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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that In cases such as this, an evidence based instrument such as the Child and Adolescent Level of Care Utilization System (CALOCUS) is indispensable in determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible. Based on this patients presentation, she is at 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 has moderate problems with her functional status (score 3) given school disruption. The patient has mild co-morbidities (score 2) as she does not have active serious medical problems but has substance use history. The patients recovery environment is mildly stressful (score 2) with a stable housing situation despite strained relationships with her mother. The patients recovery environment is supportive (score 2) as the patients father is involved in treatment and is supportive. The patient has demonstrated moderate response in previous treatment (score 3) and has been constructive in treatment (score 2) as she participates in therapy and has used coping skills learned in therapy per the records. The patients parents work actively and constructively with providers (score 2). These findings given the patients presentation a composite score of 18 which correlates with IOP level of care. According to the CALOCUS the patient would need to have a score of 23-28 in order to require treatment in an RTC. Thus, the patient can be treated in a less restrictive setting safely and effectively and the requested RTC services are not supported as medically necessary for treatment of this patients behavioral health issues. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen crosslinking with riboflavin procedure for treatment of the enrollees keratoconus. Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Based on the patients vision loss and progression, corneal collagen crosslinking was the most appropriate and effective treatment available.  Per the medical evidence, corneal collagen crosslinking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. There are a lack of other treatment options available to slow or halt disease progression. Therefore, corneal collagen crosslinking with riboflavin procedure was likely to have been of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were 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: 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets, for the duration of 12 weeks for treatment of the enrollees hepatitis C.  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 1a patients should be treated with Epclusa for 12 weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Copaxone 40 mg/mL injections three times per week for treatment of the enrollees multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication in this clinical setting. Multiple sclerosis (MS) is a progressive immune disease affecting the central nervous system (CNS), causing neurological dysfunction. MS is considered to be one of the most common neurological immunologic diseases. Multifocal inflammation of the CNS characterizes the disease and causes impaired nerve conduction, which is what causes the many different symptoms of MS. The most common form of MS is the relapsing and remitting subtype, which clinically refers to episodes of new or worsening functioning with MRI correlation and periods of clinical stability.  MS is not a curable pathology but currently, there are several therapies that can manage the disease. Copaxone is an analog of myelin basic protein (MBP), which is thought to be involved in MS. Over the 20-year history of glatiramer acetate the medication has been compared with other medications as well as with alternative dosing. Trials involving different dosing regimens have largely produced similar results of similar efficacy and tolerability. While there is some support in the medical literature as to the benefits of glatiramer acetate for treatment of MS in some patients, therapy of Copaxone 40 mg injection, three times weekly, has not been effective in treating this patients medical condition. The record supports new symptoms of incontinence, sensory disturbances, and weakness despite ongoing therapy with this regimen. Moreover, elevated liver enzymes are reported in the patients history while on current therapy. 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 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 reimbursement for Euflexxa injections for treatment of the enrollees knee pain. Findings:  Two physician reviewers found that current evidence based medical literature states that hyaluronic acid injections in the knee are recommended for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including aspiration and injection of intra-articular steroids. Hyaluronic acid injections are not recommended for any other indications such as chondromalacia patella or patellofemoral syndrome. The effectiveness of hyaluronic acid injections for these indications has not been established. Peer-reviewed literature generally supports the use of hyaluronic acid injections for chronic moderate symptomatic osteoarthritis of the knee but states that application in sports related chondropathy has yet to be fully assessed. The ideal indication in the knee seems to be moderate femorotibial osteoarthritis without swelling. This patient was diagnosed with bilateral patellofemoral chondromalacia. A series of three Euflexxa injections were recommended and performed. Evidence based medical literature does not support the use of hyaluronic acid injections such as Euflexxa for the treatment of chondromalacia patella, as the effectiveness has not been established. There is a lack of compelling evidence presented to support these injections. Therefore, the Euflexxa injections were not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in orthopedic surgery 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 patient has requested authorization and coverage for acupuncture and electro-acupuncture for treatment of the enrollees neck pain. Findings:  The physician reviewer found that the records indicate that this patient has had excessive acupuncture treatment over the last two years and he has not attained any lasting improvement. He is not reasonably expected to make further improvement through more treatment. The patient is able to make improvement through physical therapy. However, the patient did not continue with therapy at home. Instead, the records indicate that he has become dependent on acupuncture for pain relief and he is not attempting self-care. Acupuncture can be an effective short-term treatment for patients with chronic neck pain, but there is only limited evidence for long-term benefit. Moreover, studies show that acupuncture is not more clinically significant than sham-acupuncture or placebo for neck pain. Besides physical therapy, there is no evidence that the patient has been referred for proper medical management for his pain including pain management, cortisone injections, ablation, or surgery. Final Result: The reviewer determined that the requested service 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 oriental 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hypogastric nerve block injections with drugs to put the enrollee in a deep sleep (monitored anesthesia care (MAC)) services for treatment of the enrollees chronic abdominal pain secondary to Crohns disease and multiple abdominal surgeries. Findings:  The physician reviewer found that the patient has a diagnosis of chronic abdominal and pelvic pain secondary to Crohns disease status post multiple abdominal surgeries. The patient is currently maintained on Norco, Topamax and Baclofen and has failed conservative therapies. The patient previously underwent the hypogastric block with 40-50% improvement. Hypogastric blocks are an effective treatment for abdominal pain in this clinical setting. In this case, the patient has tried and failed multiple conservative measures and has noted significant improvement from prior hypogastric blocks. Furthermore, the hypogastric block is recommended to be performed on heavy conscious sedation or MAC to ensure proper needle position, patient safety, and comfort. Given these findings, the requested hypogastric nerve block injections with drugs to put the patient in a deep sleep (MAC) services are supported 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for knee surgery and all post-operative follow up appointments for treatment of the enrollees knee pain. Findings:  The physician reviewer found that evidence based medical guidelines and peer reviewed literature support the services at issue in this clinical setting. There is support in the medical literature for the management of recurrent dislocations of the patella in a young individual. Recurrent patellar instability is a common pathology and typically affects younger and more active patients. In this patients case, in order to prevent complete lateral dislocation of the patella, several procedures have been described, both osseous (tibial tubercle osteotomy) and soft tissue procedures, including reconstruction of the medial patellofemoral ligament with cadaver hamstring allograft or patients own hamstring autograft. The medial patellofemoral ligament has been identified as the primary medial stabilizer of the patella. Several techniques have been reported for reconstruction, sometimes in conjunction with other procedures, with the majority of the procedures showing success in correction of the instability consisting of recurrent patellar dislocations. However, medial patellofemoral ligament reconstruction is not free of complications, and this was the fourth surgical procedure and a second attempt at medial patellofemoral ligament reconstruction.  As such, the procedure was not only medically necessary but also necessary to perform at a tertiary institution by a provider who is experienced in revision surgery. On the basis of the foregoing, the knee surgery and all post-operative follow up appointments 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cuvitru, a brand of subcutaneous intravenous immune globulin for treatment of the enrollee who has a history of recurrent sinus infections. Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  Selective antibody deficiency with normal serum immune globulin concentrations is a deficiency of specific antibody response to polysaccharide antigens with intact response to protein antigens and normal serum level of immune globulin G (IgG) and IgG subclass.  Immune globulin replacement therapy with IVIG or subcutaneous immune globulin preparations is a treatment option for this group of patients with recurrent infections that persist after immunizing and antibiotic treatment. The studies have shown that immune globulin replacement therapy leads to significant decreases in the number of infections. This patient has normal levels of IgG, write out (IgA) and an impaired response to polysaccharide antigen challenge test. The pre-pneumococcal vaccine titer revealed 18/23 were unprotective and the post-vaccine titer showed 15/23 titers were still unprotective despite vaccination. Based on this patients examination, she qualified for the diagnosis of specific antibody deficiency with normal serum immune globulin levels with impaired response to a polysaccharide vaccine challenge. This patient also has a history of recurrent infections. 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 allergy and immunology 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 magnetic resonance imaging for evaluation of the enrollees chronic elbow pain. Findings:  The physician reviewer found that for this patient, a repeat MRI was indicated. The MRI done earlier was interpreted with less than definitive findings.  In addition, the pediatric orthopedist felt that the MRI appeared normal. Imaging of the elbow in a pediatric patient is often confusing, as there are multiple ossification centers that can have a range of normal appearances.  The most optimal imaging will generally be done at a center accustomed to imaging young patients, and at a center more specialized in orthopedics. Considering that the results of the MRI will possibly determine whether this patient undergoes surgery, it is reasonable to repeat the study at a dedicated pediatric orthopedic hospital. For these reasons, MRI was medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the continuous airway positive air pressure (CPAP) machine for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that based on the current medical literature and the presented clinical records, the CPAP machine provided was and is medically necessary for treatment of the patients medical condition. The patient is diagnosed with OSA and has been prescribed CPAP for home use. CPAP is the standard of care for treatment of OSA of all severity levels. The current accepted standard of care with regards to CPAP is for a patient to have an initial three month trial of therapy with CPAP. It is after this initial 90 day window at which compliance with therapy is assessed. More specifically a patient is required to use CPAP device 70% or more nights for at least four hours a night within a specified 30-day period. In this case, the patient is noted to have been using the CPAP device near and above this threshold in both the early stages of therapy and the most recent CPAP compliance reports. In this circumstance, the records demonstrate that the patient has been compliant with CPAP therapy as defined by current literature. Given that the patient has shown compliance with CPAP, continued use of CPAP is medically necessary for the management of the patients OSA. Final Result: The reviewer determined that the device at issue was and 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a stab phlebectomy. Findings:  The physician reviewer found that consistent with the guidelines from the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF), the requested stab phlebectomy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient has an accessory saphenous vein, which has demonstrated reflux. The patient meets all of the criteria for surgical treatment of an accessory varicose vein. She has been compliant with conservative measures and there is reflux in the accessory saphenous vein on ultrasound. All told, the requested stab phlebectomy is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three of the reviewers determined that the requested service 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, 2 & 3 are board certified in surgery with sub-specialty certification in vascular surgery 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.