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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for home sleep study (CPT 95806). The enrollee has diagnoses of obstructive sleep apnea (OSA), hypersomnia, unspecified, and primary central sleep apnea.  He underwent an unattended home sleep test. His body mass index was 28 and Epworth Sleepiness scale was three.  The results revealed findings consistent with snoring as well as severe OSA while on his side; with moderate disease while on his back.  The apnea/hypopnea index (AHI) was 67 per hour while on his side.  He had episodes of disordered breathing events, which may represent rapid eye movement (REM)-related events.  Oxygen saturation dropped from a baseline of 96% to a low of 80% when associated with sleep disordered breathing. Current literature supports diagnostic testing for obstructive sleep apnea in persons with unexplained excessive daytime sleepiness.  Literature notes individuals who complain of snoring in the absence of excessive daytime sleepiness, with two or more additional features of obstructive sleep apnea, or who work in what is considered a critical or high-risk profession, are appropriate for diagnostic testing.  The documentation does not detail this enrollee had unexplained excessive daytime sleepiness, witnessed apneas, or other possible sleep-related disorder symptoms; therefore, diagnostic testing was not appropriate.  While documentation noted the enrollee's wife reported snoring, the lack of the previously mentioned symptoms indicates a sleep study was not the most appropriate level of services at the time.  He was diagnosed with obstructive sleep apnea, but this was after the testing in question was administered.Final Result: The reviewer determined that the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in otolaryngology and sleep 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Functional Electric Stimulation Cycle Rehabilitation System (FES). The enrollee has spastic cerebral palsy. He was an active individual who was able to ambulate, work, and remain independent. He was diagnosed with C4 amyotrophic lateral sclerosis (ALS) cervical tetraplegia due to transverse myelitis. The enrollee has lost volitional motor function below C4 in his bilateral upper and lower extremities. His light touch sensation and proprioception is absent bilaterally below C4. The enrollee utilizes a standing frame weekly to maintain leg and trunk flexibility. He requires an alternative form of activity therapy since he cannot do this volitionally. Upper and lower extremity mobilization can be achieved in stable transverse myelitis enrollees with a cycle ergometer; powered by an enrollees own muscle strength, evoked by Functional Electric Stimulation (FES). His rehabilitation physician prescribed the FES. Literature describes electrical stimulation as a modality used for the rehabilitation of persons with neurological damage, effective in improving muscle strength and blood flow, decreasing atrophy, healing tissue, and decreasing pain. However, even though electrical stimulation has the capacity to produce movement in enervated, paralyzed, or spastic muscles, literature does not show a significant benefit over conventional exercise. The enrollees diagnosis would support that he would have partial or total loss of use of his limbs. The standard of care for enrollees with complete cervical spinal cord injuries is physical therapy; including range of motion exercises to prevent contractures, improve muscle tone, and to prevent skin breakdown. Further study is required to delineate which individuals are   appropriate for treatment and which symptoms FES can help alleviate. FES is approved for use in spinal cord injury and stroke enrollees. It is not approved for ALS. FES is used for traumatic spinal cord rehabilitation but the data for its use is limited and it has not been shown to improve function or outcome in ALS individuals.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in physical medicine and rehabilitation and are 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 laboratory services (CPT code 86677).Findings:  Two of three physician reviewers found that this patient presented to her provider and reported right upper quadrant pain and epigastric pain. She denied nausea or vomiting. Her provider ordered a Helicobacter pylori serology panel. The records noted positive Helicobacter pylori immunoglobulin M (IgM) serology and negative immunoglobulin A (IgA) and immunoglobulin G (IgG) serology. Treatment with omeprazole, clarithromycin and Flagyl was initiated for presumptive Helicobacter pylori infection. Consistent with standard of care, Braden noted that 13C urea breath test or the stool antigen test can be used for noninvasive screening for Helicobacter pylori in a test and treat strategy in younger patients presenting with dyspepsia without alarm symptoms without the need for endoscopic prelude to therapy or retreatment. Braden did not support serologic testing as the study of choice or standard of care. Per the medical evidence, serologic testing sensitivity and specificity falls short when compared with standard test modalities, such as detection of active infection with stool antigen or urea breath assays. In sum, laboratory services (CPT code 86677) were not likely to have been more beneficial than any available standard method of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to have been 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 gastroenterology 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: The patient has requested authorization and coverage for medical genetics counseling (CPT 96040). The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether medical genetics counseling (CPT 96040) is medically necessary for the treatment of the patients medical condition. Genetic counseling helps patients understand and adapt to the medical, psychological, and familial implications of genetic contributions to disease. This process integrates the interpretation of family and medical histories to assess the chance of disease occurrence or recurrence. Pilarski reported that the perception of risk may have a broad impact on both psychological parameters (anxiety, worry and distress) and risk management behaviors (preventive measures such as surgery, health screening, and lifestyle changes) for those at risk. In this case, genetic counseling is medically necessary. A patients anxiety about a family members condition or misunderstanding of risk may raise additional questions and/or concerns that are readily addressed by a genetic counselor. The medical evidence supports the requested services in this clinical setting. Therefore, medical genetics counseling (CPT 96040) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 clinical genetics and genomics 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 high intensity focused ultrasound (HIFU) services. HIFU consists of focused ultrasound waves that cause tissue damage by mechanical and thermal effects as well as by cavitation. Potential candidates for HIFU treatment are patients with low to moderate risk prostate cancer. The available literature mainly consists of prospective case series and retrospective studies showing short- to intermediate-term outcomes for localized prostate cancer. Overall, there is a lack of controlled trials for analysis or research on long-term patient health outcomes. The National comprehensive Cancer Network (NCCN) guideline noted that HIFU warrants further investigation as an emerging local therapy, but noted that data are lacking to establish its role in the treatment of prostate cancer. The National Cancer Institute does not list HIFU as one of the seven standard treatments for patients with prostate cancer. Moreover, the American Society for Radiation Oncology (ASTRO) guideline states that HIFU is not considered a standard care option because comparative outcome evidence is lacking. As such, HIFU is not a clinically appropriate and generally accepted standard of care for management of localized prostate cancer. This patient was initially diagnosed with a Gleason score of 6 with a prostate specific antigen (PSA) of 4.4. The current guidelines and medical literature do not support the long-term safety and efficacy of HIFU in this clinical setting. Given these findings, the HIFU surgery services were 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 HIFU surgery services were not likely to be more beneficial for treatment 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Anastrozole. Anastrozole is an aromatase inhibitor that has been used for the treatment of patients with male hypogonadism. Anastrozole increases testosterone levels by lowering serum estradiol levels and increasing gonadotropin levels. In patients receiving testosterone replacement with testosterone pellets, Anastrozole maintained therapeutic testosterone levels longer than men on testosterone pellets alone and have significantly less gonadotropin suppression and no adverse events. Anastrozole can help prevent and treat testosterone-induced gynecomastia. In this case, the patient has been treated with Anastrozole for several years to counteract the effect of painful gynecomastia without any untoward side effects. The lack of the medication would allow the patients estradiol levels to increase and promote painful gynecomastia. Therefore, Anastrozole is medically necessary as part of the treatment regimen for this patients male hypogonadism. 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 subspecialty certification in diabetes, endocrinology and metabolism 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 patient has requested authorization and coverage for Divigel. While transdermal estrogen is a preferred formulation for the delivery of hormone replacement therapy in symptomatic postmenopausal women, there are many effective treatment options. There are many transdermal formulations of estrogen for this clinical indication. Divigel is not the only product available. However, there is no preferred product in the current medical literature. This patient has tried Femring, which is a low estrogen dose for symptoms of vaginal dryness. She has also tried estrogen pellets, which are not a U.S. Food and Drug Administration (FDA) approved treatment. The records do not document an adequate trial and failure, or contraindication to, one of the Health Plans formulary alternatives. The Health Plans formulary alternatives are likely to be at least as effective as Divigel. Therefore, Divigel is not medically necessary for 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. Based on LOCUS criteria, the patient does not meet criteria for IOP treatment. The patient is at some risk of self-harm (score 2) in the setting of passive suicidal ideation but no active urges, current plan or intent. The patient has shown moderate functional impairment (score 3) as she has not been attending school and has been unable to drive. Since starting IOP, she has been improving in terms of hygiene and in her ability to leave her home. She is planning to return to college in the fall. The patient has no major medical, addictive and psychiatric comorbidities (score 2) with diagnosis of OCD, anxiety and depression. The patients recovery environment is minimally stressful (score 2) as she lives at home with her family. The patients family is supportive (score 2) and they have completed several family meetings. The patients resiliency and treatment history has been limited (score 3) as she has demonstrated some improvement in mood and functioning since admission to the IOP. The patient cares for herself, she is performing activities of daily living, and she is planning to return to college. This gives the patient a composite score of 14, which is consistent with low intensity community based services. The patient has participated in several weeks of the IOP and demonstrated improvement in mood, activities of daily living, and overall functioning. Based on her clinical improvement and lack of safety concerns, transition of this patient to outpatient level of care should help maximize her independence and functioning. For these reasons, the IOP services were not and are not medically necessary for treatment of this patient. 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 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 Kalydeco 150 mg tablets every 12 hours for one year. Current medical literature indicates that although this patients mutation is not a gate mutation defect, there is evidence that this particular mutation has the capacity to be stimulated by potentiators, such as ivacaftor (Kalydeco). Recent data shows that the W1282X mutation can be coaxed to have high ion channel activity by some medical therapies, such as Kalydeco, that were designed for other mutations (Mutyam, et al.; Xue, et al.). This patient presents with clinically worsening disease despite treatment with antibiotics, manual and pharmacological airway clearance treatments, and nutritional supplementation. This patients weight loss, severely deteriorated lung function, and high insulin demands may benefit from use of Kalydeco (Mutyam, et al.). The patient has post-tussive vomiting, which is consistent with severe reactive airway disease that will contribute to poor nutrition and further weight loss if left untreated. All told, the requested Kalydeco 150 mg tablets every 12 hours for one year 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 pulmonary disease with subspecialty certification in critical care 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether physical therapy is medically necessary for the treatment of this patient. The American Physical Therapy Association reports that the initial patient evaluation should support the need for physical therapy. The physical therapist should reexamine the patient as necessary to evaluate progress or change in patients status, and the provider may modify the plan of care accordingly or conclude the episode of care. The physical therapist should conclude an episode of care when the anticipated goals or expected outcomes for the patient have been achieved, when the patient is unable to continue to progress toward goals, or when the physical therapist determines that the patient will no longer benefit from physical therapy. In this case, the medical records do not reveal the patient has deficits that require continued skilled physical therapy. The medical records also do not show that prior skilled physical therapy has led to significant objective functional improvement. The patient was noted to be independent in a home exercise program, and the patient did not require further physical therapy sessions. The medical evidence does not support the requested services in this clinical setting. Therefore, physical therapy is 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 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 reimbursement for TMS services provided by Southern California TMS. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether TMS services that were received at Southern California TMS were medically necessary for the treatment of the patients medical condition. McDonald and colleagues reported repetitive transcranial magnetic stimulation (rTMS) as an important therapy for treatment resistant depression (TRD). Researchers noted that the U.S. Food and Drug Administration (FDA) approved TMS for treating major depressive disorder in patients who have not responded to prior antidepressant medications. TMS therapy should be considered in patients who present with a clinical diagnosis consistent with major depressive disorder for whom antidepressant medication has not provided a satisfactory clinical benefit, or for whom intolerance to medications precludes their use. For patients who experience a relapse after previously benefitting from an acute TMS course, medical evidence supports reintroduction of TMS until remission is re-achieved. In this case, the patient has previously demonstrated positive response to TMS. Medical evidence supports the services at issue in this clinical setting. Therefore, TMS services that were received at Southern California TMS were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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.