Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for emergency medical transportation service. Findings:  The physician reviewer found that the services at issue were necessary for treatment of an emergency medical condition. In this case, the patient was critically ill with a complicated medical condition at the time of transfer. The attending surgeon decided that the patient required services at an alternative facility. The patients total colonic Hirschprungs disease complicated by bacteremia and intra-abdominal abscesses is a life-threatening condition. Emergency medical transportation services provided were necessary for an emergent medical condition. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric 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: An enrollee has requested authorization and coverage for Otezla 30 mg tablets for treatment of the enrollees psoriasis. 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, but there is no documentation of treatment with any systemic medication, including orals (methotrexate or cyclosporine) or injectable biologics (Enbrel, Humira, Remicade or Stelara). The records noted that the patient will be beginning therapy with Excimer laser but has not yet at this time.  Given that there is no documented medical reason as to why the patient cannot be treated with methotrexate, cyclosporine, or the injectable biologics, the medical necessity of the requested medication has not been established. There are preferred alternative therapies available for this patient. All told, the requested Otezla 30 mg tablets are not medically necessary for the 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 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 authorization and coverage for DecisionDx-Melanoma gene assay testing for evaluation of the enrollees malignant melanoma of right upper limb. Findings:  Three physician reviewer found that the services at issue are not considered routine standard of care and are  not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. This  genetic testing examines the tissue genetics of the melanoma and can stratify whether a thin melanoma is high risk for metastasis or not. The genes are examined for certain markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some impressive accuracy determining risk of metastasis in thin melanomas, as in this patients case. However, it is unclear how the information from the results of the test will be used. There is a lack of literature to support its use in the care of patients with thin melanomas to effect health outcomes. There is not enough published data to support its routine use currently. The treatment of this patient would not change based on the results of the examination. Since this test does not provide a benefit more than established tests as they affect outcomes, DecisionDx-Melanoma gene assay testing was not likely to have been more effective than the standard options available for the evaluation of this patient. 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: Reviewers 1, 2 and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a panniculectomy for treatment of the enrollees excess skin status post weight loss surgery. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity for the requested procedure in this clinical setting. The medical literature supports a panniculectomy for treatment of skin redundancy for patients who have experienced massive weight loss. This patient has a history of weight loss status post sleeve gastrectomy. Additionally, the records indicate that this patient has failed conservative treatment for her longstanding rashes including treatment by her primary care provider. A panniculectomy will eliminate the overhanging abdominal skin that predisposes the patient to recurrent skin infections. As such, a panniculectomy with skin resection is sufficient to treat this patients infections and will relieve her functional problems from chronic rashes. Final Result: The reviewer determined that the requested procedure 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ketamine for treatment of the enrollees behavioral health conditions. Findings:  Three physician reviewers found that ketamine is not approved by the United States Food and Drug Administration (FDA) for treatment of mood disorders, bulimia or anxiety. However, ketamine has shown promise for dramatic improvement for patients with depression. Unfortunately, the duration of action is rather brief, while the poor bioavailability of oral ketamine has prompted the use of intramuscular, intravenous and intranasal delivery systems. In addition to the difficulty delivering the medication, there is also potential concern regarding the safety, addictiveness and long-term effects of ketamine therapy. Further, there is a lack of evidence-informed practice guidelines regarding pre-treatment screening and patient selection criteria, intra-treatment recommended observational metrics, dosing schedules and treatment duration, and post-treatment follow-up.  Regarding this particular case, the documentation does not to support this intervention. Per the records, it was unclear what psychiatric treatments were being provided at the time of the disputed intervention, or if the patients recently uncontrolled eating disorder required a higher level of care due to the need for re-feeding, medical treatment and/or specialized therapeutic interventions. Therefore, the records do not establish that all other standard therapies had been exhausted at the time. Final Result: The reviewers determined that the medication 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: Reviewers 1, 2 and 3 are board certified in psychiatry and are actively practicing. The reviewers are 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 platelet rich plasma (PRP) therapy. Findings:  The physician reviewer found that current evidence based medical guidelines support PRP intra-articular injections in the knee for significantly symptomatic osteoarthritis or refractory patella tendinosis. Guideline indications for significantly symptomatic osteoarthritis include the failure to respond to conservative nonpharmacological (i.e. exercise) and pharmacologic treatments after at least six months, and failure to adequately respond to aspiration and injection of intra-articular steroids. There should be evidence of mild to moderate osteoarthritis of the knee, and the patient should be over 50 years of age. For refractory patella tendinosis, criteria include failure to respond adequately to recommended conservative nonpharmacological and pharmacologic treatments after at least 12 months. Zhang and colleagues indicated that despite a lack of consensus regarding PRP indications and efficacy, there was widespread application of this treatment for a myriad of musculoskeletal injuries. Most treated patients were older than 35 years, and the most commonly treated conditions included cartilage and meniscus disorders. They concluded that further studies are necessary to guide clinicians on the value of this therapy for each clinical diagnosis. Shahid and Kundra concluded that there was a growing body of evidence to support its use for selected indications in osteoarthritis, ligament, tendon and meniscal injuries of the knee. As such, the evidence for PRP therapy is of variable quality and concerns include the heterogeneous nature of the patients, variations in treatment techniques and inconsistencies in the findings of these studies. Additionally, there is a lack of hard evidence in regards to its effects in this clinical setting. The literature recommends that before widespread use can be recommended, high quality prospective randomized studies are required. Therefore, PRP therapy was not likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result: Two of three 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 & 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. The patient sustained a left shoulder injury when falling onto the patients left shoulder while snowboarding. He was evaluated in the emergency department on the date of injury and diagnosed with a large bony Bankart lesion with displacement. He was placed in a shoulder immobilizer and advised to follow-up with an orthopedic surgeon. The patient was stabilized in the emergency room and was not seen for orthopedic surgical evaluation for three additional days. The services provided thereafter were not emergent including the echocardiogram. Thus, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Oxycodone-Acetaminophen and Tramadol for treatment of the enrollees cervicalgia, radiculopathy and sciatica. Findings:  The physician reviewer found that based on the documentation submitted for review, Oxycodone-Acetaminophen and Tramadol have not been established as medically necessary for treatment of the patients medical condition. The medical records show the patient to have chronic non-malignant pain. The current standard of care for chronic pain is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. Based on a study there are Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments, except in rare cases, such as acute neurologic compromise or other red flags, including a history of malignant neoplasms. There are a variety of anti-convulsants and anti-depressants considered adjunctive to pain management therapy. High dose opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. In addition, short-acting opiates are likely to cause adverse outcomes. Therefore, based on current medical literature and in consideration of the presented clinical records, Oxycodone-Acetaminophen and Tramadol are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications 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 anesthesiology with sub-specialty certification in pain 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: The patient has requested reimbursement for the genetic testing (gene expression profiling) provided on 10/5/16. The Health Plan has denied this request indicating that for evaluation of the enrollees cutaneous melanoma. Findings:  Three physician reviewers found that melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. DecisionDx-Melanoma Assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 consistent with a low risk of metastasis or Class 2 suggestive of a high risk of metastasis. One peer-reviewed publication indicated that there was a statistically significant association of a Class 1 signature by DecisionDx-Melanoma Assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently Class 2. The authors concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. Therefore, DecisionDx-Melanoma Assay signature may be an independent predictor of metastasis risk. However, there is a lack of peer-reviewed published studies confirming this hypothesis. Final Result: The reviewers determined that the testing 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: Reviewers 1, 2 and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a week long partial hospitalization intensive family eating disorder program. Findings:  The physician reviewer found that based on the documentation submitted for review, the request for a week long partial hospitalization intensive family eating disorder program is not medically necessary for treatment of the patients medical condition. According to a study Anorexia nervosa is a psychiatric disorder characterized by abnormal eating behaviors that results in weight loss and has serious potential medical consequences. Most of these complications are readily treatable if diagnosed and attended to early in the course of the illness. Another study indicated that outpatient treatment with modalities such as cognitive behavioral therapy (CBT) can be effective for treatment of anorexia nervosa. In regards to the appropriate levels of care for anorexia nervosa, a further study  recommend treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. In this case, the records submitted for review do not indicate that the patient has had intensive treatment for anorexia. The patients medical status is intact and the patient appears psychiatrically stable. The patient has recently lost weight and denies any history of purging. The patient had some minor laboratory abnormalities that could be addressed on an outpatient basis. The patient could be safely and adequately treated on an intensive outpatient basis. For the reasons provided, the requested services are not medically necessary for treatment of the patients anorexia nervosa, restricting type.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gastrointestinal tract capsule endoscopy for evaluation of a history of nausea, vomiting and abdominal pain. Findings:  The physician reviewer found that medical evidence fails to demonstrate the superior efficacy of the requested services in this patients case. Community standard indications for capsule endoscopy include obscure gastrointestinal bleeding, small bowel Crohns disease, assessment of celiac disease, screening and surveillance for polyps in familial polyposis syndromes. Additionally, capsule endoscopy may be beneficial for evaluating the small bowel for tumors such as lymphoma, carcinomas or carcinoids. Per the records, this patient meets none of these indications. All told, gastrointestinal tract capsule endoscopy is not likely to be more effective than other modalities for evaluating this patient.   Final Result: The reviewers determined that the requested services are 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: 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.