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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Enstilar foam, 0.005  0.064%, twice per day. The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient is being treated with Otezla. She was also treated with Enstilar, but there is no documentation of a treatment trial of other high potency topical steroids. The Health Plan has denied the request for coverage as not medically necessary because she has not failed the preferred agents. Given that calcipotriene and betamethasone are covered medications on the patients formulary and these are the components of Enstilar, it is reasonable that the patient first try the preferred agents prior to covering the branded medication. As there is no contraindication or documentation of treatment failure with the preferred agents, the medical necessity of the requested medication is not established. Therefore, Enstilar foam, 0.005  0.064%, twice per day is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication 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 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.
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. This patient presents with evidence of a relatively mild overlapping lower abdominal pannus in the setting of a ventral hernia. Based on the submitted documentation, there is insufficient medical documentation to support that the panniculectomy is required to address a functional deficit. From the American Society of Plastic Surgeons (ASPS) a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. Further, researchers noted that, 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. Given the documentation provided for review, this patient has not been shown to have functional impairment directly related to her relatively mild lower abdominal pannus. No other justification has been provided to support the panniculectomy, as it is related to the ventral hernia. Thus, the requested panniculectomy is not medically necessary for this patient.In addition, the patients abdominal pannus does not constitute an abnormal structure of the body based on the patients size. The requested surgery is not being performed to repair a functional impairment. Moreover, the surgery will not provide a more than minimal improvement in the patients appearance. All told, the requested panniculectomy is not supported as reconstructive in nature or medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary and are not reconstructive in nature 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 inpatient hospitalization services. This patient sustained a severe left hand injury in a table saw accident. He was initially evaluated in a local facility and transferred by ambulance to a regional medical center for hand surgery evaluation. He had complex lacerations and tendon injuries of the second through fourth fingers, and open fractures of the third and fourth fingers. Initial irrigation and debridement with provisional wound closure was performed. He continued on intravenous antibiotics with frequent vital signs overnight. He subsequently underwent irrigation and debridement, tendon repair, and open reduction and internal fixation of the middle and ring fingers. He was subsequently discharged. Given the severity of the injury, significant potential for infection, multiple surgical procedures, and ongoing need for vital sign monitoring and wound and neurovascular checks of the left hand/fingers, inpatient services were supported for the dates of service at issue. Therefore, inpatient hospitalization services 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: 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: Overturned Decision of Health Plan

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Epclusa 400-100 mg one tablet daily for 12 weeks. According to the most recent 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Epclusa for 12 weeks, based on a 98% cure rate in the ASTRAL-1 trial. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is needed, and the requested Epclusa 400-100 mg one tablet daily for 12 weeks is supported as 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the prostate cancer screening. Findings:  Three physician reviewers free PSA can be used to assess an added probability of finding cancer in a group of patients with this PSA, but the presence or absence of cancer in one patient can be confirmed by biopsy or on follow-up. The overall benefit from testing can help patients and providers choose their next steps with added confidence, but this testing has not been demonstrated to be more reliable than biopsy in this clinical setting. Thus, the prostate cancer screening was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the prostate cancer screening was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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 advanced lipoprotein testing. Findings:  Three physician reviewers found that guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. In sum, advanced lipoprotein testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for psychiatric emergency services. Findings:  The physician reviewer found that the patient was not medically screened to determine if an emergency medical condition existed. There was no psychiatric admitting evaluation and therefore no screening to determine if a psychiatric medical emergency existed. He did not have any symptoms so acute that absent medical care they would place his health in serious jeopardy, cause serious impairment to bodily functions, or cause serious dysfunction of any bodily organ or part. In addition, he was not experiencing a psychiatric medical emergency in that he did not have symptoms of acute severity manifesting as danger to himself or others, or immediate inability to provide care for himself (not gravely disabled). The patient did not meet the criteria for requiring emergency medical services or psychiatric emergency services at any time, on admission to the facility on 4/28/18 or thereafter. Thus, the services provided were not provided for a psychiatric medical emergency. Final Result: The reviewer determined that the services at issue were not provided for treatment of a psychiatric emergency. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the residential substance abuse treatment services provided from 4/25/18 through 5/18/18.  The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association treatment guidelines for substance use disorders recommends that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, lack sufficient social and vocational skills, and drug-free social supports to maintain abstinence in an outpatient setting. A study showed that following a brief  three-week period of abstinence and participation in a psycho-educational program, the alcohol dependent group in the study demonstrated significant improvements in relation to depression, anxiety, and 13 out of 15 maladaptive schema beliefs. Following detoxification treatment, the standard rehabilitation program is a 30-day residential treatment, which was in accordance with generally accepted standards of medical practice, clinically appropriate for the patient's illness, not more costly than an alternative service for treatment of the patients condition, and was therefore medically necessary. Therefore, the residential substance abuse treatment services provided from 4/25/18 through 5/18/18 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: 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 the rupture of membranes testing. As noted in the American College of Obstetricians and Gynecologists (ACOG) practice bulletin, most cases of premature rupture of membranes can be diagnosed on the basis of the patients history and physical examination. Specifically, sterile speculum examination provides an opportunity to inspect for cervicitis and umbilical cord prolapse or fetal prolapse, assess cervical dilatation and effacement, and obtain cultures as appropriate. Further, the diagnosis of membrane rupture typically is confirmed by the visualization of amniotic fluid passing from the cervical canal and pooling in the vagina; a basic pH test of vaginal fluid; or arborization (ferning) of dried vaginal fluid, which is identified under microscopic evaluation. Given the false-positive test results with test kits evaluating patients for premature rupture of membranes, the rupture of membranes testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the rupture of membranes testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the rupture of membranes testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for revision surgery and fusion. Based on the available documentation, including additional medical records, the requested revision surgery and fusion is medically necessary at the L3-4 level, but not medically necessary at the L4-5 level. The postoperative CT has revealed persisting central canal stenosis at L3-4 and severe bilateral foraminal stenosis at the same level. The magnetic resonance imaging (MRI) scan revealed severe central canal stenosis at L3-4 with severe neural foraminal narrowing. There is also grade I anterolisthesis at that level. Based upon this additional information, the request for decompression and fusion at L3-4 is supported as medically necessary. However, the requested exploration and decompression of the L4-5 level is not medically necessary.Final Result: The reviewer determined that a portion of the requested services are 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 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: A 74-year-old male enrollee has requested authorization and coverage for lumbar/sacral facet joint injection, for treatment of the enrollees low back pain.  Findings:  The physician reviewer found that the documentation available for review, lumbar/sacral facet joint injection are not medically necessary for treatment of this patients medical condition. Facet joint injections are not supported in the literature for treating radicular pain . In this case, the records report the patients radicular pain responded well in the past with these injections. However, there are no findings on recent documentation by the provider to support treatment of the patients radicular pain with a facet joint injection. All told, the requested authorization and coverage for lumbar/sacral facet joint injection, is not 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: An enrollee has requested authorization and coverage for viscosupplementation injection (Orthovisc CPT code J7324) to both knees. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested viscosupplementation injection (Orthovisc CPT code J7324) to both knees are supported as medically necessary for treatment of this patients knee osteoarthritis. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nystatin compound suppository. There is sufficient support for the requested medication in this clinical setting. This patient is likely to benefit from an antifungal preparation. Given her current medications, there is concern that oral antifungals would interfere with the absorption and metabolism of those agents. Although the use of oral fluconazole weekly for several months is typically the first-line of maintenance regimen, if this regimen is not feasible, then topical treatments should be considered. This patient reported that over-the-counter medications and prior prescriptions medications were ineffective, but the requested medication has been effective. Thus, nystatin compound suppository is medically appropriate in this clinical setting. Therefore, the requested nystatin compound suppository is medically necessary for the 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 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.