Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for emergency medical services. As noted in the medical literature, surgical repair in this clinical setting results in significantly better subjective outcomes than non-surgical management. Similarly, acute surgical repair has shown improved patient satisfaction, pain relief, and endurance, as well as reduced risk of complications and re-rupture when compared to chronic repair. In this case, the patient presented with an emergency condition necessitating surgery before shortening and atrophy of the avulsed muscles occurred. The diagnostic work-up and location of a specialist were necessary to assess the feasibility of surgical repairs and perform the procedure. Although these factors resulted in a delay, it did not make the surgical procedure any less of an emergency situation. Thus, the emergency medical services provided were provided for treatment of an emergency medical condition. Final Result: The reviewer determined that the services at issue were necessary for treatment of an emergency medical condition. Therefore, the Health Plans denial should be orthopedic surgery. 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 the inpatient psychiatric hospitalization from 2/16/16 through 3/10/16. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. It does not appear that the patient needed inpatient psychiatric management. The patient did not exhibit dangerous behaviors towards herself or others and was fully cooperative during treatment. It appears that she could have received mental health treatment in a less restrictive setting than an inpatient psychiatric setting due to her overall stable symptoms. She was not noted to have any severe mood swings or manic symptoms associated with her mood disorder. Current literature indicates that patients with major depressive disorder may be treated outside of a hospital setting when there is a lack of dangerous behaviors, which appears to be the case with this patient. Recent literature states that outpatient treatment with cognitive behavioral therapy has shown to be effective for reduction in reoccurrence of depressive symptoms associated with this patients illness.In cases such as this, an evidence-based, objective, instrument such as the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is indispensable in determining necessary level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. Overall, the patients score correlated with a treatment intensity level of three, which is described as High Intensity Community Based Services. According to the patients score, based on the LOCUS Psychiatric and Addiction Services risk rating scale, the requested level of treatment was not medically necessary. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the immunology test rendered. The Health Plan has denied this request as investigational for treatment and evaluation of the enrollees condition. Findings:  The immune cell function assay testing, also known as ImmuKnow is considered beneficial and clinically relevant in the case of this patients condition. The patient is status post kidney transplantation and she has chronic autoimmune medical conditions, which include multiple sclerosis and systemic lupus erythematosus. There was a clear clinical need to measure or monitor the patients level of immune suppression with a validated FDA-approved test such as ImmuKnow. Clinical studies and current peer-reviewed literature support its use. ImmuKnow has shown to be a useful non-invasive biomarker for monitoring cellular immune function for transplant recipients, a valid tool for determining risk of further infection or rejection, and a test that can optimize overall outcomes following organ transplantation.Final Result: Two of the three reviewers determined that the services at issue were 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/QualificationsAll three reviewers are board certified in internal medicine with a sub-specialty 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: An enrollee has requested reimbursement for hysterectomy surgery. The submitted documentation fails to demonstrate the medical necessity of the services at issue. Per current standard of care, a hysterectomy is considered medically necessary for the treatment of abnormal uterine bleeding when investigation has not identified specific etiology of abnormal uterine bleeding through bloodwork and imaging, hormonal therapy was tried but did not adequately treat the condition, and a uterine-sparing procedure (e.g. endometrial ablation) cannot be used. In this case, the clinical documentation reflects that the patient was evaluated by a urogynecologist and counseled for total vaginal hysterectomy and tension free vaginal tape. The submitted documentation includes the medical note for this office visit, during which alternatives such as an intrauterine device and endometrial ablation were reviewed. However, in provider correspondence written since hysterectomy was performed, the provider states that the patient's surgical history of cesarean section and bowel resection contraindicate her ability to undergo these therapies. Neither cesarean section nor history of bowel resection are true contraindications for either alternative therapy. Furthermore, there is no clinical documentation to support a thorough investigation for specific etiologies including screening for abnormal cells/malignancy. Per the American College of Obstetrics and Gynecology, a patient of this age should undergo an endometrial biopsy to rule-out malignant cells. While the provider states in post-hysterectomy correspondence that it was not indicated for an endometrial biopsy to have been performed, the provider does not explain or document their basis for this statement. Given the patients irregular bleeding pattern, as documented in the clinical notes, it would be expected that the patient would have undergone an endometrial biopsy prior to hysterectomy. In sum, the hysterectomy surgery was not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services in 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100mg/40mg tablets. The submitted documentation supports the medical necessity of the requested medication. 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 should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that cirrhotic treatment-naive genotype 1a patients should be treated with Mavyret 100/40 mg three tablets daily for 12 weeks. These recommendations are based on multiple randomized clinical trials, including the EXPEDITION-1 trial showing a 99% cure rate, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic Hepatitis C genotype 1 regardless of fibrosis stage. Although a viral load is not provided in this case, the feasibility of genotype and resistance testing proves that there is circulating and detectable Hepatitis C virus. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested medication is medically necessary for this patient.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 a subspecialty certificate 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Flexitouch pneumatic compression device.Findings:  Two of the three physician reviewers found that the Flexitouch pneumatic compression device is indicated for the treatment of lymphedema, primary lymphedema, post-mastectomy edema, edema following trauma and sports injuries, post-immobilization edema, venous insufficiencies, treatment and assistance in healing stasis dermatitis, venous insufficiency ulcers, or arterial and diabetic leg ulcers. Studies have shown that compression devices can reduce lymphedema effectively. These types of devices can be recommended for short-term use in combination with a lymphedema treatment program for reducing cancer-related lymphedema. In this patients case, cancer-related edema is present despite treatment with a standard lymphedema program and other interventions. Therefore, the Flexitouch pneumatic compression device is likely to be superior over other treatment options.Final Result: Two of the three reviewers determined that the requested device is 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:  One reviewer is board certified in internal medicine and is actively practicing. One reviewer is board certified in internal medicine and is actively practicing. One reviewer is board certified in internal medicine, with subspecialty certificates in hematology and medical oncology, 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the lipoprotein testing (CPT code 83704). Although this patient has a first degree male relative with early coronary artery disease (CAD), she has no other major risk factors for CAD. In addition, she is currently being treated aggressively for hyperlipidemia with medical therapy. Moreover, the patients standard lipid profile is well below goal levels. As she has relatively low risk for CAD and is being treated with maximal drug therapy. According to the American College of Cardiology/American Heart Association (ACC/AHA) guideline goals, there is no data or guideline recommendations that repeated advanced lipoprotein measurements and particle assessments will provide additional clinical information or risk stratification that will direct clinical management. Thus, the lipoprotein testing (CPT code 83704) 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 lipoprotein testing (CPT code 83704) 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 lipoprotein testing (CPT code 83704) 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for intensive outpatient program (IOP) services. According to the American Academy of Child and Adolescent Psychiatry (AACAP), children and adolescents should be treated in the least restrictive setting possible and to maintain and foster natural supports. Applying the Child and Adolescent Level of Care Utilization System (CALOCUS) to determine the most appropriate treatment setting, the IOP services provided were not and are not medically necessary. This patient presented with no risk of harm due to a lack of current self-harm ideation (score 1). The patient demonstrated mild functional issues given their difficultly with family relationships (score 1). The patient presented with no active serious medical problems or substance use issues (score 1). The patients recovery environment is mildly stressful, as the patient has issues with family relationships, but has a stable housing situation (score 2). The patients recovery environment is highly supportive as their parents are actively involved in treatment and attend family therapy sessions on a regular basis (score 1). The patient has demonstrated limited improvement in limited prior treatment, but their behaviors have improved during IOP sessions (score 3). The patient has been both constructive and obstructive toward treatment, as they participate in therapy, but do not demonstrate motivation to improve (score 3). The patients parents have been constructive and have worked actively with the patients providers (score 2). This gives the patients presentation a composite score of 14, which correlates with outpatient services. Moreover, the recommendations for treatment of intermittent explosive disorder include pharmacotherapy plus cognitive behavioral therapy (CBT), which can be provided on an outpatient basis. All told, the IOP services provided were not and are not medically necessary for treatment of this patients behavioral health issues. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the intensive outpatient program (IOP) psychiatric services. The records provided for review support the medical necessity of the IOP services provided for treatment of this patients behavioral health issues. Applying the American Society of Addiction Medicine (ASAM) guidelines, the patient required the direction and continuity of care provided at the IOP level of care. The patients conditions to waxed and waned, and he continued to require supervision and guidance throughout the IOP admission. In this patients case, IOP services were in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. Therefore, the IOP psychiatric 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: 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 authorization and coverage for Hizentra 7 grams, once weekly. The requested Hizentra 7 grams, once weekly, is not medically necessary for treatment of this patients primary immunodeficiency. There is a lack of evidence that Hizentra is more effective than the Health Plans formulary alternative, HyQvia. HyQvia is a once monthly subcutaneous immunoglobulin therapy with recombinant human hyaluronidase, which allows a larger amount of immunoglobulins to reach the subcutaneous tissue and be absorbed into the bloodstream to help fight infection. This patients records do not include documentation of an adequate trial of or a contraindication to HyQvia. Due to the lack of a prior trial or presence of contraindications with the preferred agent, the requested Hizentra 7 grams, once weekly is not medically necessary for treatment of this patients primary immunodeficiency. 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 internal medicine with sub-specialty certification in allergy and immunology 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 61-year-old female enrollee has requested authorization and coverage for mastectomy bra and prosthesis for left breast. As noted by the American Society of Plastic Surgeons (ASPS), cosmetic surgery is performed to reshape normal structures of the body in order to improve a patients appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. Reconstructive procedures are generally performed to improve function, but may also be done to approximate a normal appearance. This patient presents with an abnormal structure with significant breast asymmetry as the result of treatment for left breast cancer. The patients previous partial mastectomy, followed by radiation therapy, complicated by infection and wound healing problems, has resulted in an abnormal appearance and volume of the left breast. Due to significant asymmetry, she was considered for breast reconstruction, but was recommended for weight loss prior to reconstruction. Thus, an external prosthesis and mastectomy bra were recommended. The requested external prosthesis and mastectomy bra will help to approximate a normal appearance. Thus, the requested mastectomy bra and prosthesis for left breast are supported as medically necessary for treatment of this patients medical condition status post partial mastectomy. Final Result: The reviewer determined that the requested equipment 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tonsillectomy and adenoidectomy.  Findings:  The physician reviewer found that recurrent infection remains the most common indication for adult tonsillectomy. Other indications include cancer, asymmetric tonsillar growth, obstructive sleep apnea and peritonsillar abscess. According to the American Academy of Otolaryngology  Head and Neck Surgery, clinical indications for tonsillectomy include recurrent throat infection with documentation. Documentation for the recurrent throat infection indication would need to show a frequency of at least 7 episodes in the past year, or at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years, with documentation in the medical record for each episode of sore throat and one or more of the following: temperature greater than 38.3C, cervical adenopathy, tonsillar exudates, or positive test for a group A beta-hemolytic streptococcal infection. In this case, there is no documentation in the family medicine or otolaryngology records of chronology of disease or treatment for recurrent tonsillitis for this patient. Therefore, the requested tonsillectomy and adenoidectomy are 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 otolaryngology 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.