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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for speech therapy with aural habilitation, hearing therapy, and audio therapy integrated together seamlessly. Findings:  The physician reviewer found that there is a lack of studies supporting speech therapy with aural habilitation, hearing therapy, and audio therapy integrated together for children with dysarthria or receptive-expressive speech/language impairment. Furthermore, there is a lack of studies showing the utility or supporting the biomechanical method utilized. In this case, speech therapy is indicated, however integrated aural habilitation, hearing therapy, and audio therapy is not clinically indicated. In sum, aural therapy or aural rehabilitation with speech training and audiology training has not been demonstrated to be effective in the medical literature. Therefore, the request for speech therapy with aural habilitation, hearing therapy, and audio therapy integrated together seamlessly 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 physician reviewer is board certified in pediatrics with sub-specialty certification in developmental and 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center level of care services provided. Findings:  The physician reviewer found that based on the documentation submitted for review, the residential treatment center level of care services provided were not medically necessary for treatment of the patients medical condition. Residential treatment is used for acute stabilization of psychiatric conditions and is the most restrictive form of psychiatric care available. Residential treatment is not evidence based for long-term treatment. The American Academy of Child and Adolescent Psychiatry recommend that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports . Studies have shown that treatment outside of a residential setting are effective and as beneficial as residential treatment center programs . In this case, at the time of admission his overall level of anxiety was low, and he denied any thoughts of self-harm. The records indicate the patient was open in his individual and group therapy sessions throughout his stay. He was not displaying any significant or severe behavioral problems after admission. Although the patient does need more treatment to further improve his social functioning, mood, anxiety, family relationships, and behavioral issues, this did not require the restrictiveness of a residential treatment facility. In sum, the patient could have been treated in a less restrictive setting during the dates in dispute. As such, the residential treatment provided were not medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mandibular maxillary advancement performed and the related dental x-ray performed.  Findings:  The physician reviewer found that maxillomandibular advancement is an effective surgical option for obstructive sleep apnea that achieves enlargement of the upper airway by physically expanding the facial skeletal framework. Patients with high residual AHI and respiratory disturbance index (RDI) after failure of other surgical procedures for obstructive sleep apnea are likely to benefit from mandibular maxillary advancement. In this case, the patient has had chronic sleep deprivation and sleep disturbance. She has failed treatment with CPAP as well as sleep surgery. She has suffered serious sequelae from obstructive sleep apnea. As such, the pre-operative dental x-ray performed , and mandibular maxillary advancement performed were medically necessary for treatment of the patients obstructive sleep apnea, retro- and micro-gnathia and mandibular hypoplasia.  Final Result: The reviewers 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: Physician reviewer is board certified in otolaryngology and plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chiropractic treatment. Findings:  Three physician reviewers found that the patient has tried many prior conservative and non-conservative treatments for her condition. While there is a lack of research directly related to effectiveness of spinal manipulation for pelvic pain, the patient already had spinal mobilization through her physical therapy with no improvement. It is unlikely that chiropractic manipulation would provide superior results. In addition, the available studies show that there is limited evidence to support the use of complementary manual therapies such as chiropractic treatment as an option for managing low back and pelvic pain. Since the patient already had mobilization to the spine without improvement and because of the lack of studies for chiropractic and pelvic pain, the requested chiropractic treatment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the requested services are 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: Physician reviewer number one is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. Physician reviewer number two is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer number three is board certified in chiropractic medicine 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 reimbursement for lipoprotein testing provided. Findings:  The physician reviewer found that based on the records provided the patient is with increased coronary risk. In this circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine . Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits . Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld therefore, the lipoprotein testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewer 1,2 & 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 Harvoni for eight weeks.Findings:  The physician reviewer found that according to recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. For these reasons, Harvoni for eight weeks is medically necessary for the treatment of this patient.  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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Botox (botulinum toxin) treatmentsto be provided every four to six months. Findings:  The physician reviewer found that The patient who has been diagnosed with temporomandibular joint disorder and sleep related bruxism. The patient has reported mouth clenching and ear pain. the patient has  described the pain as severe and throbbing. The patient  has been treated with masseteric botulinum toxin injections. The patient requested reimbursement and prospective authorization and coverage for Botox (botulinum toxin) treatments  to be provided every four to six months. The Health Plan denied the services at issue. The Health Plan noted that the services at issue were and are investigational for treatment of this patients medical condition. There is clinical support in the efficacy of the services at issue in this clinical setting. Botulinum toxin has been shown to be effective for a variety of disorders in several medical conditions, when used therapeutically. In recent years, there has been a rising trend in the use of this pharmacological agent to control bruxing activity.  The medical literature supports the use of botulinum toxin to reduce the frequency of bruxism events and myofascial pain. Current clinical data reflect that botulinum toxin has been an effective treatment option for reducing nocturnal bruxism and myofascial pain in patients with bruxism such as in this patients case.  For these reasons, Botox (botulinum toxin) treatments  retrospectively and forward, to be provided every four to six months were and are more likely to be effective than the standard options for treatment of this patients medical condition.  Final Result: The reviewers determined that the services at issue were and 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 reviewer number 1 & 3 are board certified in otolaryngology and physician 2 is   is board certified in oral facial and maxillary surgery and all are  actively practicing. The reviewers are 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 male enrollee has requested reimbursement for residential treatment services provided.  Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patient had withdrawals which appeared to be mild in nature.  There were no Clinical Institute Withdrawal Assessment for alcohol included in the documentation. However, the patient endorsed last use four days prior. He was not a danger to himself or others.  He was medically and psychiatrically stable. According to the records, there were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  He was not manic or psychotic. His medication management did not require medical or nursing monitoring on a 24 hour a day basis. He participated in the program and desired sobriety.  His parents were sober supports. He had no comorbid medical conditions. He did not require the residential setting in the absence of unstable medical or psychiatric conditions. His vital signs were stable. His treatment could have occurred at a lower level of care. For these reasons, the residential treatment center services were not medically necessary for 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 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 Harvoni for eight weeks. Findings:  The physician reviewer found that according to 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.  This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cellular function assay performed.Findings:  The physician reviewer found that there is a lack of sufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. The use of immune cell function assays has been studied in the treatment of ulcerative colitis, however it did not prove to be definitively useful for prediction of actual disease activity . The use of such assays is not recommended for management of Crohns disease per American College of Gastroenterology or American Gastroenterological Association guidelines, which recommend other tests instead . For these reasons, the cellular function assay performed was not likely to be more beneficial for evaluation of the patients Crohns disease than any available standard therapy.Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy that was provided. Findings:  The physician reviewer found that studies evaluated the relationship between ABA treatment intensity and treatment outcomes for individuals with ASD. The studies found that a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress was demonstrated. The studies concluded that These results add to the existing support for higher intensity treatment for children with ASD. The Behavior Analyst Certification Board indicate that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, the patient has made progress in many areas as evidenced by the progress reports, however he continues to demonstrate noncompliance in addition to level 2 vocal, physical and visual stereotypies. Based on the clinical documentation submitted for review, the request for 40 hours per week of direct ABA therapy provided has been established as medically necessary for treatment of the patients ASD. Final Result: The reviewer 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 physician 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for Developmental Individual-Difference Relationship (DIR)/Floortime provided for treatment of the enrollees autism.Findings:  The physician reviewer found that there is a lack of peer-reviewed literature supporting the services at issue as medically necessary for treatment of the patients medical condition. There is some medical literature demonstrating that the DIR/Floortime model improves functional development levels and Childhood Autism Rating Scale (CARS) scores in children with autism. However, the data in support of DIR/Floortime is mostly pilot studies with a minimal number of participants. There is sufficient support in the peer-reviewed literature demonstrating that evidence-based ABA therapy is effective for the treatment of patients with autism. All told, the DIR/Floortime provided from March 2015 through December 2015 was not medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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 physician 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.