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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for hyperbaric therapy services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees chronic non-healing radiation induced wound and osteomyelitis of scalp bone.Findings: There is sufficient support in the medical literature and in the submitted documentation for the requested services in this clinical setting. There is significant evidence to support the use of hyperbaric therapy for radiation induced osteonecrosis and chronic refractory osteomyelitis. In addition, the Centers for Medicare and Medicaid Services guidelines support its use in individuals who have been diagnosed with radiation induced skin injury. This patient was seen by various disciplines and had undergone graft treatments. The records indicate that this patient, who has been diagnosed with radiation induced skin injury with osteomyelitis, was unresponsive to multiple modalities. Therefore, in this patients case, where they have tried several standard wound treatments, hyperbaric services as an adjunctive therapy would be medically indicated. As such, hyperbaric therapy services have been demonstrated as medically necessary for treatment of this patients medical condition.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 internal medicine with expertise in wound care 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 parent of a 15-year-old male enrollee has requested authorization and coverage for weekly individual therapy sessions with a psychologist or therapist and benzodiazepine. In the current medical literature, there is a lack of defined frequency or duration for the amount of psychotherapy required for each patient. It is generally accepted that patients in crisis require more frequent sessions than those who are stable. Studies reported that the average rate of change during psychotherapy can be expected to diminish with each additional session irrespective of the length of treatment. Thus, the current literature supports an acute course of 12 sessions of weekly individual therapy sessions. However, benzodiazepines are not recommended for adolescents for the treatment of anxiety. Studies have not demonstrated that these medications are safe and effective for children and adolescents given the risks of possible addiction, developmental delay, and cognitive impairments. Given these findings, weekly psychotherapy for 12 sessions is medically necessary, while the requested benzodiazepine is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for omeprazole suspension. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of intractable seizures, cerebral palsy and global developmental delay.Findings: According to the American Academy of Child and Adolescent Psychiatrys (AACAP) most up to date practice parameter on obsessive compulsive disorder (OCD), cognitive behavioral therapy is the first line of treatment for mild to moderate cases of OCD and the combination of cognitive behavioral therapy and medication is indicated for moderate to severe cases of OCD. Treatment resistance is considered when a patient has persistent OCD symptoms despite engaging in adequate treatment that is known to be effective. The patient in this case has a history of multiple medication trials and failure of treatment at the outpatient level of care. A research study on residential treatment for adolescents with OCD noted, Patients with complex comorbidity or previous unsuccessful treatment attempts may require more intensive monitoring, multimodal interventions, and greater intensity of treatment delivery than even intensive outpatient CBT provides...residential treatment provides a greatly increased number of hours of CBT provided per week...constant placement in the treatment setting and removal from direct contact with family members accommodating their symptoms, and around-the-clock staff monitoring and support to assist with ritual prevention, homework compliance, and other treatment targets. The patients treating provider at the residential facility noted that the patient required intensive support throughout her time at the residential facility due to the patients escalating anxiety when participating in exposures and response prevention.  Based on the patients clinical history, including psychiatric comorbidities and treatment resistant status, and current medical literature, the residential level of care was medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that 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 sub-specialty 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the residential treatment center (RTC) services. Applying the child and adolescent level of care utilization system (CALOCUS), the RTC services provided to this patient were not medically necessary. The patient presented with some risk of harm (score 2) due to the patients history of impulsive actions and aggression. However, the medical records indicate that the patient was not actively suicidal. The patient demonstrated moderate functional impairment (score 3) with some school disruption due to substance use. The patient had mild co-morbidity (score 2) with a history of substance use. The patients recovery environment was mildly stressful (score 2) with a positive recovery environment and a stable housing situation. The patients recovery environment was supportive (score 2) as the patients parents are actively is involved in treatment and often took her on passes. The patient has demonstrated limited positive response to previous treatment (score 3). The patient was noted to be constructive in treatment (score 2) as she participated in therapy and used coping skills learned in therapy. The patients parents were constructive (score 2) as they worked actively and constructively with the patients providers. This gives the patients presentation a composite score of 18, which correlates with intensive outpatient services. This score is judged by the acuity of the patients symptoms and environment during the period under dispute at the RTC. According to the CALOCUS, the patient would need to have a score of 23-28 in order to require treatment in an RTC. In summary, the RTC services provided were not medically necessary. 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: There is lack of support in the medical literature for the medical necessity of the services at issue in this clinical setting. The American Society of Addiction Medicine (ASAM) criteria is an accepted, national standard for determining the appropriate level of care for adults with substance use problems. This criteria was used to assess the appropriate level of care in this patients case. On 9/21/16, the patient was having mild anxiety from withdrawal of alcohol. He was medically stable and was not undergoing severe withdrawal symptoms. The documentation did not report that the patient had homicidal or suicidal thoughts. Under Dimension 1, the patients score is a 1, which correlates to acute intoxication and/or withdrawal potential. Under Dimension 2, which correlates to biomedical conditions and complications, the patients score is a 1. The patient had elevated liver function enzymes, but it does not appear that the patient was symptomatic. Dimension 3 measures emotional, behavioral or cognitive conditions or complications medical/addictive/psychiatric co-morbidities. The patients score is a 2. The patient had defense mechanisms that distracted from recovery efforts, but there was not an immediate threat to safety, and this did not prevent independent functioning. Dimension 4, correlates with readiness to change. The patients score is a 2. The patient was reluctant to agree to treatment and was passively involved in treatment. Under Dimension 5, which correlates to relapse, continued use or continued problem potential, the patients score is a 2. The patient had impaired recognition and understanding of potential substance use relapse issues, but was able to self manage with prompting. Dimension 6, recovery/living environment is scored a 1. The patient was struggling in his marriage. However, the patient did have family support who put together the intervention. On 9/21/16, based on the ASAM criteria, the patient could have been treated in an intensive outpatient program (IOP). The patient did require treatment for his alcohol use disorder, but this could have been performed in a less restrictive environment. Therefore, the residential treatment center services from 9/21/16 through 10/14/16 were not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the Medtronic 670G insulin pump. Findings:  Three physician reviewers found there is sufficient support for the requested device in this patients case. Per the medical evidence, the requested Medtronic 670G insulin pump is likely to reduce fluctuations in glycemia. This patient has difficulty communicating episodes of hypoglycemia given his age. This device has been used successfully in children. In this clinical setting, the Medtronic 670G insulin pump will allow the patient to experience less glycemic variability and reduced hemoglobin A1c levels. In sum, the requested Medtronic 670G insulin pump is likely to be of greater benefit than other available treatment options. Final Result: The reviewers determined that the requested device 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: Physician reviewers 1 and 3 are board certified in pediatrics and are actively practicing. Physician reviewers 2 is board certified in pediatrics and pediatric endocrinology and is 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

An enrollee has requested authorization and coverage for Mavyret 100-40 mg tablets eight week treatment. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kwo, et al; Zeuzem, et al).  The ENDURANCE-1 trial showed that only eight weeks of treatment is needed (Zeuzem, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Mavyret 100-40 mg tablets for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified internal medicine with sub-specialty certification in gastroenterology 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: A patient has requested authorization and coverage for Orthovisc injections for treatment of the enrollees osteoarthritis of the left knee.  Findings:  The physician reviewer found that submitted documentation supports the medical necessity of the requested medication. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of hyaluronan therapy were safe and effective in the treatment of pain associated with osteoarthritis of the knee. There is no maximum amount of injections established by high quality scientific evidence. This patient presents with a history of increasing left medial knee pain that is limiting the patients activities of daily living. The clinical examination findings are consistent with x-ray evidence of tricompartmental osteoarthritis, most severe in the medial compartment. The record indicates that reasonable conservative treatment, including pain medications, activity modification, weight loss, and corticosteroid injections, has failed to provide adequate symptom relief. The patient is unable to take nonsteroidal anti-inflammatory drugs due to prior gastric bypass surgery. The patient reported that prior viscosupplementation injections in 2015 and 2016 had been more effective than corticosteroid injections and had provided pain relief allowing the patient to exercise for weight loss. The medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the requested Orthovisc injections are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Norco. The submitted documentation does not support the medical necessity of the requested medication. Opioids are not first-line medications for osteoarthritis of the hip or for chronic low back pain. The American College of Rheumatology recommends trials of acetaminophen, oral and topical nonsteroidal anti-inflammatory drugs, tramadol and intra-articular injections of corticosteroids. The records did not indicate that these modalities have been used exhausted. Long-term use of opiates is not recommended outside of a defined pain management plan, including a formal risk assessment and urine toxicology screening. Therefore, Norco is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for removal of left saline breast implant for treatment of the enrollees deflated left saline breast implant.   Findings:  The physician reviewer found that the patient is noted to have a breast saline implant rupture on the left side and a capsular contracture on the right side. Based on the entirety of the documentation, the patient is planning to undergo treatment of a standard complication following cosmetic surgery. Augmentation mammaplasty is a common cosmetic procedure. As noted in the peer-reviewed medical literature, complications that arise from this surgery are documented to include implant rupture and capsular contracture.  In this patients records, there is no evidence of specific functional impairment related to the deflated side. In addition, the treatment plan is to replace both implants with silicone implants and perform a mastopexy. This treatment plan is consistent with cosmetic surgery. There are no extenuating circumstances sufficiently documented to justify this as a reconstructive procedure. Therefore, removal of left saline breast implant is not supported as 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 plastic 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for general anesthesia services. The Health Plan has denied this request indicating that the requested services are not medically necessary for management of the enrollees dental condition.  Findings: There is sufficient support in the documentation provided for the requested anesthesia services in this clinical setting. Local anesthetics are the pharmacologic mainstay for pain control during oral surgery procedures. General anesthesia would need to be employed in order for the patient to tolerate the procedure.  Performance of the procedure under general anesthesia will result in improved safety for the patient and allow for a blunted autonomic response to stress and anxiety. For these reasons, general anesthesia services is medically necessary for the management of this patients medical condition.Final Result: The reviewer determined that 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 oral and maxillofacial 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.