Persius/hicric huggingface dataset:
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 that were received at a time when the enrollee was under 18 years of age.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for a child or adolescent needing mental health treatment. In this case, in terms of risk of harm, the records support a score of 4, which corresponds with a serious risk of harm. This is due to documented suicidal ideation. With regards to functional status, the records support a score of 3, which reflects moderate functional impairment, due to the patient having been unable to go to school in the period preceding her admission to the residential treatment center. In terms of comorbidity, the records support a score of 4, which corresponds with major comorbidity, due to the patients major depressive disorder and generalized anxiety disorder. With regards to level of stress of the recovery environment, the records support a score of 3. The patients recovery environment was moderately stressful. In terms of level of support of the recovery environment, the records support a score of 3, which reflects limited support in the environment, as the patients mother was supportive. With regards to resiliency and treatment history, the records support a score of 4. The patients score reflects that the patient was not able to maintain a stable mood despite therapy for some years. In terms of acceptance and engagement of the patient and her parents, the records support a score of 3. This score reflects that the patients parents were not both accepting of the patients mental health treatment. Thus, the patient had a composite score of 24. This score correlates with a treatment intensity level of care of Level Five, or Medically Monitored Residence Based Services.In this case, given the severity of the patients illness, which involved a risk of harm associated with the patients long history of intermittent suicidal ideation, a residential treatment center level of care was clinically appropriate for the patient. Accordingly, residential treatment center services were medically necessary to treat the patients medical condition.Final Result: 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for lab tests. The enrollee has glioblastoma multiforme, World Health Organization grade IV, estimated glomerular filtration rate gene amplifications positive, monosomy 10 q isocitrate dehydrogenase wild type, methyl guanine methyl transferase negative. The enrollee underwent gross total resection of the right temporal lobe lesion. He was treated with concurrent Temodar from and completed six cycles of high-dose adjuvant Temodar. Literature reports glioblastoma grows rapidly, is highly aggressive, and its clinical outcome is independent of its histological pattern. Professional society guidelines described molecular/genetic testing as additional diagnostic to aid in prognostic information, but cautioned it should not be used in place of standard histologic assessments. The guideline also noted there were no identified agents which demonstrated effectiveness for treating glioblastoma. Testing for glioblastoma has not shown to show improvement in treatment options, and does not change the prognosis of the disease. The results of the tests did not modify the treatment recommendation for this enrollee as the enrollee had no evidence for recurrence.Final Result: Two of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in radiation oncology and are 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

The patient has requested authorization and coverage for weekly or biweekly psychotherapy services and transcranial magnetic stimulation (TMS). Patients with treatment-resistant depression have failed to improve, despite multiple antidepressants and augmentation strategies. This patients records document the presence of treatment-resistant depression. She has failed adequate trials of standard medications used in the treatment of depression including Abilify, Seroquel, Zoloft, and Prozac, as well as others. The American Psychiatric Association (APA) guidelines for the treatment of depression support the use of TMS in the acute phase of treatment. Researchers provided data demonstrating that TMS was significantly more likely than sham treatment to produce remission in patients with treatment-resistant depression. Similarly, TMS has been shown to be safe and effective with minimal side effects. The available data support TMS as an effective treatment for use in treating this patients treatment-resistant major depressive disorder. Moreover, researchers noted that, psychotherapy is an integral part of patients treatment and should be considered for initial therapy for mild depression and as augmentation to an antidepressant for moderate or severe depression or for patients with adherence problems. Moreover, the authors noted that psychotherapy is effective for acute depression, particularly in combination with antidepressants, and can help in preventing depressive relapse and recurrence. Given the support in the medical literature and APA guidelines, the requested weekly psychotherapy services and TMS are medically necessary for treatment of this patient. 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 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

The enrollee is requesting authorization and coverage for laser hair removal. The enrollee has a recurrent pilonidal cyst. He underwent cyst excision. The enrollee reports the cyst did not cause problems for a year after laser hair removal, but then it recurred. The enrollee is status post pilonidal Gips procedure. He reports pain with sitting. The surgeons recommendation was for a new referral for repeat laser hair removal. Literature does not support the requested laser hair removal is medically necessary to treat the enrollees condition, as there are other depilatory methods to remove hair. The literature is not definitive in its recommendation regarding laser hair depilation for the treatment of pilonidal cyst disease. Further randomized trials are needed to clarify the role of newer techniques for treating pilonidal disease. A literature review showed a lower recurrence rate after laser hair removal, but the sample size was small and the studies were of limited methodological quality. A separate literature review on laser hair depilation in pilonidal disease and its effect on disease recurrence showed the literature published to date is of small sample size and has limited generalizability.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for the Decision DX-Melanoma assay. The enrollee has malignant, residual invasive melanoma on his left anterior thigh. The residual component showed a Breslows depth of 1.35 millimeters and is not associated with any of the abundant background biopsy site changes. A prior shave showed a Breslows depth of at least 3.5 millimeters. As the residual invasive component does not exceed that of the prior biopsy, the prior staging parameter remains unchanged. The Castle Biosciences report indicated the melanoma class was 2 and sub-class was 2B. A class 2B signature is associated with the highest risk of recurrence within five years. The Decision DX-Melanoma assay is not known to be effective based on a lack of scientific evidence showing that the results will accurately guide care and health outcomes. The use of this testing is not supported by scientifically based guidelines of national medical research or governmental agencies. Professional guidelines report routine genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Current evidence does not support increased surveillance imaging as a result of gene expression profiling (Decision DX Melanoma assay) tests. Similarly, treatment and follow-up recommendations are not likely to change as a result of gene expression profiling (Decision DX Melanoma assay) results until studies have confirmed a benefit and adjuvant therapy has demonstrated a meaningful impact in earlier-stage disease.Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in dermatology and are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 23-month-old female who has been diagnosed with a CDKL5 gene mutation with infantile spasms, medically refractory epilepsy and global developmental delay.  The patient was described as having developmentally delayed fine motor skills. She was noted to babble and smile. The patient was noted to sustain a hands and knees position with support. The patient was assisted with rolling to a sitting position. In a letter, the provider noted the patient had improved truncal tone and head control since beginning physical therapy with the Anat Baniel Method, and was now able to sit without support for two minutes. The patients parent has requested reimbursement and prospective authorization and coverage for neuromuscular reeducation physical therapy from May 2019 onward. The Health Plan denied the request and reported the services at issue were not and are not medically necessary for the treatment of this patient. At issue in this case is whether neuromuscular reeducation physical therapy from May 2019 onward was and/or is medically necessary for the treatment of the patients medical condition. Studies reported that Some interventions with a task-orientated framework can improve gross motor outcomes in children with developmental coordination disorder or cerebral palsy. These findings are limited by the very low quality of the available evidence. However, in each respect, only a single study has been judged as being of sufficient methodological quality to arrive at this conclusion and all reflect comparatively small sample sizes from single-center studies. The authors noted, To date, no large-scale multisite randomized control trial (with adequately blinded assessors) has been conducted in relation to any motor skills intervention intended to remediate the impact of developmental coordination disorder. There is a lack of evidence supporting the benefits of neuromuscular reeducation physical therapy or the Anat Baniel Method. The current medical evidence does not support the services at issue in this clinical setting. Therefore, neuromuscular reeducation physical therapy from May 2019 onward was not and is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 neurology with special qualification in child neurology 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 the medication HP Acthar Gel.Findings:  Three of three physician reviewers found that the current medical literature does not support the use of the medication HP Acthar Gel in this clinical setting. The requested medication, HP Acthar Gel, is an injection of corticotropin that provides anti-inflammatory effects. While researchers have reported the clinical course of three patients with uveitis who were treated with Acthar Gel, the efficacy of the medication in the setting of macular edema is less documented. In particular, the submitted medical records do not document that this patient has active inflammation (no cells in the anterior chamber, no vitreous haze or cells) and only reflect cystoid macular edema (CME). In this setting, there are more effective drugs than HP Acthar Gel that may be available through a uveitis specialist. Accordingly, the requested HP Acthar Gel is not likely to be more beneficial for treatment of the patients condition than any other available standard treatments.Final Result: Three of three reviewers determined that the requested medication is not likely to be more beneficial than any other available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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 BRCA genetic testing.Findings:  Three of three physician reviewers found that National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology support the use of BRCA 1 and BRCA 2 gene testing in this clinical setting. According to the National Comprehensive Cancer Network (NCCN) guidelines on BRCA screening for breast cancer, BRCA 1/2 screening is warranted in individuals with a personal history of breast cancer who have two or more close relatives who have also been diagnosed with breast cancer (at any age). After risk assessment and counseling has been performed, BRCA 1/2 testing is then recommended. The patient in this case has met this NCCN criteria. Up to 10% of breast cancers are due to specific mutations in single genes that are passed down in a family. Specific patterns of hereditary breast/ovarian cancers are linked to mutations in the BRCA 1/2 genes. Testing for BRCA 1/2 in this case is thus both evidence based and a best practice. Accordingly, BRCA genetic testing provided on 8/19/19 was likely to have been more beneficial than any other available standard testing for the patients medical condition.Final Result: Three of three reviewers determined that the services at issue were likely to be more beneficial than any other available standard testing for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in genetics 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 enrollee is requesting authorization and coverage for the medication Enbrel. The enrollee has a diagnosis of rheumatoid arthritis.  She has been off prednisone and does not use ibuprofen often.  The enrollee was provided with a one-month supply of Enbrel samples. After using the medication, she reported an improvement of about 40-50 percent.  She continues to have some mild shoulder pain, but she thinks this is due to her work. The enrollees physician reports the enrollee cannot use standard medications because she has liver problems. This reviewer found no study data that addresses the question of what the relative gastrointestinal risks, especially liver, and side-effects are among these four medications. All of them can affect the liver but the relative risks are different. Methotrexate is well-known to require liver function monitoring and can result in liver toxicity. Sulfasalazine requires regular monitoring. There is also a small risk of idiosyncratic severe hepatitis. Limiting the risk of that in a person with fatty liver is reasonable if there are other alternatives, which there are. Enbrel is Food and Drug Administration-approved as a monotherapy for rheumatoid arthritis. Plaquenil can cause liver problems but this is rare. However, Plaquenil usually takes months to work and this enrollees is steroid-dependent, so using a medication that is likely to work faster and better, once again, is a reasonable choice.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in rheumatology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services. Based on LOCUS criteria, this patient met the criteria for IOP services. The patient was at low risk of harm (score 2), as she had self-reported suicidal ideation during her days prior to discharge without an active plan. The patient demonstrated mild functional impairment (score 2). The records document that the patient has a strained relationship with her family and has plans to attend college. The patient has significant comorbidities (score 3), as she has a history of an eating disorder with food restrictions that have resulted in unstable vital signs. She had a low heart rate and orthostatic vital signs. Moreover, the patient has not started menses due to her anorexia. The patients recovery environment was mildly stressful (score 2) due to her strained relationship with her family. The patients recovery environment was supportive (score 2), with community resources in place with an outpatient therapist. The patient has shown moderate response to treatment (score 3) and was described as adherent with her program but struggled with her anorexia during outpatient treatment. This gives the patient a composite score of 14, which is consistent with low intensity community-based services, similar to the services provided to this patient at the IOP facility during the period under review. All told, the IOP services were medically necessary for treatment of this patient.Final Result: 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 with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.