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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient had struggled with eating disordered behavior.  Her symptoms had worsened in 2016 and resulted in physical sequelae, and both psychiatric and medical comorbidity.  Despite residential and inpatient care, the patient continued to struggle with her eating habits.  Per the records, the patient continued to subscribe to rigid eating disordered schemas.  The patient was overheard vomiting.  She continued to engage in food rituals and restrict her intake until discharge.  In sum, despite her treatment up to that point, the patient had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  The residential treatment provided was safe, appropriate and consistent with good medical practice.  The duration of services for a case of this complexity was consistent with community standards.  Finally, the entire course of care was reasonably expected to improve her condition and prevent a more serious episode of illness.  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: A parent of an enrollee has requested reimbursement and prospective authorization for residential treatment center (RTC) services from 2/24/16 forward.Findings:  The physician reviewer found that the documentation provided does not support the medical necessity of the services at issue in this clinical setting. By 2/24/16, the patient no longer needed the restrictiveness of a residential psychiatric treatment facility as she had stabilized enough to transition to a less restrictive setting. The patient did not have suicidal or homicidal ideation or psychosis. While she had continued symptoms of depression, she did not engage in any self-harm behaviors. She was doing well in school, cooperating in family therapy and was noted to make progress when dealing with distress. She was no longer displaying any significant or severe behavioral problems while in the RTC. Outpatient treatment and least restrictive options are considered first lines of care as referenced by the American Academy of Child and Adolescent Psychiatry. The standard of care for treatment of children and adolescents should be in the least restrictive setting as possible in order to maintain and foster natural supports. It is further recommended that children should be treated in the setting that is least restrictive and disruptive to their lives. Inpatient or residential treatment is indicated only in emergencies or for children who have not responded to efforts at outpatient treatment. There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting.  A study found that treatment outside of a residential setting are effective and appropriate and are as beneficial as RTC programs: children in intensive in-home therapy were more likely in the future to live with family, make progress in school, not have trouble with the law, and have better placement permanence than youth in residential treatment. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for autonomic testing. Findings:  Three physician reviewers found that there are multiple methods of diagnosing POTS including the use of tilt table testing. There are sufficient diagnostic criteria established for tilt table testing that it can be considered a useful method of diagnosis. Further, autonomic testing has been demonstrated to be useful in the diagnosis of POTS as a thorough evaluation of the autonomic nervous system. In addition, the use of transcranial Doppler may help establish whether the patients cerebral blood flow has been compromised. All told, the current peer-reviewed medical literature supports the requested autonomic testing as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the requested testing 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: All three physician reviewers are board certified in neurology 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 Otezla 30 mg tablets, 60 per 30 days. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has tried and failed therapy with topical steroids and excimer laser.  She reports a needle phobia, making the injectable biologics a poor option for therapy.  The Health Plan guidelines indicate that Otezla may be a covered benefit after failure or contraindication to treatment with methotrexate, acitretin or cyclosporine.  The provider noted that methotrexate cannot be used as the patient is of childbearing potential.  However, the potential for childbearing is not an acceptable contraindication.  There are no definite contraindications (such as current pregnancy, transaminitis, or active hepatitis) to methotrexate therapy, and there has not been a treatment failure with the medication. Therefore, Otezla 30 mg tablets, 60 per 30 days is not medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Shingles vaccine treatment for history of shingles.  Findings:  The physician reviewer found that the request for Shingles vaccine is not medically necessary for treatment of the patients medical condition. In this case, the records do not demonstrate that the patient has recurrent zoster although she had pain at the site of a prior eruption two years later. Even if recurrent zoster is present, the Shingles vaccine has not been shown to reduce the recurrence rate. Final Result: The reviewer determined that the requested service 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 in infectious 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 reimbursement for the balloon sinus ostial dilation procedure performed.  Findings:  The physician reviewer found that Balloon sinuplasty is a U.S. Food and Drug Administration (FDA) approved treatment for well selected patients with chronic sinusitis. However, this patients CT scan did not reveal significant disease that would be amenable to treatment with balloon sinuplasty. In addition, the patient had not been adequately treated with proper medical therapy including a longer course of antibiotics and nasal steroids prior to undergoing balloon ostial dilation. Accordingly, the balloon sinus ostial dilation procedure performed was 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 procedure at issue was 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 & 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for gene testing. Findings:  The physician reviewer found that the patient has a history of longstanding shoulder winging and a first degree relative with facioscapulohumeral muscular dystrophy (FSHD). On examination, the patient reported shoulder weakness. The patient described symptoms that were consistent with a diagnosis of FSHD.  The patients provider requested genetic testing to ensure the patients diagnosis and guide clinical treatment. There is sufficient support in the medical literature for the efficacy of the requested services in this clinical setting. Genetic testing is the gold standard and is considered standard of care when diagnosing FSHD. This patients provider would need to obtain the correct diagnosis for this patient in order to guide management, provide therapeutic options, give proper counsel, and to arrange for the most appropriate multisystemic disease monitoring. Furthermore, gene testing could end the diagnostic work-up for this patient if tested negative. But if the patient tested positive, additional etiologies for the patient's symptoms could be explored. Gene testing would significantly improve the ability to effectively manage this patient. If the patient has FSHD, arrangements for hearing, cardiac, and visual disease monitoring would be different than if FSHD is not present.  Final Result: The reviewers determined that the requested services are 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: the physician reviewers are board certified in neurology 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 genetic testing, prostate cancer antigen 3 (PCA3)/kallikrein-3 (KLK3) antigen for evaluation of elevated prostate-specific antigen (PSA) level. Findings:  Two physician reviewers found that PCA3 is a non-coding gene specifically overexpressed in prostate cancer.  The product of the KLK3 gene, known as PSA, is expressed by the prostate and other tissues.  Abnormally high levels of PSA in the blood are found in men with prostate disorders, including prostate cancer.  PSA is an important tumor marker used in the diagnosis and monitoring of prostate cancer.  However, the testing performed in this patients case has very limited data.  There is a lack of randomized, clinical trials showing long-term benefits from the services at issue, such as progression-free survival or overall survival.  Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 authorization and coverage for prostatic arterial embolization. Findings:  The physician reviewer found that the patient is with over a decade  year history of benign prostatic hyperplasia (BPH).  He presented to his provider with symptoms of urgency, frequency, weak stream, difficulty voiding and nocturia.  The patient has requested coverage for prostatic artery embolization to treat his BPH. The Health Plan has denied this request. Per the Health Plan, prostatic artery embolization is considered investigational for treatment of this patient. The medical literature does not show that prostatic artery embolization provides the same degree of improvement when compared to transurethral resection of the prostate or laser ablation of the prostate in patients with BPH. The embolization procedure appears to have a higher degree of urinary retention in the post procedure period, and there are irritative symptoms that persist for months after the procedure.  At this point in time, there are not enough studies to suggest that embolization is as efficacious as other more accepted forms of treatment for BPH. All told, prostatic arterial embolization is not likely to be more beneficial than other standard therapies for the treatment of this patient. 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 & 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the inpatient mental health treatment services provided. Findings:  The physician reviewer found that due to the fact that the patient was no longer suicidal and was cooperative in treatment, the patient was a candidate for treatment in a less restrictive setting for the dates of dispute. The progress notes from the disputed period indicate that the patient was cooperative in treatment and open to therapy. The patient did not express suicidal ideation or severe mood lability during the disputed period. The functional impairment that the patient was struggling with borderline personality disorder. One of the mainstays of treatment for borderline personality disorder is dialectical behavior therapy, which can occur in a less restrictive setting once patients are free from safety concerns, which was the case for this patient. In addition, the Level of Care Utilization System (LOCUS) recommended treatment with high intensity community based services. The patients functional status was moderate due to significant inability to fulfill responsibilities and obligations and her treatment and recovery history were moderate due to minimal treatment response in the past. However, the patient had a lack of current suicidal ideation, was cooperative and demonstrated insight into her need for treatment, and had a stable recovery environment. All told, the inpatient mental health treatment services provided from the dates of dispute were not medically necessary for treatment of this patients medical condition.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla (apremilast) for treatment of her psoriasis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has a history of plaque psoriasis and concomitant hepatitis B infection, on therapy.  The patient is not able to take methotrexate and cyclosporine due to presence of hepatitis B infection. She has already tried and failed therapy with acitretin due to intolerance and itching. Otezla is a newer medication that is not considered to be immunosuppressive. However, there is minimal data to suggest that Otezla is safe for those with hepatitis B. Although considered to be more immunosuppressive, the anti-tumor necrosis factor agents have a longer history of use and there is data in the literature to suggest that their usage may be safer for patients who may have a history of hepatitis B infection. Moreover, there is no documentation as to this patient having tried and failed phototherapy. Therefore, due to the lack of medical evidence supporting the safety of Otezla in patients with a history of hepatitis B, as well as a lack of documentation as to the trial and failure of phototherapy in this patient, Otezla is not medically indicated for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the heart computed tomography (CT) scan performed for evaluation of the enrollees history of chest pain, dizziness and seizure. Findings:  Two physician reviewers found that this patient presents with multiple medical conditions, some coronary risk and chest/shoulder pain that was not further characterized at the clinic visit. In this circumstance, the records provided for review do not support an indication for a cardiac CT scan. There is no documentation to suggest the patients chest discomfort is suspicious for angina, and no other symptoms or objective findings are concerning for coronary ischemia. When chest discomfort is suspicious for coronary ischemia, then the guidelines recommend stress testing. Coronary CT scanning provides an assessment of coronary anatomy only and does not assess the functional significance of any stenosis identified. The current guidelines endorsed by several national organizations do not consider coronary CT scanning appropriate based on the documentation provided. For these reasons, the heart CT scan performed 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 diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  All three physician reviewers 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.