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 and prospective authorization and coverage for inpatient psychiatric hospitalization. The patients characterological organization, affective illness and anxiety burden is complicated by a poorly defined self-concept, the confluence of which contributes to a recurrent and refractory symptom complex.  Currently, the patient is symptomatic and in need of specialty care. Based on her longitudinal history and psychosocial stressors, coupled with the symptom complex that includes need for assistance with activities of daily living, outpatient-based services would be inadequate at this time. However, the patient is not suffering from an acute psychiatric syndrome.  She is not suicidal, and she is not psychotic. She is neither disorganized in thought nor agitated in behavior. She is sleeping well and has good impulse control. Per the medical records, treatment at the residential level of care was and is medically appropriate. Therefore, inpatient psychiatric hospitalization was not and is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for the gene panel testing. Findings:  Two of the three physician reviewers found the submitted documentation supports a portion of the services at issue. The noninvasive prenatal testing was performed because the patient will be greater than 35 years of age at the time of delivery. The American College of Obstetricians and Gynecologists endorses the use of noninvasive prenatal testing in this high-risk patient population. Advanced maternal age is a risk factor for aneuploidy. Per the medical evidence, aneuploidy screening was likely to have been more efficacious than other available modalities for evaluating this patient. However, given that the records do not document sex-linked specific risk factors, fetal sex determination was not indicated. All told, a portion of the services at issue was likely to have been more beneficial than other modalities for evaluating this patient. Specifically, all tests of the performed gene panel testing, except fetal sex determination, were likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that a portion of 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 partially overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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 the residential treatment center (RTC) services provided. The records indicate that the patient experienced behavioral health conditions. The patient was not a danger to himself or others, nor did he engage in self-harm. There were no emotional, behavioral, or cognitive issues to warrant RTC level, nor was he manic or psychotic. He was psychiatrically stable, and his other medications did not require RTC level of care for management. His vital signs were stable and he was noted to be cooperative and an engaged participant in the recovery process. Although remaining a risk for relapse due to impaired insight and judgment, the issues he was working on in therapy could have been addressed in an ambulatory setting. The records indicate that the patient could have continued his recovery treatment on an ambulatory level of care, with community support in a 12 step programs and working with a sponsor and counselor. All told, the RTC services provided were not medically necessary for treatment of this 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 with sub-specialty certification in addiction 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 the Zoll LifeVest. Guidelines of the American College of Cardiology (ACC) recommend use of the LifeVest for patients with left ventricular dysfunction and ventricular arrhythmias at risk for sudden death when an internal cardioverter defibrillator has already been placed and must be removed due to infection. Medical literature shows that overall, studies do not support use of the LifeVest even in patients with left ventricular dysfunction. The researchers reported that the wearable cardioverter defibrillator has not been proven to improve outcomes and more study is needed. Given these findings, the Zoll LifeVest provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the current data from multiple trials and registries have advocated the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction with an ejection fraction of 35% or less.Final Result: Two of the three reviewers determined that the device 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:  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial laser hair removal. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria and are not reconstructive in nature. Findings: Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. The record notes that hormone therapy has not been effective in treating this patients excessive facial hair. She has reported anxiety over being misgendered despite hormone therapy. Therefore, facial laser hair removal is medically necessary for treatment of this patients gender dysphoria.With regards to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is considered an abnormal body structure. It would be abnormal for a female to have terminal hair on the face. The patients abnormal appearance is the result of gender dysphoria, a disease classified in the Diagnostic and Statistical Manual of Mental Disorders. Facial laser hair removal can provide substantial improvement in the appearance of terminal hair and create a normal appearance to the best extent possible. Additionally, facial laser hair removal would also provide more than a minimal improvement in the appearance of this patient as well as improve the patients emotional function. For these reasons, facial laser hair removal is reconstructive in nature. 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anesthesia services. The records document that this patient has an ASA preoperative physical status classification score of 2. According to the current medical literature, intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported, given the patients low preoperative physical status classification score. For these reasons, the anesthesia services were not medically necessary for evaluation of the 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 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: An enrollee has requested reimbursement for Guardant360. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees adenocarcinoma of the lung.Findings:  Two of the three physician reviewers determined the National Comprehensive Cancer Network guidelines note that broad molecular profiling is advised to identify rare driver mutations for which effective drugs may be available or to counsel patients regarding clinical trials. In this patients case, the initial therapy was based on the presence of the EGFR mutation.  Second-line treatment in that setting, would have been based on whether there was a T790M mutation.  The medical evidence supports T790M and BRAF components of the test, and the records indicate that these particular components were covered by the Health Plan. However, the superior effectiveness of the remaining testing has not been demonstrated. Thus, Guardant360 was not likely to have been more effective than other methods of evaluating 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: Physician reviewers 1, 2 and 3 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene tests. Findings:  Two of the three physician reviewers found the submitted documentation supports a portion of the services at issue. The current medical evidence supports routine screening and screening specific to this patients history. Screening for fragile X is not routine, and the family history she provided does not indicate a history of fragile X. However, the American College of Obstetricians (ACOG) and Gynecologists supports spinal muscular atrophy screening for all women who are considering pregnancy or who are pregnant. Additionally, ACOG supports offering cystic fibrosis screening to all women who are pregnant. Thus, spinal muscular atrophy screening and cystic fibrosis screening were likely to have been more effective than other methods of evaluating this patient. However, the medical evidence fails to demonstrate the superior efficacy of the remainder of the services at issue.Final Result: The reviewers determined that a portion of 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 partially overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacroiliac (SI) joint radiofrequency ablation (RFA). In the documentation available for review, the provider states the patient had two weeks of pain relief after an injection. However, the medical literature suggests that radiofrequency ablation should be performed after a diagnostic block with local anesthetic alone and a pain diary with notations of medication usage. This patients records do not include documentation that this procedure was followed. In addition, the most recent physical examination by the provider is not specific to SI joint dysfunction. Therefore, SI joint RFA is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found SI joint RFA is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the SI joint RFA is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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 referrals to an endocrinologist two times per year. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Hypothyroidism is a common condition of thyroid hormone deficiency. While the presentation may vary greatly, common symptoms include fatigue, lethargy, cold intolerance, weight gain, constipation, change in voice, and dry skin. Levothyroxine is the treatment of choice for people with hypothyroidism. The diagnosis and treatment of hypothyroidism is generally carried out in a primary care setting. In this case, the patients hypothyroidism is straightforward, and she does not appear to have comorbid conditions, aside from her anxiety. The records indicate that it is reasonable for her to continue under the care of her primary care provider at this time. Therefore, the requested referrals to an endocrinologist two times per year are not medically necessary for 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 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 laboratory testing (genetic or chemical) Findings:  Three physician reviewers found the current literature fails to demonstrate the superior effectiveness of the services at issue. Mild cognitive impairment is a diagnosis made on clinical findings. Patients with mild cognitive impairment have a significantly increased likelihood of conversion to dementia at the rate of 10 to 15% per year. Per the medical evidence, no reliable clinical markers or diagnostic tests can predict the likelihood that an individual patient with mild cognitive impairment will develop dementia. Thus, laboratory testing (genetic or chemical) was not likely to have been superior over other methods of evaluating 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine 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 surgical removal of an Interstim device. Findings:  The physician reviewer found that removal of the patients Interstim device did not constitute an emergency medical service. Although removal of the stimulator was necessary in order to allow the patient to undergo further workup of her neurological symptoms, it did not rise to the level of an emergency procedure. While the signs and symptoms the patient experienced leading up to the removal of the Interstim device were concerning and required further evaluation, they were not consistent with the presence of an emergency medical condition. The medical records provided do not document that the patients pain level was severe. The medical notes indicated physical examination of the cervical, thoracic and lumbar/sacral spine demonstrated no spine tenderness on palpation, no masses, full range of motion and no pain with motion in any direction. Additionally, it noted right-sided paresthesias/discomfort with neck pain. A pain assessment score was not included and no further details regarding the patients pain level were documented. The provider recommended further work-up with MRI imaging but did not indicate it was required on an emergent basis. All told, the submitted clinical documentation does not demonstrate that the patient received emergency medical services. Final Result: The reviewer determined that the patient did not receive emergency medical services. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurological 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 enrollee has requested reimbursement for the blood test (Guardant360 biopsy-free tumor sequencing test). Molecular diagnostic studies in non-small cell lung cancer are considered within the standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) guidelines strongly recommend broad molecular profiling with the goal of identifying rare driver mutations for which effective medications may be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with lung cancer. Testing of lung cancer specimens for alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Given this support, the blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that when repeat biopsy is not feasible, plasma biopsy should be considered. The submitted information does not indicate that repeat biopsy would be contraindicated or not possible. Thus, the blood test (Guardant360 biopsy-free tumor sequencing test) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.