Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Cologuard test. Findings:  Two of the three physician reviewers found that there is support for the services at issue in this patients case. Cologuard testing has been approved by the U.S. Food and Drug Administration (FDA) to test for colon cancer. This testing can detect most (but not all) adenomas if they have high-grade dysplasia. In this case, the patient was due for colorectal cancer screening, had average risk for colorectal cancer, and did not have a family history of personal history that would place her at elevated risk for colorectal cancer. In sum, Cologuard test was likely to have been more efficacious than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 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: An enrollee has requested authorization and coverage for the medication Premarin (hormone replacement therapy). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees post-menopausal symptoms. At issue in this case is whether the requested medication Premarin (hormone replacement therapy) is medically necessary for treatment of the enrollees medical condition.Post-menopausal vasomotor symptoms (hot flashes) result in significant impairment of activities of daily living when they are severe. According to various medical societies including the North American Menopause Society, the recognized, preferred and effective therapy is estrogen replacement. This may be in oral or transdermal form. The medication Premarin (hormone replacement therapy) is an oral form of estrogen used for hormone replacement therapy. For a woman with a uterus, the estrogen must be balanced with progesterone to protect against endometrial cancer. In this case, in order to improve this woman's quality of life by reducing significant hot flashes, estrogen therapy is medically necessary. It is advised that this therapy be discontinued by age 60. Therefore, the requested medication Premarin is medically necessary.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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for neuropsychological testing performed. The Health Plan has denied this request indicating that the requested testing was not medically necessary for treatment of the enrollees autism; attention deficit hyperactivity disorder (ADHD); cognitive deficits; learning disability; sensory processing disorder; motor deficits; and speech and language disorder. At issue in this case is whether the requested neuropsychological testing provided was medically necessary for treatment of the enrollees medical condition.Determining the neurocognitive profile through neuropsychology testing is medically necessary in the care of individuals with autism, ADHD and accompanying comorbidities for several reasons. To begin, neuropsychology testing can be used to identify core processing speed deficits and executive functioning errors. This information can then be used to better understand how to proceed pharmacologically, and also provides valuable baseline information which can be used to gauge treatment effect as noted by colleagues. Not only does neuropsychology testing inform pharmacotherapy, but can also be used as therapy itself. Colleagues reported in a recent study on neuropsychology testing, frontal/executive programming was used in individuals with autism, and was shown to be effective in improving impaired executive functioning in autism spectrum disorder patients and may also lead to improvements in some aspects of social functioning. Lastly, the use of neuropsychology testing in individuals with an autism spectrum disorder (ASD) and comorbid ADHD demonstrate significant clinical heterogeneity. In a recent study, significant differences in the neuropsychological characteristics of children with ASD + ADHD compared to those with ASD only was observed. Children with ASD + ADHD showed higher symptoms of anxiety, worse working memory, and less empathy. This suggests that having ADHD brings further challenges to individuals with ASD and may negatively impact their management and outcome. Utilizing this information allows for more targeted pharmacotherapy, effecting clinical outcomes as indicated by colleagues. It is for these reasons that neuropsychology testing was medically necessary in this case. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 mental health services from 5/11/18 to 5/14/18. The Health Plan has denied this request indicating that the requested services were not medically necessary for treatment of the enrollees severe depression. A review of the record indicates the enrollee was diagnosed with severe depression. The enrollee was admitted to a hospital on 5/2/18 due being a danger to self. During the period of 5/11/18 through 5/14/18, the provider noted the enrollee had continued to experience symptoms consistent with the reason for admission. On 5/15/18, the enrollee entered a residential program upon discharge from the hospital.The American Psychiatric Association guidelines note Admission to a hospital  may also be indicated for severely ill patients who lack adequate social support outside of a hospital setting, who have complicating psychiatric or general medical conditions, or who have not responded adequately to outpatient treatment. Given the severity of the patients suicide attempt and that, he remains with suicidal thoughts as well as helplessness and not attending to self-care, his risk remains high. Thus, admission for this patient from 5/11/18 through 5/14/18 was in accordance with generally accepted standards of medical practice and clinically appropriate for the patient's illness, and is therefore medically necessary.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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a sleep study performed on 8/29/16. The Health Plan has denied this request indicating that the requested procedure was not medically necessary for treatment of the enrollees obstructive sleep apnea.At issue in this case is whether the requested sleep study performed on 8/29/16, was medically necessary for treatment of the enrollees medical condition.In this case, the patient was noted to have had a problem with sleep, specifically sleep disordered breathing. However, in this case the patient is noted to have undergone diagnostic sleep testing in 2011. That study reportedly led to a diagnosis of UARS. However, the patient's AHI was noted to have been 20. Based on the diagnostic standards in effect at that time (The International Classification of Sleep Disorders 2nd edition), that RDI would have led to a diagnosis of obstructive sleep apnea (OSA). A RDI of five or greater met criteria for OSA.The patient otherwise reported no change in symptoms or weight since the time of initial diagnosis. In this setting, it can be said that the patient already had an established diagnosis of OSA (based on current diagnostic criteria/standards). Given that a diagnosis of OSA has been established, there would not have been a need or indication for repeat diagnostic testing to be undertaken. Such services would otherwise have been duplicative to those services previously provided.  Therefore, the sleep study on 8/29/16 would not have been medically necessary.Final Result: The reviewer determined that the requested procedure was 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 neurology with subspecialty certification in 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 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 artificial intervertebral disc. Findings:  Three physician reviewers found that this patient presents with progressively worsening neck pain radiating into the bilateral upper extremities, with numbness, tingling and weakness. The enrollee's pain was reportedly constant and interfered with activities of daily living. Clinical examination documented positive Spurlings test consistent with imaging evidence of severe spinal stenosis at the C4-5, C5-6, and C6-7 levels. The enrollee also had symptoms consistent with electrodiagnostic evidence of bilateral ulnar neuropathy, left greater than right, and bilateral carpal tunnel syndrome. The enrollees provider recommended hybrid surgery with cervical total disc replacement at C4-5 and C5-6 and anterior cervical discectomy and fusion at C6-7. The current medical literature suggests that hybrid surgery may be an effective alternative to multilevel fusion for cervical spondylosis. However, studies with larger sample sizes and longer follow-up periods have been recommended to provide further evidence. There is a lack of large volume, long-term, peer-reviewed outcome studies to support the use of these procedures for this patient. Therefore, the requested artificial intervertebral disc is not likely to be more effective than other treatment options. 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, 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx Uveal Melanoma testing. Findings:  Three physician reviewers found Local treatment for primary uveal melanoma is effective in preventing local recurrence in over 95% of cases, yet up to 50% of patients remain at risk for metastatic disease. Gene expression profiling has been shown to be superior to chromosomal markers, as well as clinical and histopathological prognostic factors, for defining groups at high risk for the development of metastatic disease. Using primary uveal melanoma samples obtained by fine needle biopsy, gene expression profiling classifies tumors as having Class 1, consistent with a low risk or Class 2, which suggests a high risk for metastatic. Moreover, this profile test is considered within the standard of care and is recommended by the National Comprehensive Center Network (NCCN) guidelines. Accordingly, the DecisionDx Uveal Melanoma testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.For these reasons, the DecisionDx Uveal Melanoma testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the DecisionDx Uveal Melanoma testing was 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon ostial dilation. Findings:  Three physician reviewers found that the records noted a history of posterior nasal discharge and an episode of presumed rhinosinusitis 2.5 months previously which had been medically managed with appropriate therapy. The patient had no clinical evidence of chronic sinusitis.  The single report of the objective finding of the computed tomography (CT) scan from 2018 did not show evidence of chronic sinus problems, as there was no clinical evidence of opacification of any of the paranasal sinuses, and the ostiomeatal units were open, not obstructed. The nasal endoscopy suggested no evidence of any acute sinus problems. The only physical finding was that of a moderate deviated nasal septum, which is not treated with balloon sinus ostial dilation. Balloon sinus ostial dilation is a technique to improve symptoms of recurrent acute rhinosinusitis to help widen and dilate the sinus pathways. However, at this time, functional endoscopic sinus surgical techniques are considered the surgical treatment of choice for the management of chronic rhinosinusitis refractory to medical management. In this case, the patient does not meet medical criteria for surgical treatment of the paranasal sinuses based on the medical records. Therefore, the requested balloon ostial dilation is not likely to be of greater benefit than other treatment options. 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, 2 and 3 are board certified in otolaryngology 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 parent an enrollee has requested authorization and coverage for clinical speech therapy in addition to speech-language pathology services provided at school. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees neuromuscular disorder, hypomyelination with atrophy of the basal ganglia and cerebellum.At issue in this case is whether the requested clinical speech therapy in addition to speech-language pathology services provided at school is medically necessary for treatment of the enrollees medical condition.Fried-Oken and colleagues describe that regular re-evaluations and continual treatment are essential for individuals with neurodegenerative diseases who use AAC devices. As the disease progresses, the author notes that `strategies will change over time and use multiple modalities to capitalize on patients' strengths`. Fried-Oken and colleagues also note, `Patients can maintain effective, functional communication with AAC supports. Individualized communication systems can be implemented ensuring patients remain active participants in daily activities`.Hustad and colleagues explain the difference between the speech therapy typically provided in school, compared with that provided by a speech therapist who is an expert with AAC devices. Interventions provided to the children by general speech-language pathologists (who were not AAC experts) tended to be broader in scope, focusing on reducing underlying impairments. Interventions provided by AAC experts tended to focus on improving activities and participation and were oriented toward improving functional communication.`The requested speech therapy is medically necessary for treatment of the patients medical condition. It is essential that the patient be provided with the resources necessary in order for him to communicate his wants and needs. Without the ability to use an AAC, he will be unable to express himself; including letting his family know when he is in pain. Therefore, the speech therapy is medically necessary.Final Result: The reviewer determined that the requested treatment 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 pediatrics and neurology with special qualification in child neurology 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: enrollee has requested authorization and coverage for radiofrequency nerve ablation. Findings:  Three physician reviewers found that there is a lack of support for the requested services in this clinical setting. Failure of the second radiofrequency ablation to produce analgesia is not an uncommon problem. Son and colleagues reported up to 15% of repeat radiofrequency ablation procedures fail to produce adequate analgesia. Derby and colleagues found wide variation in the efficacy and diagnostic accuracy of medial branch blocks, with false negative response rates of 47.1%.  When the radiofrequency ablation fails, there may also be disease progression. It is not indicated to repeat a failed procedure. Therefore, the requested radiofrequency nerve ablation is not likely to be superior over other available treatment options. 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, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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 high-intensity focused ultrasound procedure, procedure code C9747.Findings:  Three physician reviewers found that once diagnosed with local prostate cancer, men are faced with many treatment options, including radical prostatectomy, external bean radiotherapy, brachytherapy, androgen deprivation therapy, and even observation. Each of these options carries with it significant risks and complications, the most significant of which include incontinence and sexual dysfunction. There have been several options explored for focal disease, including radiotherapy, cryotherapy, and high-intensity focused ultrasound. These offer the advantage of minimizing side effects, while at the same time, do not treat the entire gland.  Initially, this was a limitation, as prostate cancer is often multicentric, and can be found in scattered areas of the prostate gland. However, this limitation is lessened by increasingly advanced imaging modalities, including MRI, which can more accurately localize suspicious tissue. High-intensity focused ultrasound is generally accepted as an alternative for patients who have failed prior radiation therapy, but at that point, the treatment options are more limited. At this time, high-intensity focused ultrasound has not gained universal acceptance as a primary treatment option. Thus, high-intensity focused ultrasound procedure, procedure code C9747, was not likely to have been more efficacious than other treatment options. Final Result: The reviewers determined that the services at issue were 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, 2 and 3 are board certified in diagnostic radiology 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.