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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an electrophysiological study. Findings:  The physician reviewer found that Al-Khatib and colleagues note that in patients with non-ischemic cardiomyopathy who experience hemodynamically unstable ventricular tachycardia or stable sustained ventricular tachycardia, an implantable cardioverter defibrillator (ICD) is recommended. In this case, the patient has symptoms of near syncope and seizure like activity, and MRI shows evidence of non-ischemic cardiomyopathy and possible infiltrative process. While he currently has no symptoms of heart failure and an EF of 45%, an electrophysiological study would delineate whether the patients ventricular ectopy is hemodynamically significant and stratify his risk for sudden cardiac death. Given that the results of the requested service would aid in the ongoing management of the patients condition, and guide in determining if ventricular tachycardia ablation or ICD placement is appropriate, the requested service is medically indicated. Therefore, an electrophysiological study (CPT code 93653) is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gamunex-C infusions (2 gm/kg administered over 3-5 days for 3 months). Current evidence does not endorse the use of IVIg in the treatment of FOSMN. In this case, the patient has a primary diagnosis of amyotrophic lateral sclerosis, with a differential diagnosis of FOSMN. Studies report that while a link has been suggested between FOSMN and amyotrophic lateral sclerosis, the underlying pathogenesis of FOSMN remain to be fully elucidated. There is a lack of medical literature showing the use of, response to, or long-term benefit of IVIg therapy in this clinical setting. Therefore, Gamunex-C infusions (2 gm/kg administered over 3-5 days for 3 months) are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Gamunex-C infusions (2 gm/kg administered over 3-5 days for 3 months) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 is board certified in neurology with sub-specialty certification in vascular neurology and is actively practicing. Physician reviewer 2 is board certified in neurology with sub-specialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 3 is board certified in neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computer-assisted surgical navigation during the left hip arthroplasty performed at a hospital. Current medical literature does not endorse significant ultimate outcome differences in functionality and/or pain reduction with hip replacement using computer-assisted navigation over a standard procedure. In a randomized controlled study of 60 patients, researchers concluded that computer-assisted surgery used for cup placement did not confer any substantial advantage in function, wear rate, or survivorship at ten years and that future studies were needed to identify what clinically relevant advantages computer-assisted surgery offered, if any, to justify its continued use in total hip arthroplasty. In a comparison of robotic-assisted and conventional acetabular cup placement in total hip arthroplasty, researchers reported that while radiographic improvements were noted, it remained to be seen if these would translate into clinical benefits for patients such as reductions in component impingement, acetabular wear, and prosthetic dislocations, or in terms of improved longevity. In this case, the patient presented to her provider with a history of pain and discomfort of the left hip, rated at nine-and-a-half out of ten. The patient reported constant sharp, aching, throbbing, shooting, and incapacitating pain. An x-ray showed severe end-stage arthritis of the left hip. While hip replacement was recommended, there is a lack of sufficient high-quality clinical outcomes reported in the current peer-reviewed medical literature to support the use of computer-assisted navigation during the procedure. Therefore, computer-assisted surgical navigation during the left hip arthroplasty performed at a hospital was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the computer-assisted surgical navigation  during the left hip arthroplasty performed at a hospital was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment 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 orthopedic 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: The patient has requested authorization and coverage for mental health visits with a licensed therapist once per week. The American Psychological Association guidelines do not support the use of preventative psychotherapy services without a clear event, trauma, adjustment, symptoms, or impairment of functioning. Psychotherapy, when conducted in an evidence-based way, is time limited and with defined goals to ameliorate a patients specific symptoms. In this case, the documentation does not reflect psychiatric symptoms or diagnoses, current mental health issues, or that the patient is at risk of developing psychiatric symptoms. The patient reports seeking preventative mental health to increase emotional intelligence and awareness, and the provider has recommended community- based resources to meet the patients stated goals. Given that the submitted documentation fails to demonstrate that the patient is at risk of developing mental health symptoms, has current mental health issues, or a need for psychotherapy due to clear events or trauma, the requested services are not medically indicated. Therefore, mental health visits with a licensed therapist once per week are not medically necessary for the treatment of this patient.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 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 mammaplasty augmentation surgery with prosthetic implant.The World Professional Association for Transgender Health (WPATH) lists feminizing mammoplasty as a treatment for gender dysphoria. The WPATHs Position Statement on Medical Necessity of Treatment (2016) states that non-genital surgical procedures are often of greater practical significance in a patients daily life than reconstruction of the genitals. The WPATH states that these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. The WPATH has identified the criteria for breast augmentation (implants/lipofilling) in male-to-female patients as, 1. Persistent, well-documented gender dysphoria; 2. Capacity to make a fully informed decision and to consent for treatment; 3. Age of majority in a given country (if younger, follow the SOC for children and adolescents); 4. If significant medical or mental health concerns are present, they must be reasonably well controlled.` (WPATH 2016).In this case, the patient's therapist attested to the then 51-year-old patients diagnosis of gender dysphoria, her capability of making appropriate decisions and consenting to treatment, and the lack of psychological contraindications to the breast augmentation procedure. Both the patient's internist and her therapist attested to the medical necessity of feminizing mammoplasty for the patient. Under these circumstances, the mammaplasty augmentation surgery with prosthetic implant at issue was medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients 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 Community-Based Adult Services (CBAS) non-residential day program.Appropriate screening, diagnosis, and management by primary care clinicians are necessary to prevent adverse chronic kidney disease-associated outcomes, including cardiovascular disease, end-stage kidney disease, and death. Hypertension is possibly the most powerful, modifiable risk factor for the development of heart failure. Chronic hypertension drives cardiac remodeling within the left ventricle resulting in hypertensive heart disease, which ultimately manifests as heart failure. Early detection and appropriate management are necessary to prevent heart failure as well as other cardiovascular diseases.In this case, the patient has multiple health conditions that would benefit from/require dietary management, lifestyle interventions (including exercise) and close medical management. The records do not otherwise indicate that the patient lacks the cognitive faculties, physical capacity or resources to manage his general health conditions in the community. Records indicate that the patient has the cognitive, physical faculties and resources to manage his basic self-care, instrumental activities of daily living, and mobility in the home and community setting. In the long term, the patient is at risk for adverse health outcomes due to his underlying medical conditions, but no substantive and marginal difference in clinical course or outcomes is reasonably expected with the addition of the proposed services over compliantly followed management (e.g., medication intake) of his underlying medical conditions, which the records do not show that he lacks the capacity to execute. Under these circumstances, the requested Community-Based Adult Services (CBAS) non-residential day program is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for interventional radiology services at a tertiary level of care. This patient presents with symptomatic uterine fibroids. There are many options for treatment of uterine fibroids including hormones, hysteroscopic or abdominal myomectomy, and hysterectomy. Uterine arterial embolization provides a minimally invasive and uterine-sparing treatment option. Per the American College of Obstetrics and Gynecology (ACOG), uterine arterial embolization is an acceptable treatment option for patients who would like to avoid surgical management with hysterectomy. Ideal candidates include patients who are premenopausal, with heavy menstrual bleeding or dysmenorrhea caused by intramural fibroids, with no desire for future pregnancy. This patients records demonstrate that she meets the clinical criteria to undergo uterine artery embolization. As noted in the medical literature, uterine arterial embolization is performed by interventional radiologists who are trained in performing this specific procedure. Given these findings, the requested interventional radiology services at a tertiary level of care are medically necessary for treatment of 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for a SpaceOAR hydrogel procedure. Findings:  The physician reviewer found that Karsh and colleagues note that the SpaceOAR system creates distance between the prostate and the rectum, so that the rectum is out of the radiation treatment field. The authors note that spacer application has a high technical success rate and significantly reduces the rectal radiation dose. The National Comprehensive Cancer Network (NCCN) guidelines for the management of prostate cancer endorse the use of perirectal spacers to improve the sparing of the adjacent rectum. In this case, records noted that magnetic resonance imaging (MRI) reported a total prostate size of approximately 52 cc, and that a prostate biopsy reported Gleason 3+3 disease. The patient had an elevated PSA of 21.4. The providers recommendation of SpaceOAR placement to improve sparing of the adjacent rectum is supported by current medical literature. Therefore, a SpaceOAR hydrogel procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested SpaceOAR hydrogel procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 10 mg tablets. The records provided for review document that this patients alopecia areata has been uncontrolled with standard steroid regimens. The provider charted complaints of chronic eye irritation and inflammation. Without eyelashes, which function to prevent debris from damaging the eye, the patient reports chronic eye irritation and inflammation. This also increases the patients risk of developing vision problems. To manage her symptoms, the patients provider recommended treatment with Xeljanz. For challenging patterns of alopecia areata, one safe and effective treatment option is Xeljanz. Researchers noted that Xeljanz doses can be up-titrated to 10 mg twice daily to achieve the desired therapeutic response. Researchers evaluated 90 patients with severe alopecia areata treated with Xeljanz. The authors reported that 77% of patients showed evidence of clinical response without serious adverse events. In the most recent Alopecia Areata Consensus of Experts, 30 experts agreed that janus kinase (JAK) inhibitors can be an effective monotherapy in the treatment of severe alopecia areata. Given these findings, the requested Xeljanz 10 mg tablets are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Xeljanz 10 mg tablets are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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 authorization and coverage for Prolastin-C infusion augmentation therapy.Findings:  The physician reviewer found that the submitted medical records and laboratory data do not support that the requested intravenous augmentation therapy is medically necessity for the patient. The current peer reviewed literature supports that augmentation therapy is not recommended for patients who are heterozygous and whose serum AAT level exceeds 11 micromol/L or 57 mg/dL (Sandhaus, R., et al.). In this case, the patient is heterozygous with a normal allele and one abnormal allele that is not associated with clinically significant alpha-1 antitrypsin deficiency. Furthermore, the patients serum AAT level of 106mg/dL is well above the threshold of 57mg/dL. Under these circumstances, the requested Prolastin-C infusion augmentation therapy is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested therapy is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in both internal medicine and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Insulin Potentiated Targeted Chemotherapy involving Gemzar and Cytoxan. Findings:  The physician reviewer found that Insulin potentiated targeted chemotherapy with Gemzar and Cytoxan is not a standard chemotherapy regimen. Insulin potentiated targeted chemotherapy with Gemzar and Cytoxan is not FDA approved, nor is it supported by major drug compendia or the medical literature. This approach is not mentioned in the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for breast cancer. Studies are largely in vitro and not in vivo and published in open access journals. Accordingly, the requested Insulin Potentiated Targeted Chemotherapy involving Gemzar and Cytoxan is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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.