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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that although continuing psychiatric care and chemical dependency specialty services were indicated, the medical records submitted for review fail to demonstrate the medical necessity for the residential level of care treatment in dispute. Upon admission, the patient had a normal mental status examination. The patients physical examination was unremarkable.  There was no evidence of intoxication or withdrawal.  The patient was described as well-developed and well-nourished, and in no apparent distress. The patient was normotensive with a heart rate of 77. The patients height of inches and weight of pounds correlated with a normal body mass index of. The patient had overconsumed alcohol a few times per week while on vacation and was described as a binge drinker. The patient had not used cannabis in the month prior to the disputed service. The acute distress that led to her overdose had resolved. The patient did not endorse a history of chronic suicidality or prior attempts.  The patient described the overdose as a cry for help. The patient was happy to be alive and motivated to feel better. The patient was well-connected with her supportive parents, and had access to safe housing.  The patient was well-educated and employed. Although the patient had been treated by a psychiatrist for several years, there was no evidence that the patient had engaged in PTSD-specific therapies, more intensive psychiatric treatment settings or chemical dependency services. Further, systematic medication management, trauma-focused therapy and diagnostic psychological testing, all of which the patient received during the admission, could have been safely and adequately been provided in an outpatient-based setting. In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been unsafe, inappropriate or inadequate at the time. All told, the residential treatment center services provided were not medically necessary for treatment of the patients behavioral health 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement and prospective authorization and coverage for enhanced external counterpulsation (EECP) for treatment of the enrollee who has been diagnosed with Peyronies disease.  Findings:  The physician reviewer found that There are limited trials that note the efficacy of the services at issue. Additionally, the medical literature does not indicate if EECP therapy is safe and effective in decreasing the pain and curvature that are associated with Peyronies disease. His degree of curvature is not documented and the outcome of the therapy have not been documented. EECP is not accepted as a standard of care for the management of Peyronies disease. In recent trials, certain novel therapies have shown to be superior to EECP. Moreover, this patient does not have any trouble with intercourse. Therefore, EECP services were not and are not likely to be more efficacious than the standard methods of treating this patients medical condition. Final Result: Two of three reviewers determined that the services at issue were not and 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 reviewer number one is board certified in urology 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.Physician reviewer number two is board certified in urology 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.Physician reviewer number three is board certified in urology 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 magnetic resonance imaging (MRI) of the lumbar spine for evaluation of the enrollees back and leg pain.  Findings:  The physician reviewer found that The requested MRI of the lumbar spine is not medically necessary for evaluation of the patients medical condition. In this case, a trial of conservative treatment such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs is medically reasonable and appropriate. In addition, the patients medical condition is complicated by use of Forteo which has known side effects including dizziness, tachycardia, muscle cramps, leg cramps, and joint pain. For the reasons provided, the requested diagnostic procedure has not been established as medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 authorization and coverage for Lantus Pen. Findings:  The physician reviewer found that the request for the Lantus Pen has been established as medically necessary for treatment of the patients medical condition. Lantus is a once-daily, long-acting insulin analog that is specifically designed to provide basal insulin requirements. There is ample evidence in the peer-reviewed literature demonstrating that treatment with Lantus is associated with A1c reduction as well as decreased glycemic variability when compared to NPH insulin. In addition, retrospective studies have shown that switching patients from NPH insulin to Lantus insulin leads to significant improvement in glycemic control. Therefore, the request for Lantus Pen is medically necessary for the treatment and management of the patients diabetes. 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 sub-specialty certification in endocrinology, diabetes 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: An enrollee has requested reimbursement and prospective authorization and coverage for Trental and verapamil for treatment of the enrollees Peyronies disease. Findings:  The physician reviewer found that There is a lack of strong evidence based literature to support the medical necessity of the medications at issue in this clinical setting. The use of verapamil injections has been studied for management of patients who are diagnosed with Peyronies disease (PD). However, the literature recommends that further studies need to be conducted to determine its efficacy for the treatment of PD and the associated symptoms with this disease. The American Urological Association Guidelines (AUA) guidelines on PD state that clinicians who consider the use of intralesional verapamil as a treatment option for symptoms of PD should fully consider the weakness of the evidence demonstrating its efficacy. In particular, clinicians should be aware that the lack of control for PDs history in most of the available literature creates substantial uncertainty, particularly given the focus on patients in the acute phase with symptoms that are in a dynamic state. The panel notes that the overall balance between benefits and risks/burdens of intralesional verapamil, therefore, remains unclear given these concerns. The use of greater than 70 treatments with verapamil has not been reported in medical literature. Most trials reported outcomes of once weekly injection for approximately three to six months.  In addition, this patient reported that he does not have trouble with intercourse and his degree of curvature is not documented. As such, the outcome of the therapy in this patients case has not largely been monitored objectively. With respect to Trental, the medical studies are lacking to support its efficacy as a treatment option for patients diagnosed with PD. Hence, the use of Trental is not considered a standard of care for management of patients with PD. For these reasons noted above, Trental and verapamil were not and are not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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 urology 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 gene expression profiling testing for evaluation of the enrollees melanoma. Findings:  The physician reviewer found that that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx-Melanoma test has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, gene expression profiling testing  was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: Two of three 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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 residential treatment center services. Findings:  The physician reviewer found that the records noted slight improvement but continued anxiety, and the patient reported feeling overwhelmed. The provider noted that the patient was sad, depressed and tearful. Further, the patient was not sleeping well at night while her meal plan remained in flux. In sum, the record suggests that the patient had not consolidated the treatment gains necessary to succeed in a less restrictive setting. Thereafter, the patient remained engaged in active treatment during the entire admission, which also served to engage the family in the therapeutic process and arrange appropriate aftercare. Based on the relevant history, severity of the addictive disease and concerning psychiatric comorbidity, effective treatment could not have been safely and adequately delivered in a setting less restrictive than the residential level of care during the dates of service in dispute. In sum, the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards and facilitated transition to a less restrictive setting. Additionally, the services were reasonably expected to improve her condition and prevent a more serious episode of illness. All told, residential treatment center services provided during the dates of service in question were medically necessary for the treatment of this patient. 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: An enrollee has requested authorization and coverage for hydrocodone/acetaminophen 10-325 mg, cyclobenzaprine 10 mg, and diazepam 10 mg for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that In the documentation available for review, the stepwise World Health Organization (WHO) ladder for pain relief is considered a reasonable approach to pain control in the palliative and the non-palliative settings. However, in this patients case not all non opioid treatment options have been utilized. The medical literature suggests clinicians to consider alternative options to opioids as well as to wean patients to lower doses of opioids or even off opioids. Furthermore, the records do not mention a completion of physical and behavior therapy despite much research to support its use. Objective treatment goals for pain and function are not documented for the requested medications. The Centers for Disease Control and Prevention (CDC) states regarding co-prescription of opioids with benzodiazepines, epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. In addition, multiple minimal requirements for opioid prescribing have not been performed and the need to use them as the primary medication treatment strategy for pain has not been established in this patients case. Finally, not all non opioid medication classes have been optimized or tried in this case. For all these reasons, the requested hydrocodone/acetaminophen 10-325 mg, cyclobenzaprine 10 mg, and diazepam 10 mg, are not medically necessary for treatment of this 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an echocardiography, procedure code 93306. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity of the services at issue. Based on the records provided the patient has no cardiac risk factors, no cardiac history, no cardiac symptoms, a normal cardiovascular physical examination and a normal electrocardiogram scheduled for low risk knee surgery.  In this circumstance of a stable patient with no documented cardiac abnormalities, an echocardiogram is not medically necessary and not considered standard accepted practice in the medical community. Current guidelines endorsed by several national organizations do not consider echocardiography clinically appropriate in this setting. For these reasons, the echocardiography, procedure code 93306, performed was not medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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 cardiovascular 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cochlear implants for treatment of the enrollees left-sided hearing loss. Findings:  The physician reviewer found that the current medical literature reports some benefit to patients with SSD after cochlear implantation in the affected ear, but most of the reports refer to a small number of clinical cases. Colleagues reported that 45% of patients reported tinnitus suppression following cochlear implantation. Other articles report comparable results, but state that information regarding long term outcomes is lacking and that further studies are necessary to document the degree of improvement with cochlear implantation in SSD. Colleagues reported that Although some studies have shown encouraging results on cochlear implantation and SSD, all fail to provide a high level of evidence. Larger studies are necessary to define the tangible benefits of cochlear implantation in patients with SSD. Similarly, colleagues reviewed the evidence and stated that There are no high-level-of-evidence studies concerning cochlear implantation in patients with SSD. Based on the current level of medical literature, the request for cochlear implant has not been established as medically necessary for treatment of the patients medical condition. 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 otolaryngology 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.