including EGFR, ALK, ERBB2, BRAF, MET, ROS1, and RET because of the availability of 12 different matched therapies. Therefore as the number of genomic targets with matched therapies grows and the tissue biopsy samples are limited, many studies have evaluated the use of ctDNA in NSCLC. On review of the available data, there has been a significant amount of work recently published describing the utility of ctDNA and its role in therapeutic care of patients with NSCLC. Based on the results of this data the U.S. Food Drug Administration (FDA) approved Guardant360 test for EGFR mutations in patients with NSCLC in June 2016 and the most recent version of NCCN guidelines, the testing is supported in the most recent diagnostic and therapeutic algorithm. Guardant360 testing was performed at two different time periods to help direct this patients oncologic care. In this patients clinical situation, the testing provided information about other relevant EGFR mutations which could have supported sensitivity or resistance to treatment. The repeat testing performed in August 2016, although not yet described by therapeutic guidelines as standard practice, was indicated to potentially alert the treating provider of the development of resistance to current therapy. As such, the Guardant360 gene test performed on date A and date B was 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 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 reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that, according to the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient would need to have a score of 23-28 in order to require treatment in an RTC. It appears that the patient had stabilized sufficiently to allow transition to a less restrictive setting.   Dialectical behavioral therapy (DBT) on an outpatient basis has been proven to be beneficial in reducing mood symptoms, emotional dysregulation and suicidal behavior in adolescents. Final Result: The reviewer determined that the services at issue were not and 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has authorization and coverage for Acessa ablation minimally invasive procedure. Findings:  The physician reviewer found that surgical options for uterine preservation in the treatment of fibroids include myomectomy, uterine artery embolization, magnetic resonance imaging (MRI) guided focused ultrasound surgery and radiofrequency ablation. The Acessa procedure uses radiofrequency ablation, which targets the fibroids, with the goal of decreasing secondary affects to the organs adjacent to the uterus which share the same blood supply. There are currently insufficient data in the peer-reviewed literature to adequately assess the Acessa procedure. Final Result: The reviewers determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: the physician 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.