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 shoe inserts for her diagnosed plantar fasciitis. Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity for the requested equipment in this clinical setting.  In this particular case, it is well documented that this patient has a diagnosis of painful heels with plantar fasciitis. The patient is noted to complain of painful heels with a past medical history of left heel fracture. It is standard of care to treat plantar fasciitis with conservative treatment options including stretching, icing, anti-inflammatory medicine, and custom functional orthotics. Custom functional orthotics have been standard of care treatment for plantar fasciitis for several years. The medical studies have shown that orthotics improve abnormal biomechanics of the foot which tend to cause plantar fasciitis. For the reasons mentioned above, the requested shoe inserts are medically reasonable and necessary to treat this 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 podiatry 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 the enrollee has requested reimbursement and prospective authorization and coverage for 81.7 hour per month of direct one-on-one applied behavioral analysis (ABA) services, 10.75 hours per month of supervision by a Board Certified Behavior Analyst, and 32.25 hours per month of social skills group for treatment of his son's autism.  Findings: The physician reviewer found that the services at issue were not and are not medically necessary for treatment of the patients medical condition. According to the records submitted for review, the patient has had documented improvement in skill acquisition in all areas, and most goals have been met. The anti-learning behaviors displayed by the patient do not pose a danger to himself or others. The Behavior Analyst Certification Board recommends fading out, not escalation of services when goals are met. Based on the clinical documentation submitted for review, the request for 81.7 hour per month of direct one-on-one ABA services, 10.75 hours per month of supervision by BCBA, and 32.25 hours per month of social skills group provided were not and are not medically necessary in this clinical setting. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam therapy. Findings:  Three physician reviewers found that there is a lack of published data to support proton beam therapy for treatment of this rare tumor. Proton beam therapy is being evaluated in National Cancer Institute sponsored trials for head and neck cancers. However, there is no published research or articles for proton desmoid fibromatosis. The references pertaining to proton beam therapy are limited to treatment for sarcoma.  Moreover, the attending provider did not provide dose volume histogram comparison of photon based intensity modulated radiation versus proton beam therapy. While the consultation services with a radiation oncologist are not considered investigational, treatment with proton beam therapy was not supported by available data and the submitted documentation. Therefore, the consultation and related services were likely to have been more effective over standard options available for evaluating this patient.  On the other hand, proton beam therapy performed was not likely to have been more efficacious in treating this patients medical condition than other treatment options. Final Result: The reviewers determined that a portion of the services 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 partially overturned. Credentials/Qualifications: All three physician reviewers are board certified in radiation 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continuous positive airway pressure (CPAP) machine and supplies for treatment of his obstructive sleep apnea (OSA). Findings: The physician reviewer found that the records provided for review document the patient was noted to have an AHI of 7.8. Per the American Academy of Sleep Medicine (AASM) for OSA, this patient meets the criteria for a diagnosis of OSA. The patient has witnessed apneas and the results of the diagnostic home sleep test provided objective measurements of snoring and apneas. The patient is also noted to have had an AHI greater than five, which further supports a diagnosis of OSA. In reviewing current practice guidelines on the treatment of OSA, there is a recommendation that patients with OSA be treated with CPAP as a first-line of therapy. While the records do not indicate that the patient had a co-morbid condition as required by the Health Plan, the current literature and practice guidelines do not require the presence of such co-morbid conditions for treatment with CPAP. Therefore based on current literature the requested CPAP machine and supplies are supported as medically necessary for treatment of this 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 neurology with sub-specialty certification in sleep 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: The parent of the enrollee has requested reimbursement for the residential treatment services provided for treatment of the enrollees behavioral health issues.Findings: The physician reviewer found that at the time of her admission the patient did not meet medical necessity criteria for residential treatment. She was not at imminent risk of decompensation and her conditions could have been managed in a less restrictive environment. As noted by the American Academy of Child and Adolescent Psychiatry (AACAP), many programs are available to enhance social interaction and improve pragmatic speech. In addition, the patients depression and anxiety could have been managed in a less restrictive environment and the changes made to her psychotropic medications could have been made without 24-hour per day supervision.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: An enrollee has requested reimbursement and prospective authorization and coverage for continuation of treatment at a skilled nursing facility (SNF), including physical therapy for her acute promyelocytic leukemia and muscle weakness.  Findings: The physician reviewer found that the documentation does not reveal that the patient has needs for SNF services. The patient does not require SNF services to prevent a deterioration in her condition or to establish a safe and effective maintenance program. The documentation does not demonstrate that the patient requires skilled therapy services on a daily basis or SNF services on a daily basis. The records indicate that the patient has made minimal gains in physical therapy and is limited by fatigue. She also is noted to have severe peripheral neuropathy limiting her coordination therefore she would not be expected to make measurable gains within a reasonable and predictable period of time. The patients therapy needs can be met at a lower level of care such as custodial care or home health services with caregiver support. The patient does not require therapy services on an inpatient daily basis, at a SNF level of care. Thus, the continuation of treatment at a SNF, including physical therapy, was not and is not medically necessary for treatment of this patients medical condition.  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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an insulin pump for treatment of the enrollee's diabetes with servere hypoglycemia. Findings:  Three physician reviewers found that studies have shown that insulin pump therapy promotes tighter control of blood glucose levels and greater reduction of hemoglobin A1C, thereby reducing the chance of long-term complications associated with diabetes (Millstein, et al). Although this patients hemoglobin A1C is at or near goal, he continues to experience a high degree of glycemic variability, with frequent episodes of both hyperglycemia and hypoglycemia. Glycemic variability has been demonstrated to be associated with micro- and macrovascular complications and mortality independently of the hemoglobin A1C level (Gorst, et al). By using an insulin pump, this patient will likely be able to maintain an excellent hemoglobin A1C level while minimizing his variability, thereby lowering his risk of complications. Accordingly, the requested insulin pump is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. Findings: The physician reviewer found that according to the most 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 1 patients should be treated with Epclusa for 12 weeks, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Feld, et al).  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is needed, and the requested treatment with Epclusa 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 in 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: An enrollee has requested authorization and coverage for Victoza subcutaneously daily for treatment of the enrollees diabetes. Findings: The physician reviewer has found that adding Victoza to multiple daily insulin injections in people with type 2 diabetes has been shown to improve glycemic control without an increased risk of hypoglycemia, reduces body weight, and enables patients to lower their insulin doses. Studies related to use of liraglutide and type 1 diabetes have shown benefits. Victoza was associated with reductions in hypoglycemic events, bolus and total insulin dose, and bodyweight, and increased heart rate. Victoza is also safe for patients following bariatric surgery.  Victoza is an U.S. Food and Drug Administration (FDA) approved therapy for obesity at doses 1.2-3 mg per day. The records document that this patient is benefitting from Victoza given her food intake, weight and insulin requirements. Studies indicate that Victoza is safe for type 1 diabetes patients and it is approved for treatment of diabetes type 2 and for the treatment of obesity. Thus, the requested Victoza 1.8 mg subcutaneously daily is medically necessary for this patients medical condition. 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan with computed tomography (CT) attenuation for evaluation of her anal carcinoma. Findings: The physician reviewer found that this patient does not have evidence of recurrent cancer based upon serology, clinical examination including anoscopy and physical findings. Most recent PET showed no evidence of residual tumor. The National Comprehensive Cancer Network (NCCN) guidelines specify CT of the chest abdomen and pelvis as the preferred method of surveillance after PET/CT has been performed for initial staging. In this particular patient, the most recent PET/CT showed resolution of abnormal scan findings and there is no clinical evidence to suggest recurrence. Overall, the NCCN guidelines do not support the use of PET/CT as a surveillance in lieu of standard CT scanning every six months for three years after completion of treatment. Thus, the requested PET scan with CT attenuation is not medically necessary for evaluation of this patients anal carcinoma.Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheldCredentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin for treatment of the enrollees short stature with diagnosis of hypopituitarism.Findings: The physician reviewer found that the review of the patients longitudinal growth charts from birth to seven years of age shows that there was deceleration in both length and weight upon shifting from the supine length curve, which is used to plot supine length measurements in children under three years of age, to the standing height curve used to plot standing height measurements in children over three years of age. This may have been due to true discrepancies in measurements between height and length, one or more inaccurate measurements, or true downward channeling that can occur in normally developing children under three years of age that is not due to GH deficiency. The patients height as plotted between ages six to 612 years shows a normal steady trajectory along the 10-25th percentile. Review of prior growth data shows a length at 31 months of age that is at the 25-50th percentile while weight is at the 75th percentile. A measurement plotted at two years six months of age on the standing growth curve is at the 50th percentile. Overall, the records do not demonstrate that there has been recent growth deceleration. This patients growth factors and bone age are normal and there is no evidence of pituitary deficiency. Poor results on provocative GH testing does not alone support a diagnosis of GH deficiency in the absence of evidence of growth failure based on accurate serial growth assessments, pituitary hormone deficiency, or midline brain abnormality. All told, the requested Nutropin AQ NuSpin is not supported as medically necessary for treatment of this patients medical condition.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 pediatrics with sub-specialty certification in pediatric endocrinology 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 behavior therapist at the frequency of eight hours per week, board certified behavior analyst (BCBA) supervision at the frequency of six hours per month, parent training at the frequency of six hours per month and assessment and treatment planning at the frequency of three hours per month for treatment of the autism. Findings: The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. Adolescents with autism spectrum disorders have a high rate of irritability and aggressive symptoms (Robb). Matson and colleagues note that because of adults increased physical size and longer history of these problems, treating these behaviors effectively is important. Psychological methods, particularly ABA therapy, and pharmacotherapy have been the most frequently addressed treatments for challenging behaviors associated with autism spectrum disorder. The medical literature demonstrates that severe problem behaviors such as aggression, self-injury, and property destruction can result in injury, and that behavioral interventions can significantly reduce such behaviors. In this case, the patient is displaying aggressive behavior and property destruction that could result in injury to himself or others. As such, the request for behavior therapist at the frequency of eight hours per week, BCBA supervision at the frequency of six hours per month, parent training at the frequency of six hours per month and assessment and treatment planning at the frequency of three hours per month are medically necessary for treatment of the patients autism. 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 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.