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 inpatient drug and alcohol treatment. The submitted documentation supports the medical necessity of the requested services. In this case, the patients medical condition was complicated by bipolar illness, which is a severe mental disease that has poor outcomes and an exceedingly elevated suicide rate, even in the absence of alcoholism. This patient was prescribed complex pharmacotherapy. He remained symptomatic despite specialty care in the outpatient setting.  The patients medical condition was central to his daily routine and contributed to his significant impairment across multiple domains of functionality. Further, the patient had failed intensive outpatient services and community programming. Considering the relevant peer-reviewed literature and current practice guidelines, service delivery at the residential level of care is safe, appropriate and consistent with good medical practice, and reasonably expected to improve the patients condition and prevent a more serious episode of illness. In sum, inpatient drug and alcohol treatment is medically necessary for the 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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for aprepitant capsules. The submitted documentation does not support the medical necessity of the requested medication. Aprepitant has been approved by the U.S. Food and Drug Administration for the prevention of chemotherapy-induced nausea and vomiting. Chronic use of this medication is not recommended. In this case, the requested treatment is for aprepitant , to be used chronically for the treatment of nausea and vomiting associated with migraine headaches. The medical evidence does not support the requested medication in this clinical setting. The documentation does not support that the patient has exhausted the formulary options. There is a lack of documentation to support extenuating circumstances that would require the patient to be treated only with aprepitant. Therefore, aprepitant  capsules are not medically necessary for the 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 internal 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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for additional ceftriaxone sodium injection (HCPCS-J0696) with accompanying supplies and home infusion nursing visits (CPT 99601). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has a history of neurologic disorder. Findings:  The documentation provided does not support the superior efficacy of the requested services. While there is documentation that this patient has been diagnosed with Lyme disease, the available records do not substantiate conclusively the presence of Lyme disease or any other infection in this patient.  However, even if the records support the diagnosis of Lyme disease in this patient, peer reviewed literature supports treatment for no more than four weeks with any antibiotics. This patients request is for intravenous ceftriaxone for a period in excess of four weeks. Based on the documentation provided as well as the medical literature, additional ceftriaxone sodium injection (HCPCS-J0696) with accompanying supplies and home infusion nursing visits (CPT 99601) is not likely to be of greater benefit when compared to the available standard duration for treatment of this patients medical condition. Final Result: All three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  Two reviewers are board certified in internal medicine with sub-specialty certification in infectious disease and is actively practicing. One reviewer is board certified in internal medicine with expertise in Lyme disease. 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 parent of the enrollee has requested authorization and coverage for 35 hours of applied behavioral analysis (ABA) services per week. ABA therapy covers a variety of methods concerned with the application of behavioral science to socially important functions, particularly in patients with intellectual disabilities (Virues-Ortega). Common features of ABA based therapies include the objective measurement of behavior, structured control of the environment, and the implementation of procedures based on scientifically established principles of behavior. The Behavior Analyst Certification Board (BACB) state that, comprehensive treatment often involves an intensity level of 30-40 hours of one-to-one direct treatment to the client per week, not including caregiver training, supervision, and other needed services. In the medical literature, Orinstein and colleagues reviewed the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder and found no correlation between the number of hours provided per week and outcomes. The authors noted that the age at which ABA therapy was started and duration of treatment were correlated with patient outcome. Based on the available documentation, the provision of direct ABA therapy hours to 28 per week as recommended by the Health Plan is appropriate. The patient has been making progress in most areas, and decreasing direct ABA hours is appropriate. All told, the requested 35 hours of ABA services per week are not 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 pediatrics and neurology with special qualification in pediatric 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for services with a specialist who is a certified Lyme literate medical director (LLMD) and/or a member of the International Lyme and Associated Diseases Society (ILADS). This patient reportedly had a Lyme antibody, which is not the diagnostic standard for Lyme disease. The standard approach is to obtain a Lyme antibody then western blot for confirmation. However, this patients records do not include a confirmatory western blot. In addition, the diagnosis and treatment of Lyme disease could be treated with any board certified infectious disease specialist. The treatments including doxycycline and cephalosporins are routine for infectious disease specialists. Given these findings, the requested services with a specialist who is a certified Lyme literate medical director (LLMD) and/or a member of the International Lyme and Associated Diseases Society (ILADS) are not supported as medically necessary for evaluation and treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are 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 internal medicine with sub-specialty certification in infectious disease 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 percutaneous tibial nerve stimulation. Findings:  Two of the three physician reviewers found the medical evidence supports the requested services in this clinical setting. This patient has failed multimodal primary and secondary treatments for her condition. Thus, percutaneous tibial nerve stimulation is appropriate in this patients case. Percutaneous tibial nerve stimulation is considered to be an appropriate salvage therapy for patients with intractable lower urinary tract symptoms, including frequency and nocturia. In sum, percutaneous tibial nerve stimulation is likely to be superior over other available treatment options.Final Result: The reviewers determined that the requested services are 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, 2 and 3 are board certified in urology 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: The parent of an enrollee has requested reimbursement for intensive outpatient program services. The Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 3. The patient has a history of self-injurious behavior. She last cut four days prior to the disputed timeframe and described the cutting as superficial and light. At the time, she denied any acute suicidal ideation. With regards to functional status, the records support a score of 2. The patient was attending her activities of daily living. In terms of comorbidity, the records support a score of 2. The records did not document substance use.  In terms of environmental stress, the records support a score of 2. The patient had interpersonal conflict with family. The patient had expectations for good grades which created discomfort and anxiety. With regards to environmental support, the records support a score of 2. The patients parents were supportive of the patient and were attending family therapy. In terms of resiliency, the records support a score of 3. The patient had an equivocal capacity to deal with stressors in her environment. With regards to acceptance and engagement, the records support a score of 2. The patient was cooperative with treatment. She was able to form positive relationships with her providers. Thus, the records support a composite score of 16. Thus, the patient met criteria for routine outpatient treatment and could have been treated in a less restrictive environment. She continued to need treatment for her major depressive disorder and generalized anxiety disorder, but this could have been done in a less restrictive environment. Therefore, intensive outpatient program services were not medically necessary for the treatment of this patient. 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 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 reimbursement for inpatient psychiatric hospitalization. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavior health condition.Findings: The documentation supports the medical necessity of the services at issue in this clinical setting. The records indicate that this patient was undergoing a formidable mental illness burden in context of multiple psychosocial stressors. The patients mood disorder was characterized as severe and complicated by anxious distress.  In both clinical practice and in the medical literature, anxiety ridden mood disorders are difficult to treat. The patient reported that she felt terrible and wished for death. The patient required two doses of anxiolytic medication, prescribed as needed within the previous 24-hour period.  The provider noted anxiety, depression and suicidal ideation, and articulated a reasonable rationale for continued hospitalization.  The attending provider recommended continued inpatient treatment as the patient remained symptomatic with the illness complex that prompted the admission.  The patient was engaged in active treatment and had completed three ECT treatments by the last covered day.  Due to the severity of the illness burden and considering that a premature discharge would be both unsafe and inadequate, it was medically indicated for the patient to remain in the hospital to assess the aftereffects of the fourth ECT treatment. This provided the opportunity for the providers to finalize the discharge plan, ensuring a safe decision consistent with good medical practice.  As such, the services in dispute were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  Accordingly, inpatient services were medically necessary for the treatment of this 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Gel-One injection. Findings: The submitted documentation supports the medical necessity of the requested medication. A study 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 the hyaluronans 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 significant right knee pain that is limiting his activities of daily living. Reasonable conservative treatment, including medications and activity modification, have failed to provide adequate symptom relief. Prior viscosupplementation has been performed in the past, with significant relief allowing for resumption of physical activity. Per the records, Supartz injections in 2008 and Synvisc injections in 2013 resulted in significant relief. 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. This patient presents with significant right knee pain that is limiting his activities of daily living. Therefore, the requested Gel-One injection is medically necessary for the 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: An enrollee has requested authorization and coverage for a power operated wheelchair. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for the enrollees mobility.Findings: The submitted documentation fails to demonstrate the medical necessity of the requested equipment. The standard criteria for use of power mobility equipment generally involves severe weakness of the upper extremities due to a neurological or muscular disease and/or condition such as a spinal cord injury, cerebral palsy, multiple sclerosis, or stroke with residual dense hemiplegia. Such patients may qualify for coverage of a power wheelchair or scooter if they have paralysis or severe weakness of their arms and legs. Patients whose diagnoses are limited to non-neurological conditions such as chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, arthritis, or obesity rarely meet the standard criteria for coverage of a power operated wheelchair. In this patients case, although he has a history of end stage renal disease and the patient likely has a fistula for dialysis, the documentation has noted that he is currently able to use a manual wheelchair. It does not appear from the records that this patient has severe weakness of his upper extremities. In addition, he is residing in an accessible skilled nursing facility where his mobility deficits can be appropriately addressed through the use of standard mobility aides. Therefore, the request for a power operated wheelchair has not been established as medically necessary for management of this patients medical condition.Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 DecisionDx-Melanoma Gene Assay testing. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Gene Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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 reimbursement for platelet rich plasma injection for treatment of the enrollees foot and ankle pain.  Findings:  The physician reviewer found that after careful review of the enclosed information and the pertinent guidelines concerning platelet rich plasma injections for plantar fasciitis, platelet rich plasma injection is not considered more beneficial than standard treatment for this patients right heel pain. Currently, most of the studies on platelet rich plasma injections have been performed for the treatment of lateral epicondylitis. The medical literature states that platelet rich plasma injections may improve plantar fasciitis treatment outcomes, but the treatment is still not considered standard of care. Moreover, most of the studies recommend further double blind placebo controlled studies to evaluate the efficacy of platelet rich plasma injections for treatment of plantar fasciitis. For these reasons, the platelet rich plasma injection was not likely to have been more effective than the standard methods available in treating this patients medical condition.Final Result: All three reviewers determined the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in podiatry 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.