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

Nature of Statutory Criteria/Case Summary: The patient has a diagnosis of herpes simplex virus. There is no history documented to indicate whether this was an acute or chronic problem. The duration and severity of the symptoms are not described. There is no documentation of a physical examination of the oral mucosa and no documentation to indicate whether prior treatments have been used for a cold sore. At issue in this case is whether the requested acyclovir is medically necessary for treatment of the patients medical condition.There is insufficient support for acyclovir in this clinical setting. The medical records indicate that topical acyclovir has been requested. Studies compared the treatment of herpes simplex virus infections of the oral mucosa in immunocompetent patients. Regarding the use of topical antiviral therapy, randomized trials of topical antiviral agents have inconsistent findings and show no clear evidence of efficacy. Studies found that when indicated, oral agents are the preferred treatment for this condition.  Other studies concluded that topical antiviral treatments are no more effective than placebo. Therefore, acyclovir is not medically necessary for treatment of the 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 physician reviewer is board certified in family practice 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 a partial hysterectomy. Hysterectomy may be indicated for abnormal uterine bleeding and pelvic pain when symptoms do not respond to hormonal treatments in patients for whom the benefits of surgery will outweigh the risks of surgical complications. In this patients case, the records do not document a clear indication for partial hysterectomy. The patient has pelvic pain and abnormal uterine bleeding that cannot entirely be attributed to her fibroid uterus. Her symptoms also include upper abdominal pain, pain in the ribcage area, irritable bowel syndrome, and examination findings of abdominal wall and pelvic floor myofascial pain. A hysterectomy will not alleviate these symptoms. Based on her clinical history and physical examination findings, her symptoms are multifactorial in origin. Although she has undergone a trial of Mirena intrauterine device, there is a lack of documentation demonstrating that she has tried other conservative options.  At this time, it is not medically necessary for the patient to undergo a hysterectomy, especially when individualizing the risk given her comorbid conditions. The risks associated with surgical intervention for this patient are significant. Alternative treatment options include medications such as progesterone medications, pelvic floor physical therapy, a trial of Lupron to decrease the uterine size and temporarily shut down the hormonal stimulation to see if the pain improves, and uterine fibroid embolization. Therefore, the requested partial hysterectomy is not medically necessary for the treatment of this patient. 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 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 and prospective authorization and coverage for psychiatric intensive outpatient program services. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association guidelines indicate that admission to an intensive day program, 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. In this patients case, the records document posttraumatic stress disorder and generalized anxiety disorder complicating her condition. She has not responded adequately to lower levels of care. Given the severity of the patients illness, including prior suicide attempt and resistance to multiple prior treatments, the services at issue were and are medically necessary. Therefore, psychiatric intensive outpatient program services were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are 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: Overturned Decision of Health Plan

The patients parent has requested authorization and coverage for a pediatric amplified pain rehabilitation (PAPR) program for treatment of the patients complex regional pain syndrome (CRPS). The American Pain Society (APS) recommendations for children with chronic pain state that intensive pain rehabilitation programs (several hours per day of treatment) using interdisciplinary treatment approaches are an option for children who are unable to receive or benefit from outpatient management. One study of a day hospital pediatric pain rehabilitation program, performed by colleagues, included pediatric CRPS patients who failed to improve with outpatient treatment. Treatment included daily physical, occupational and psychological therapy, for a median duration of three weeks. The authors found that statistically significant improvements from admission to discharge in pain intensity, functional disability, subjective reports of limb function and occupational performance, these functional gains were maintained or further improved at follow-up. Similarly, colleagues observed complete resolution of pain in children with CRPS after intensive inpatient rehabilitation, which consisted of physical, occupational, and psychological therapy, with no other medical intervention, followed by a home program. In this case, the patient was diagnosed with CRPS following a left ankle fracture sustained when a hockey puck struck her ankle. She has failed to improve with an intense multidisciplinary outpatient approach including physical therapy, aquatherapy and psychotherapy since. The provider noted that the patient has been compliant with her treatment plan and adherent to her home exercise program. She has also been treated with gabapentin 200 mg three times a day with no improvement in her symptoms. The notes from the provider express concern that if her CRPS continues to remain active and recalcitrant to intensive outpatient therapy it may progress to chronic CRPS. Based on the position statement from the APS, the requested intensive inpatient PAPR program is the next logical treatment step. Based on these findings, the requested PAPR program services are medically necessary for treatment of this patients CRPS.Final Result: The reviewer determined that the requested services are 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 anesthesiology with subspecialty certification in pain management 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:The patient has requested authorization and coverage for magnetic resonance imaging (MRI). Findings:  The physician reviewer found that The use of a repeat MRI after a patients confirmed biopsy without concomitant plans for rebiopsy, such as with MRI guided or ultrasound fused biopsy, is not supported per the American Urological Association (AUA) or National Comprehensive Cancer Network (NCCN) guidelines. Review of the records indicates that this patient is at moderately low risk category for advancing prostate cancer. In this patients case, the Health Plan has denied an MRI since it was requested without an associated biopsy, which would be appropriate. A multiparametric MRI will have the highest sensitivity in evaluating the prostate capsule and extraglandular disease. Coupling the multiparametric MRI study with the ability to perform a biopsy during the examination would be reasonable given this patients clinical history. Thus, the requested MRI is not supported as medically necessary for evaluation and treatment of this patients prostate cancer. Final Result: The reviewer determined that the requested services are 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee underwent a total knee arthroplasty. She is requesting reimbursement for OxyContin 20 mg tablets that she received. The Health Plan has denied the request and reported that the medication at issue was not medically necessary. Per the Health Plan, OxyContin is a non-formulary medication. The Health Plan noted that there are other long-acting opioids, including fentanyl transdermal patch, methadone, tramadol extended-release, and morphine extended-release, with similar efficacy compared to OxyContin which were available. This denial is the subject of this appeal and determination. At issue in this case is whether the OxyContin 20 mg tablets that the patient received were medically necessary for her medical condition.In this case, the provider prescribed a non-formulary drug, a long-acting opioid, OxyContin. Long-acting opioids diminish the perception of pain and are used for chronic pain. Chronic pain is defined as pain that typically lasts over three months or past the time of normal tissue healing. Postoperative pain is acute and not chronic pain. In this case, the opioid medication was prescribed for postoperative pain control. As such, prescription of a non-formulary opioid such as OxyContin was not medically necessary. Therefore, OxyContin 20 mg tablets received were not medically appropriate and therefore not medically necessary for the treatment of this patient.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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  A female patient has requested reimbursement for the porcine xenograft wound treatment that was utilized during surgery. The Health Plan has denied this request and reported that the services at issue were investigational for the treatment of the enrollee, who was status post excision of malignant melanoma. A review of the record indicates that the enrollee was diagnosed with malignant melanoma of the right foot. Per the records, excision was performed. The provider noted that the graft was required due to the size of the surgical defect and tightness of the closure on this anatomical location. Per the provider, the surgical defect was partially closed, with the remainder of the defect filled with a porcine xenograft to facilitate secondary healing. The Health Plan indicates that the services at issue were investigational for the treatment of the enrollees medical condition. Therefore, the Health Plan has denied reimbursement for the services at issue. At issue is whether porcine xenograft wound treatment utilized during surgery was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy.Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. This patient had a malignant melanoma on the dorum of the foot, Breslow level 0.3, which required wide excision with a 1 cm margin. The skin over the dorsum of the foot is thin and subject to radial stresses with motion.  There is not a lot of redundancy that would allow a flap to be rotated in.  The defect was closed in layers, leaving an open area that would need to granulate in and would cause contraction.  Porcine xenograft was used to cover the defect, allow healing without tension, and provide a suitable lattice for epidermal ingrowth. The other alternative would have been a skin graft, which involves a higher morbidity. Therefore, porcine xenograft wound treatment that was utilized during surgery was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested treatment 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: Physician reviewers 1, 2 and 3 are board certified in general 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: Upheld Decision of Health Plan

A patient has requested authorization and coverage for transoral incisionless fundoplication. The Health Plan has denied this request, indicating that the requested services are investigational for the treatment of the patients gastroesophageal reflux disease. A review of the record indicates that the patient has been diagnosed with irritable bowel syndrome, gastroesophageal reflux disease with esophagitis, diaphragmatic hernia without obstruction or gangrene, alcohol abuse, and other lactose intolerance.  Abdominal ultrasound revealed no acute process. A distal esophageal biopsy was performed. The pathology report noted mild chronic esophagitis with features suggesting reflux. The results were negative for intestinal metaplasia, dysplasia or malignancy. The records noted that the patients gastroesophageal reflux has been under control, but he experiences relapsing symptoms if he misses a dose of proton pump inhibitor. The Health Plan indicates that the requested services are investigational for the treatment of the patients medical condition. Therefore, the Health Plan has denied coverage for the requested services. At issue in this case is whether the requested transoral incisionless fundoplication is likely to be more beneficial than any other available standard treatments for the patients medical condition.Analysis and Findings:  Three physician reviewers found that there is a lack of support for the requested services in this patients case. The transoral incisionless fundoplication procedure has shown durable response in selected patients with gastroesophageal reflux disease.  In this patients case, he is neither medically refractory, nor is his preoperative assessment complete. Of note, the records do not document pH testing or manometry. Per the records, the patients gastroesophageal reflux disease is not refractory to medical management. He currently benefits significantly. The standard of care in this clinical setting is daily therapy, which the records document as effective for him. In addition to improved medical compliance, the patients gastroesophageal reflux disease may further benefit from lifestyle modification, including curtailment of alcohol intake. Therefore, transoral incisionless fundoplication is not likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested transoral incisionless fundoplication is not  likely  to  be  more  beneficial  than  any other available  standard  treatment.  Therefore, the Health Plans denial should be upheld.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients diagnosis is type 1 diabetes. The patient is currently being managed with a Medtronic 670 G insulin pump. The patients hemoglobin A1c was 7.5 % and her body mass index (BMI) was 22. She was started on Victoza therapy and was on liraglutide (Victoza) for six weeks, with noted improvement in postprandial blood sugars, decreased glycemic variability, and no episodes of hypoglycemia.The primary effects of glucagon-like peptide-1 (GLP-1) agents in type 1 diabetic patients are improved glycemic control, decreasing episodes of hypoglycemia and glucagon secretion, lowering glycemic excursions, and weight loss. Researchers concluded that treatment with Victoza in type 1 diabetes reduces insulin dose with improved or unaltered glycemic control. However, there is lack of large scale randomized controlled studies that have evaluated GLP-1 agents in type 1 diabetic patients. Further, GLP-1 agonist Victoza has been approved by the U.S. Food and Drug Administration (FDA) for patients with type 2 diabetes. As this patient has type 1 diabetes, Victoza therapy is not medically necessary for treatment of 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 endocrinology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

At issue is whether the prosthetic implant that the patient received was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy. The patient complained of ongoing increasing low back pain associated with numbness, weakness, and left foot drop. Previous treatments included physical therapy, epidural steroid injections, and left lower extremity strength exercises. The patients diagnosis included lumbar degenerative disc disease with herniated nucleus pulposus at L4-5. The concern was for a neurological deficit due to an acute disc herniation.Findings:  Two out of three physician reviewers found that there is adequate data in the peer-reviewed medical literature demonstrating the benefits of an artificial disc replacement in this clinical setting. Reviewed studies comparing total disc replacement with a lumbar fusion. The authors conclude that total disc replacement is significantly better in terms of reduced clinical symptoms, improved physical function, and preserved range of motion for the treatment of lumbar degenerative disc disease compared to anterior lumbar interbody fusion. The operative report documented insertion of the ProDisc-L artificial disc to the L4-5 disc space. The ProDisc-L total disc replacement is approved by the U.S. Food and Drug Administration (FDA). The FDA states that this device is indicated for patients who are skeletally mature, have degenerative disc disease at one level in the lumbar spine, have no more than grade 1 spondylolisthesis at the involved level, and have had no pain relief after at least six months of non-surgical treatment. Colleagues concluded that patients undergoing ProDisc-L total disc replacement maintained significant improvement during the five-year follow-up.Final Result: The reviewers determined that the requested prosthetic implant was 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 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: An enrollee has requested reimbursement for neuropsychological testing. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records document borderline personality disorder, major depressive disorder and generalized anxiety disorder. The medical evidence does not support the need for neuropsychological testing for these diagnoses. There is some support for neuropsychological testing in the setting of brain injury. In this case, the records do not document brain injury. The patients reported symptoms included difficulty keeping a job and sleep issues. Per the standard of care, these symptoms may be appropriately treated with medication and psychotherapy. Therefore, neuropsychological testing was not medically necessary for the evaluation of this patient.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 psychologist 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.