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

Nature of Statutory Criteria/Case Summary:  The enrollee is requesting reimbursement for CPAP machine. According to the record, the patient has a history of recurrent laryngeal papilloma. He underwent a flexible scope laryngoscopy and the physician noted the enrollee had worn a continuous positive airway pressure (CPAP) mask for sleep apnea for many years with resolution of daytime somnolence; however, the mask began improperly fitting and leaking. Results of the original study are not provided. His body mass index is 28.6 and his neck circumference 17.5 inches.  A home sleep test was performed indicating mild sleep disordered breathing and obstructive sleep apnea (OSA). He had three minutes of total study time below 88% oxygenation. His physician prescribed CPAP supplies for the diagnosis of OSA to replace the old one that stopped working after approximately 10 years. The enrollees obstructive sleep apnea was noted to benefit with continuous positive airway pressure (CPAP) therapy. Although the home sleep study showed mild obstructive sleep apnea, a berlin questionnaire administered prior to study was positive in categories one and two indicating high risk of obstructive sleep apnea. The sensitivity of this test regarding probability of having sleep apnea is 86 percent. CPAP therapy has been shown to result in significant reduction in daytime sleepiness in OSA patients. Thus, the enrollees ESS score of four, not showing significant daytime sleepiness, is not unexpected since the enrollee was on CPAP for many years. Neck circumference (NC) is a clinical feature that may be associated with OSA. The enrollees neck circumference of 17.5 suggests a high probability of OSA. As well, oxygen desaturation index of 9.7/hour indicates the enrollee desaturates in his sleep. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in sleep medicine, pulmonary medicine, critical care medicine and internal 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Orthovisc injections for both knees.Findings:  The two out of three physician reviewers found that the requested services are likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some enrollees with osteoarthritis, data has not established which enrollees will benefit. Guidelines from studies indicate that the data on the safety and efficacy of viscosupplementation remain inconclusive. As such, the guidelines do not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for enrollees with a history of lasting benefit from prior injections and in cases where the remaining options are limited. This enrollee presents with a history of osteoarthritis of both knees. The enrollee complains of bilateral knee pain, left greater than right, associated with functional limitations. Physical examination and imaging studies show end-stage osteoarthritis of both knees. The enrollee has exhausted conservative treatment including nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and corticosteroid injections. As the remaining alternative is a total knee arthroplasty, Orthovisc injections for both knees are likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.Final Result: Reviewers determined that the requested services are likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in orthopedic surgery and is actively practicing. One reviewer is board certified in orthopedic surgery and is actively practicing.  One reviewer is board certified in orthopedic surgery and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for an interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion. There is a paucity of prospective randomized controlled clinical trials demonstrating improved patient health outcomes with use of an interspinous process stabilization or distraction device. Researchers concluded on their retrospective study of 1,108 patients that the ultimate failure rate requiring additional surgery was 9.6%. The authors noted that the reasons for revision, which always involved removal of the original implant, were acute worsening of low-back pain or lack of improvement, recurrence of symptoms after an initial good outcome, and implant dislocation. In this patients case, there is no documented spinal instability. There is no need for a spinal stabilization device. There is no medical indication for the device in this case. All told, the requested interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion 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 interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion is not likely to be more beneficial for treatment of the patient's 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 reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. The patient has a composite score of 10. This score correlates with treatment in a community-based outpatient clinic setting such as outpatient treatment. Therefore, the RTC services provided 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested CPT nasal/sinus surgery with dilation maxillary sinus and nasal/sinus surgery with frontal and sphenoid sinus dilation. Findings:  Three physician reviewers found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The American Academy of Otolaryngology, Head and Neck Surgery (AAOHNS) defines chronic rhinosinusitis (CRS) as a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12-week consecutive duration. Characteristics of CRS include two or more symptoms, one of which is nasal blockage or nasal discharge, and reduction or loss of smell with endoscopic evidence of mucopurulence, edema, and/or polyps and/or CT presence of mucosal thickening or air fluid levels in the sinuses. The AAOHNS defines recurrent acute sinusitis as four or more recurrent episodes of acute rhinosinusitis with complete clearing of symptoms between episodes over a one-year period. This patients records do not describe chronic rhinosinusitis since there is a lack of documentation of three months of consecutive disease, nor recurrent acute sinusitis as there was no documentation of four or more recurrent episodes over a one-year period. The record do not document the chronology of the patients condition, prior treatment and responses, and symptoms. Further, the patient has not exhausted maximal medical therapy prior to the CT scan. The patient does not meet the criteria for balloon sinuplasty. Thus, the requested services are 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 up 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for DecisionDx-Melanoma test. The enrollee was diagnosed with malignant melanoma of the right mid upper back.  He was seen for evaluation of moles on his trunk that had been present for years.  He has a family history of melanoma. An irregular brown macule was noted on his right mid-upper back and a shave biopsy was done. Findings:  The physician reviewer found that the dermatopathology report showed malignant melanoma, superficial spreading type, arising in association with a nevus,without ulceration, peripheral margins involved. A complete excision of the lesion was performed. The pathology report showed dysplastic nevus with free margins.  The DecisionDx-Melanoma test result was Class 1 Sub-class: 1A, which is associated with a low risk of recurrence within five years. His physician indicates this information helps determine the most appropriate treatment plan for these enrollees. The results of the DecisionDx-Melanoma test revealed the enrollee has class 1A associated with the lowest risk of recurrence within five years, which suggests a very low risk of metastatic potential already ascertained on the original biopsy. There are no long-term follow up studies available regarding the effectiveness of the test. The testing would not be effective or useful in treatment planning. The initial evaluation for risk of metastasis in enrollees with cutaneous melanoma uses the staging criteria, which includes sentinel lymph node status. The stage at presentation of melanoma has a significant impact on the course of the disease, holds prognostic value and dictates the recommendation in treatment.  The sentinel lymph node status is a proven prognostic tool that identifies a subset of the enrollees with high-risk disease. Although there are recent studies that show statistical analysis related to enrollee outcomes, the OncotypeDx-Melanoma test has not been supported by current guidelines. The results of this testing has not yet been accurately correlated into treatment that will improve enrollee outcomes. In a enrollee with a low risk, there is no medical justification available in current medical literature for a genetic test that has only completed interim data analysis, and has not yet definitely been shown to improve enrollee health outcomes. DecisionDx-Melanoma test is not currently recommended by any standard treatment guidelines.Final Result: Three of the three reviewers determined that the requested service was 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 dermatology 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees representative is requesting authorization and coverage for Genotropin pen. Findings:  The physician reviewer found that the enrollee has a diagnosis of idiopathic short stature who was evaluated by an endocrinologist. Her bone age at age 13 years, 10 months was read as 12 years. Her endocrinologist indicates her height was below the 1st percentile and -2.36 standard deviations below the norm. Her growth velocity was 3.97 cm/year which was also below the 1st percentile for age and gender. Mid-parental height is 157.48 cm Insulin like growth factor (IGF) 1 was 1462 ng/ml. Her endocrinologist states it is imperative she receive growth hormone therapy. Review of the record indicates chemistry and lab data are normal except for IGF-1, which is greater than 2 standard deviations above the upper limit of normal. Her predicted height is estimated to be approximately 60 inches (152.4 centimeters, 4.4 percentile) and is within one standard deviation of the mid-parental height. The enrollee has short stature appropriate for a diagnosis of idiopathic short stature with a height less than -2.25 standard deviations and use of growth hormone therapy.  However, the indication for use of growth hormone therapy, as indicated by the FDA, also indicates the enrollee should have growth unlikely to result in normal adult stature. Humatrope is indicated for the treatment of idiopathic short stature, also called non-GH [growth hormone] deficient short stature defined by height SDS [standard deviation]  -2.25 and associated with growth rates unlikely to permit attainment of adult height in the normal range. This enrollee has a growth velocity of 12.55 centimeters per year and a height prediction of within one standard deviation of the mid-parental target height as well as above the 3rd percentile.Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatric endocrinology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage of Prolia. Findings:  The physician reviewer found that the enrollee has a medical history of osteoporosis, recurrent gastric ulcer, and rectal cancer. She was treated with Ibandronate and Fosamax for osteoporosis. Her physician indicated these were ineffective.  An esophagogastroduodenoscopy (EGD) showed an antral ulcer and bulbar diverticulum for which proton pump inhibitors were prescribed. Her symptoms persisted and Carafate was prescribed. She had a bone density study which confirmed osteoporosis. Prolia injections were prescribed. The provider explained to the enrollee that bisphosphonates were contraindicated due to the enrollees severe reflux and ulcers. The health plan has denied coverage for the Prolia injections as not medically necessary. They indicate the enrollee needs to have tried treatment with a bisphosphonate, as studies do not show treatment with Prolia works better than treatment with a bisphosphonate. The medical literature for Boniva, a bisphosphonate, indicates Boniva should not be given to patients with active upper gastrointestinal disease and should be discontinued in patients who develop any symptoms of esophagitis. This enrollee has active upper gastrointestinal symptoms in spite of proton pump inhibitor therapy and Carafate. Under these circumstances, Prolia is a recommended alternative for the treatment of osteoporosis and is a medically necessary treatment in patients with active upper gastrointestinal symptoms.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal medicine and gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for residential treatment center (RTC) services. Findings: The physician reviewer found that the diagnoses of alcohol abuse and anxiety.  She was hospitalized with a blood alcohol level of 0.48 after which she attended outpatient treatment.  She was hospitalized again with a blood alcohol level of 0.58 and then received treatment at an inpatient facility.  She was sober for a month, but then she spent additional days in a hospital after which she began outpatient therapy, but continued to drink. The enrollee indicates that despite outpatient and inpatient treatment, she continued to abuse alcohol and it was affecting her physical health, her family, and social life.  She also lost her job. She feels the residential treatment gave her the needed structure and support to begin recovery. All of the residential treatment center (RTC) services provided were medically necessary to treat the enrollee's medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 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 lab work  Based on current publications, there is not enough clinical data or randomized controlled trials demonstrating its use for initiating therapy or making clinical decisions. The American College of Rheumatology (ACR) does not support the use of this testing for evaluation in this clinical setting. These tests include patient input, tender/swollen joint counts and other biomarkers to determine disease activity. In this case, there are multiple lab tests, but no recent history, examination or clinical findings to determine the patients current disease activity. As such, the lab work 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 lab work was not likely to be more beneficial for treatment of the patient's 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 subspecialty certification in rheumatology 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 partial mastectomy of right breast. Visscher and colleagues stated that sclerosing adenosis is a proliferative lesion that is commonly found in benign breast biopsies. The authors noted that, does not further stratify risk in women diagnosed with other forms of proliferative breast disease, either with or without atypia Findings: the physician reviewer found that the American Cancer Society states that, women with adenosis do not need treatment, but might be watched closely. Overall, the role of SA in breast carcinogenesis remains undefined. The literature suggests that SA may be a predictor of an increased risk of breast carcinoma in either breast, but it does not appear to be precancerous. Therefore, the requested partial mastectomy of the right breast is not medically necessary to treat this patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.