Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the Afirma gene expression testing. The Bethesda System recommends a diagnostic hemithyroidectomy for this type of nodule. The recent American Thyroid Association guidelines state that for nodules with atypical of undetermined significance cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. If the genetic test is suspicious, the risk of malignancy increases to 40% and the risk of malignancy decreases to less than 6% with benign findings. In this case, the result of the Afirma gene expression testing was suspicious for malignancy. This increases the patients risk of malignancy to 40%. This information was important to determine whether to perform thyroidectomy, and if so, the extent of surgery. For these reasons, Afirma gene expression testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing 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 overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for the Medtronic Minimed 630G insulin pump for evaluation of adrenal insufficiency. Findings:  The physician reviewer found that The records document that this patient has remained symptomatic despite treatment with hydrocortisone in divided doses. Delivery of subcutaneous hydrocortisone has been recommended in an attempt to mimic the patients natural circadian rhythm. However, there is a paucity of controlled or peer-reviewed studies to indicate that the insulin pump is able to effectively deliver hydrocortisone for the treatment of adrenal insufficiency. The most recent guidelines from the Endocrine Society do not include use of a hydrocortisone infusion pump for the management of adrenal insufficiency. Patients that do not respond to short acting hydrocortisone may be treated with prednisone, prednisolone or dexamethasone in one or two doses. In addition, the Medtronic 630G insulin pump has been approved by the U.S. Food and Drug Administration (FDA) for the subcutaneous delivery of short acting insulin of patients with diabetes mellitus. In this case, there is no documentation that the patient has diabetes mellitus or has been treated with the other available glucocorticoid preparations including prednisone or dexamethasone. Based on the information available and review of the current peer-reviewed medical literature, the requested Medtronic Minimed 630G insulin pump is not likely to be more beneficial for treatment of the patients adrenal insufficiency than any available standard therapy. Final Result: The reviewers determined that the te requested Medtronic Minimed 630G insulin pump is not likely to be more beneficial for treatment of the patients adrenal insufficiency than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: A 23-year-old female enrollee has requested reimbursement for the residential treatment center (RTC) services. Applying the Level of Care Utilization System (LOCUS) criteria, the RTC services provided were not medically necessary for treatment of this patients medical condition. The patient was at moderate risk of harm (score 3) given her history of two prior suicide attempts. The first suicide attempt occurred after the patient cut her wrists and forearms. The second suicide attempt occurred after the patient overdosed. The providers letters state that the patient was emotionally unstable during the residential stay. However, the documentation does not endorse that the patient continued to have suicidal or homicidal ideation. The records did not indicate that the patient was at an acute risk for suicide. In addition, the patient demonstrated moderate impairment (score 3) as she was able to achieve during her academic pursuits and she continued to have conflicted relationships and interpersonal deficits with others. The patient showed significant co-morbidity (score 3) given the presence of chronic adrenal insufficiency. However, it did not appear that the patient required 24-hour medical or psychiatric monitoring. The patient had a moderately stressful recovery environment (score 3) with significant discord within her family. The patient had a limited support (score 3) as her parents were supportive, but her family had experienced caregiver fatigue. The patient had demonstrated limited response to treatment (score 3) and had prior dialectical behavioral therapy (DBT) treatment and outpatient therapy. The records demonstrated that the patient continued to experience recurring emotional dysregulation with treatment. The patient was limited in her engagement and recovery (score 3) as she refused to participate in activities, was inconsistently compliant with taking medication, and expressed hesitation and uncertainty in accepting her mental illness. These findings give the patient a composite score of 21, which is consistent with partial hospitalization program (PHP) level of care. Thus, the patient continued to need treatment for her psychiatric and medical conditions, but this could have been done in a less restrictive environment. Accordingly, 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 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 enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP). Findings: The physician reviewer found that there is sufficient support in the documentation provided for the medical necessity of IOP level of care in this clinical setting. Per the provided documentation, the patient was symptomatic and remains symptomatic. The records through 2018 document this patients mood as depressed, irritable, and anxious.  The patient has been documented as having a lack of motivation and difficulty with attending to activities of daily living. The patient was documented as relapsing on alcohol.  The patient was noted to minimize his relapses as well as other problems related to his substance use. The American Society of Addiction Medication (ASAM) criteria, a set of objective guidelines used by clinicians to assist with treatment planning, advocates for service intensity provided in the least intensive but safe treatment setting. The patients progress with his treatment as well as the progress notes from his treatment providers support IOP level of care. As such, based on current medical literature, ASAM criteria, and the patients documented clinical history, this patients admission to the IOP level of care was and is medically necessary. Final Result: The reviewer has determined that services at issue were and 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 with sub-specialty certification in child and adolescent psychiatry and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ablation of the left great saphenous vein (GSV) and bilateral sclerotherapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee's medical condition. Findings: The submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting. The classical and standard treatment regimen for varicose veins due to GSV incompetence and varicosities is to offer conservative therapy as first line options. If the patients succeed with conservative therapy, no further intervention would be required. However, if they fail, then ablation or removal of the axial veins and interruption of significant non-axial accessory varicosities would be indicated. This patient has documented left GSV insufficiency but the records provided do not document a trial and failure of conservative therapy. This patient may require further therapy if conservative measures fail, and once the patient completes conservative therapy, the patient should be reevaluated. However, currently, the medical necessity for ablation of the left GSV and bilateral sclerotherapy has not been demonstrated 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 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 reimbursement and prospective authorization and coverage for continued skilled nursing care. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollee who has a history of brain injury.Findings: There is a lack of support for the medical necessity of the services at issue in this clinical setting. At the time of admission, the patient required skilled rehabilitation services to improve function. Skilled nursing needs included the care for a feeding tube with administration of enteral nutrition and medications. The patient did not require any skilled nursing or rehabilitation services on a daily basis.  The patient was not expected to make measurable gains within a reasonable and predictable period of time and did not require skilled therapy to prevent deterioration with mobility or activities of daily living. Based on the submitted records, the patient did not require skilled therapy to establish a safe and effective maintenance program and did not require skilled services on an inpatient basis. The patient did not have any parental medications, complex wound care or care for a tracheostomy. The patient received skilled care with minimal improvement and the records indicated that his function had plateaued. Although care for a feeding tube is considered skilled care, the patient remained stable and monitoring of his feeding tube could have been performed at a lower level of care. As such, the patient required custodial services and not skilled care. Therefore, continued skilled nursing care was not and is not medically  necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for evaluation and 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic pain.Findings: There is a lack of peer reviewed evidence based studies, which support Norco as an effective treatment in this clinical setting. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach for pain control in the palliative setting. However, in the documentation available for review, there were no objective treatment goals for pain and function noted. Thus, the need to use an opioid as the primary medication treatment strategy for pain has not been established, in this patients case. The Centers for Disease Control and Prevention (CDC) recommends that when opioids are started, clinicians should prescribe the lowest effective dosage. In addition, CDC states epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose and so, clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. The records indicate that this patient is also prescribed benzodiazepines.Additionally, the records do not mention if behavior therapy has been performed, despite much research to support its use. There are other non pharmacological ways of addressing the patients pain that have not been exhausted. In this case, no clear objective goals have been established by the provider or the patient. Moreover, the requested medication is not considered evidence based treatment for fibromyalgia. Also, not all non opioid medications classes have been optimized or tried. It is also reasonable to consider alternatives to opioids and weaning the patient to a lower dose of opioids or even off opioids. There are relevant guidelines regarding the most appropriate method for weaning and terminating opioids for this patient.  In addition, this patient should not be using opioids with sleep related problems. As such, the medical necessity of Norco for treatment of this patients medical condition has not been established. For all these reasons, Norco is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for high frequency chest wall oscillation (HFCWO) system. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees recurrent pneumonia.Findings: There is support in the medical literature for the medical necessity of the requested device in this clinical setting.  High frequency chest wall oscillation (HFCWO) was developed to improve airway clearance in those where normal mucociliary transport system has failed (chronic bronchitis, bronchiectasis, and cystic fibrosis). The majority of patients in whom airway clearance systems have been studied have cystic fibrosis. However, the research bears out the utility of these systems in airway clearance. There is sufficient peer reviewed literature to support the efficacy of this device in this patients case. This patient has a history of very complex pulmonary disease with chronic lung disease and pulmonary hypoplasia, as well as gastrointestinal disease resulting in recurrent aspiration pneumonia despite fundoplication. The enrollee has had recurrent pneumonia and chronic cough demonstrating his inability to adequately clear his airway. With the severity of his gastrointestinal disease, standard airway clearance techniques are not appropriate and this patient would be at significant risk of developing bronchiectasis if he does not maintain adequate airway clearance. This has been borne out with demonstrated improvement upon initiation of HFCWO for airway clearance. As such, continued use of HFCWO for airway clearance (vest therapy) is medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested device 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical artificial disc replacement, single level. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees cervical pain.Findings: There is sufficient support in the medical literature for the requested services in this clinical setting. Cervical total disc replacement at one or two levels, anterior cervical discectomy and fusion, as well as hybrid surgery with a combination of the two, significantly improve general and disease specific measures compared with baseline. There are significant benefits documented in the literature with respect to total disc replacement, which results in improved general and disease specific outcome measures and a lower rate of reoperation in the two level disc replacement or hybrid patients versus two level anterior cervical discectomy and fusion control patients. Recent medical literature with regards to the long term results of cervical total disc replacement including one and two level and hybrid surgery, such as in this patients case, find significant benefits over the conventional multi-level anterior cervical discectomy and fusion. The literature indicates that there is motion preservation, decreased incidence of adjacent segment disease, and improved clinical outcome as well as decreased need for revision surgery. Therefore, the medical necessity for the requested cervical artificial disc replacement, single level has been demonstrated in this patients case. Final Result: The reviewer determined that 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 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 reimbursement and prospective authorization and coverage for custodial care. Chronic alcoholism is associated with gait ataxia due to cerebellar degeneration. This is a chronic, degenerative condition that is not expected to improve spontaneously through neurological recovery. Functional recovery is primarily based on reconditioning and compensatory techniques. In the present case, there are no indications in the available records that the patient has been making any significant functional progress. The enrollee has chronic pains from arthropathies. There are no indications that he has any skilled nursing needs, active medical needs, or an indication for the services at issue. The patient needs housing help and assistance for his self-care and basic mobility as well as community services. However, the patients needs are not medical in nature and do not require custodial medical facility services. All told, the custodial care from 1/12/18 forward was not and is not medically necessary for treatment of the 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 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.