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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gastric bypass surgery for treatment of her morbid obesity.  Findings: The physician reviewer found that based on the documentation submitted for review, the request for gastric bypass surgery is medically necessary for treatment of the patients morbid obesity. The patient meets standard nationally accepted criteria for bariatric surgery including the American Society for Metabolic and Bariatric Surgery guidelines. This patient is an adult with morbid obesity given the BMI of 48.9 kg/m2. In addition, the patient has failed dietary efforts and completed a multidisciplinary evaluation that did not reveal any obvious dietary, behavioral or medical barriers to surgery. As such, the medical necessity for the requested surgery is indicated in this clinical setting.Final Result: The reviewer determined that the requested surgery 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 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: An enrollee has requested authorization and coverage for use of Strattice during breast reconstruction revision, exchange bilateral breast implant surgery for treatment of the enrollees congenital marked asymmetry of the breastsFindings:  The three physician reviewers found that acellular dermal matrix may be used at the primary aesthetic implant surgery or during revision surgery. Acellular dermal matrices are generally reserved for treatment of capsular contracture once it has occurred and are incorporated during revision surgery. In most cases, a total capsulectomy with site change to the subpectoral plane will be chosen. Symmastia has traditionally been corrected by medial capsulorrhaphy with plication of the capsule to itself to bolster the implant laterally alone or site change with neopocket formation in addition to medial capsulorrhaphy. While these techniques have produced success in patients with tissue strong enough to support the correction with a new pocket and/or suturing alone, further revision surgery is common and many patients will have thin tissue leading to recurrence of the original problem. In these patients, use of an acellular dermal matrix to further buttress the implant into its new position can produce a long-lasting solution. This patient has mild capsular contractures, symmastia, and is undergoing revision surgery for correction of asymmetry. The use of Strattice in the revision surgery for capsular contracture and symmastia from breast reconstruction initially done for congenital asymmetry is likely to be more beneficial for treatment of the patients medical condition than revision surgery that does not use an acellular dermal matrix. Final Result: Three reviewers determined that the requested treatment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in plastic 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 25 hours per week of direct applied behavioral analysis (ABA) therapy and six hours per month of supervision and treatment training provided for treatment of the autism.  Findings:  The physician reviewer found that in this case, the patient demonstrates significant delays in social skills and adaptive skillsets as measured across multiple domains. The patient needs a high level of support to transition appropriately and interact with peers. The patient also requires ABA supports to address flight risk concerns. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. Given the medical necessity of ABA for children with autism, coupled with the clinical documentation submitted for review, the request for 25 hours per week of direct ABA therapy along with six hours per month of supervision and treatment training provided at a summer camp setting were and are medically necessary for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 whole exome sequencing (WES) for his treatment of cerebellar ataxia, spasticity, dystonia, and tremor of unknown cause.Findings: Three physician reviewers found that the medical studies do not support the requested services in this clinical setting. At this time, whole exome sequencing WES has been reported to be diagnostic in 26% of patients. This patient has already had testing of the genes most commonly associated with ataxia, with no genetic cause found. As such, in this patients case, whole exome sequencing (WES) is not likely to provide an additional benefit in finding a diagnosis, especially as his providers feel a structural etiology may be involved. Accordingly, the documentation provided does not indicate that whole exome sequencing (WES) would be beneficial for this patient as a clinical test. Therefore, WES is not likely to be more beneficial than other methods for the evaluation of this patients medical condition. Final Result: Three 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: All three reviewers are board certified in medical genetics and genomics 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided.  Findings: The physician reviewer found that the patient who presented to the emergency department with reports of dizziness and photophobia. The patient reported sensation of lightheadedness when she stands and walks that become bothersome at work that day. The patient denied spinning sensation and stated her symptoms were not consistent with vertigo which she had experienced before. She denied fever, vomiting, chest pain, tinnitus or vision changes. Her pupils were equal. Cranial nerves and speech were intact. No focal neurologic deficits were noted. An electrocardiogram (EKG) showed a sinus rhythm without acute changes. Laboratory data was unremarkable, including a normal troponin and creatine phosphokinase (CPK). A chest x-ray and computed tomography (CT) scan of her head were negative for acute abnormality. The patient was assessed with dizziness and discharged with advisement to follow up with her primary care physician as needed. The patient has requested reimbursement for emergency medical services provided.The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with a sensation of lightheadedness that had commenced abruptly while at work. The patients symptoms were unlike vertigo she had experienced previously. The patient had a past medical history significant for hypercholesterolemia a risk factor for coronary artery disease. Although the patient denied chest pain, women, in particular, may experience atypical symptoms with acute coronary syndrome (ACS), putting them at risk for delay in diagnosis. Therefore, an EKG and laboratory testing were obtained. Likewise, posterior cerebrovascular accidents may present with dizziness (Anderson, et al). A CT scan of the head was performed to rule out this entity. After these two conditions were ruled out the patient was safely discharged home. Based on the clinical documentation submitted for review, the patient received emergency medical services.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 emergency 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: An enrollee has requested reimbursement for FoundationOne gene test provided for evaluation of his esophageal adenocarcinoma. Findings:  Three physician reviewers found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers that can help guide therapy decision making. Per the National Comprehensive Cancer Network guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis for other than KRAS, NRAS, and BRAF mutations. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. As FoundationOne provides genetic testing to guide therapy and this is the subject of an ongoing phase II trial, it would be considered investigational/experimental for this patient. Many clinical trials would not require molecular profiling, especially many immunotherapy trials. As such, FoundationOne gene test provided was not likely to have been more beneficial than the standard of care for the evaluation of this patient. Final Result: Three reviewers determined that the services at issue were not likely to have been 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 medical oncology 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 continued custodial care for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the request for continued custodial care is not medically necessary for treatment of this patients medical condition. A providers note indicated that the patient did not require  restorative programs of ambulation, range of motion, eating/swallowing training, dressing/grooming, amputation/prosthetic care, bowel/bladder care, group/individual exercise, proper positioning, transfers, bed mobility, wheelchair mobility, splint. She did not require therapy or assistance. The documentation indicates that discharge planning has been in progress focusing on the patients discharge goals, involving an interdisciplinary team and the patient and addressing her preferences. The patient has been given information regarding returning to the community and contact has been made with local agencies regarding a community transition program. A written discharge summary was not noted yet in the documentation as the patient has not located a definitive discharge location at this time. Given these findings, continued custodial care is not medically necessary to prevent a deterioration in the patients 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested  authorization and coverage for a Group 4 motorized wheelchair for treatment of her rheumatoid arthritis.  Findings: The physician reviewer found that the requested Group 4 motorized wheelchair is medically necessary for treatment of the patients medical condition. Edwards and colleagues state that The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem. According to the Centers for Medicare and Medicaid Services (CMS), the criteria for a Group 3 PWC include a minimum top end speed of 4.5 miles per hour (mph), minimum range of 12 miles, a minimum obstacle climb of 60 mm and dynamic stability incline of 7.5 degrees. Per CMS, the criteria for a Group 4 PWC includes a minimum top end speed of 6 mph, minimum range of 16 miles, minimum obstacle climb of 75 mm and a dynamic stability incline of 9 degrees. These devices differ in that the Group 4 device has parameters more conducive to community use. In this case, the patient has a high level of independence and a Group 4 power wheelchair is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: An enrollee has requested authorization and coverage for high dose rate (HDR) brachytherapy with Leipzig applicator for treatment of the enrollees basal cell carcinoma. Findings:  The 3 physician reviewer found that Basal cell carcinoma is a non-melanoma skin cancer which develops in response to long-term sun exposure. The standard of care for basal cell carcinoma on the nasal tip is considered to be Mohs micrographic surgery for margin control. The use of brachytherapy is not considered to be standard of care for the treatment of basal cell carcinoma on the nasal tip. The National Comprehensive Cancer Network (NCCN) guidelines state that there is insufficient long-term efficacy and safety data to support the routine use of electronic surface brachytherapy. Given that the requested treatment is not considered to be standard of care and NCCN guidelines do not recommend its use, the requested HDR brachytherapy with Leipzig applicator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested services are not likely to be more beneficial for treatment of the enrollees 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 radiation 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ThyGenX services provided for evaluation of the enrollees thyroid nodules. Findings:  2/3 of the physician reviewers found that the report indicates that the cytopathology of the thyroid nodules was benign. The Bethesda System indicates that the risk of malignancy is 0 to 3% in benign nodules. The newest 2015 American Thyroid Associations guidelines state that nodules larger than 4 cm, like the dominant nodule in this case, might have larger risk for malignancy. The American Thyroid Association also recommends taking the patients history, ultrasound appearance and other clinical factors, including the institutions rate of malignancy, in consideration in order to make medical and surgical decisions. In this patients case, the provider recommended the ThyGenX test for the largest nodule. The result determined the management in this case, which was to perform radiofrequency ablation of the nodule to decrease its volume, rather than thyroidectomy. The study was indicated for the large thyroid nodule, in order to confirm benignity and determine management. Thus, ThyGenX services provided were likely to have been of greater benefit than other methods of evaluating this patient. Final Result: 2/3 of the reviewers determined that the services at issue were 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mechanochemical ablation procedures for treatment of the enrollees varicose veins. Findings:  2/3 physician reviewer found that the submitted records fail to demonstrate the superior efficacy of the services at issue. There is no documentation of symptoms or recent response to conservative treatments.  There is no recent pulse examination documented. Additionally, there is no formal duplex report demonstrating the reflux status of the truncal veins. It is not clear why a single vein was treated one day and a different single vein treated the following day. In sum, mechanochemical ablation procedures performed were not likely to have been of greater benefit than other treatment alternatives. Final Result: 2/3 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 reviewer number one is board certified in vascular 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.Physician reviewer number two is board certified in vascular 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.Physician reviewer number three is board certified in vascular 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.