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 Vemlidy 25 mg for treatment of the enrollees hepatitis B. Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this patients case. Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. All told, Vemlidy 25 mg 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a nutrition evaluation and follow up for evaluation and treatment of the enrollees obesity. Findings:  The physician reviewer found that Based on the clinical documentation submitted for review, a nutrition evaluation and follow up is clinically indicated for this patient. Childhood obesity is a growing problem with significant implications for future health issues. Impaired glucose tolerance is of major concern in overweight children. In addition, obesity is associated with risk factors for cardiovascular disease, including development of atherosclerotic lesions. Hannon and colleagues noted that obesity is the most important risk factor for the development of type 2 diabetes mellitus (T2DM) in youthincreasing rates of T2DM among children and adolescents will have considerable long-term implications for the affected individuals, society, and the public health system as a whole. The authors reported that in addition to their impact on physical well-being, the economic, social, and psychological impact of these conditions is enormous. In this case, the patient presents with a longstanding history of obesity and is beginning to experience chronic complications due to the patients weight, including joint pains, mild hypertriglyceridemia and hypertension. The patients provider has documented discussion about diet and exercise at each visit. When chronic conditions are multifactorial, more involved interventions and education may be necessary. The direct supervision of a nutritionist, whose expertise is in guidance toward healthy diet and lifestyle choices, is medically reasonable and appropriate. Because of the potential for significant complications such as hypertension, obstructive sleep apnea, and diabetes, expert intervention is critical. As such, the request for a nutrition evaluation and follow up have been established as medically necessary for evaluation and treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics and pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the residential behavioral health treatment for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that In cases such as this, an evidence-based, objective, instrument such as the Level of Care Utilization System (LOCUS) is indispensable in determining the appropriate level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. The patient demonstrated a low risk of harm (score 2) due to a lack of current suicidal ideation and her functional status was moderate (score 3) given her intact activities of daily living but she had a history of issues with daily functioning due to theft. The patients medical, addictive and psychiatric co-morbidity were moderate (score 2) due to overall medical stability, some substance abuse issues, anxiety, and kleptomania symptoms. The patients recovery environment was mildly stressful (score 2) with a stable living environment, and her level of support was supportive (score 2) due to an overall supportive recovery environment with her family. The patients treatment and recovery history was moderate (score 3) with minimal treatment response in the past but also a minimal past history of treatment. The patient was noted to be cooperative and engaged in treatment (score 2) with apparent insight into her need for treatment. This gives the patients presentation a composite score of 16, which correlates with high intensity community based services such as intensive outpatient program (IOP) treatment. Given these findings, the residential behavioral health treatment provided were not medically necessary for treatment of this patients behavioral health condition. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI). Findings:  The physician reviewer found that the current medical evidence does not support the services at issue in this patients case. The issue of whether it is worthwhile to screen patients for brain aneurysms has been discussed in the medical literature. As noted by studies, patients with at least two first-degree relatives who have had an aneurysmal subarachnoid hemorrhage have significantly higher risk of both aneurysmal subarachnoid hemorrhage and aneurysm when compared with the rest of the population. In another study, the authors noted the risk of aneurysmal subarachnoid hemorrhage is slightly increased in the cases with one, but strongly increased in cases with two or more affected first-degree relatives. Studies concurred, noting in families with two or more members affected with intracranial saccular aneurysm or subarachnoid hemorrhage, there is an increased occurrence of these disorders in first-degree and possibly second-degree relatives of those with either diagnosis. Per the literature, it is the standard approach not to aggressively screen patients who only have a single relative with an aneurysm. Therefore, MRI provided was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for platelet rich plasma injections. Findings:  The physician reviewer found that There is a paucity of high level literature regarding the application of PRP in the management of patellar and Achilles tendinopathy. Dupley and colleagues concluded that there is a paucity of randomized controlled trials evaluating the role of PRP in patellar tendinosis. Their results suggest that, based on limited evidence, PRP is superior over other established nonsurgical treatments (dry needling and extracorporeal shockwave therapy) for refractory patellar tendinosis. However, larger randomized controlled trials may allow better characterization of the role of PRP in this condition. This patient presents with a six month history of chronic right knee pain with no history of trauma or injury. Clinical examination findings and imaging evidence are consistent with patellar tendinitis. It is noted that he has attended physical therapy without benefit. However, there are no details regarding the type or duration of physical therapy. There is no documentation of additional conservative treatment, including medications, activity modification, or strapping/taping. There is a lack of large volume, long term, peer reviewed outcome studies to support the use of PRP in the treatment of patellar tendinopathy as discussed above. Additionally, there is limited support for PRP in refractory patellar tendinosis in patients who have not responded to comprehensive treatment for at least 12 months, which is not the case in this situation. Therefore, in this patients case, the request for PRP injections are not medically necessary for the patients knee pain. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing. Findings:  Three physician reviewers found that the cytopathology of the left thyroid nodule was consistent with Hurthle cell neoplasm, in the same category as follicular neoplasm, Bethesda Category IV. The risk of malignancy is 15 to 30% in this category. The Bethesda System recommends a surgical lobectomy for this type of nodule.  If the genetic test is suspicious, the risk of malignancy increases to 40%. The risk of malignancy decreases to less than 6% with benign findings by Afirma Gene Expression Classifier testing. The information from Afirma Gene Expression Classifier testing can assist providers in determining whether to perform thyroidectomy or not, and the extent of surgery. The test is in vitro, which confers no physical risk to the patient. The sample is obtained at the same time of the fine needle aspiration biopsy, and no additional procedure is needed. Thus, Afirma Gene Expression Classifier testing provided was likely to be superior over other available methods of evaluating this patient. Final Result: 3 of 3 reviewers determined that the services at issue were 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: All three physician reviewers 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage laparoscopy anti-reflux surgery utilizing LINX Reflux Management System treatment of the enrollees gastroesophageal reflux disease (GERD). Findings: The three physician reviewers found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Appropriate patient selection is crucial before anti-reflux procedures.  In this case, the patient has acid reflux as based on pH recording. However, it appears the patient has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory to acid blocker drugs. Also, implantation of LINX in the patients clinical setting must be approached with caution given documentations of both dysmotility, and of failure to eliminate all acid reflux at the time of initial LINX placement. Based on the clinical information provided for review, the request for laparoscopy anti-reflux surgery utilizing LINX Reflux Management System cannot be deemed likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested procedure is 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 physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the neck. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has no documented red flags to warrant immediate MRI evaluation.  There were no neurological deficits documented in the provided records. The medical necessity of MRI cannot be established without the presence of an acute change in symptoms, including neurological deficit, which can be ascribed to a specific dermatome absent a six-week trial of conservative management. The current medical evidence does not support the requested services in this patients case. All told, the requested MRI of the neck is not medically necessary for the evaluation of this patient. 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee's parent has requested authorization and coverage for 24 therapist hours per week and 25 supervisor hours per month of applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, for 24 therapist hours per week and 25 supervisor hours per month of ABA services are not medically necessary for treatment of the patients autism spectrum disorder. ABA therapy covers a variety of methods concerned with the application of behavioral science to socially important functions, particularly in individuals with intellectual disabilities. 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. In this case, the documentation indicates that the Health Plan has authorized a three-month bridging period of ABA therapy with an in-Plan ABA provider. As such, the requested services have not been established as medically necessary for treatment of the 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 child 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 gene mutation testing for evaluation of the enrollees visual changes, supraventricular tachycardia (SVT), bicuspid aortic valve, aortic root dilation and patent foramen ovale (PFO). Findings: The three physician reviewers found that according to the documentation submitted for review, the patient does not have any history of definite embolic or thrombotic disorders. In addition, the medical records do not show that the patients father underwent genetic testing. Guidelines of the American Heart Association and American Stroke Association do not support use of testing for prothrombin deficiency when suspected cerebral ischemic events are being evaluated. In addition, Gupta and colleagues do not support genetic testing for hypercoagulable state unless an unprovoked deep vein thrombosis is identified. As such, the gene mutation testing provided 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 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: All three physician reviewers 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the ReWalk Exoskeleton System/durable medical equipment (DME) (HCPC: E1399)  one unit. Findings:  Three physician reviewers found that the proposed equipment is not an efficient, reliable or practical means of mobility for persons with paraplegia in comparison to standard mobility devices such as manual wheelchairs. Recent evidence suggests that these type of exoskeletal ambulation devices have high feasibility challenges and have not met users high expectations of benefits. There is no expected significant health benefit of passive walking using an externally powered exoskeleton to power the lower limbs. In this clinical setting, the standard of care is employing appropriate pressure relieving maneuvers using volitionally intact musculature, and promoting physical activity using volitionally active musculature, including regular propulsion of a manual wheelchair, wheelchair sports and other adaptive sports/exercise activities. Compared to these standard activities, the physical activity promoted by powered exoskeleton-aided ambulation is modest. The benefits of the proposed device with respect to health and mobility in the setting of the patients medical condition have not been established.  The available, published data are scarce and low quality. Moreover, there is a risk of injuries, especially if it is used outside of a controlled environment like a physical therapy gym. Thus, the ReWalk Exoskeleton System/DME (HCPC: E1399)  one unit is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the requested equipment is 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 reviewers number one and three are board certified in physical medicine and rehabilitation and are actively practicing. Physician reviewer number two is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 15 therapist hours per week and 10 supervisor hours per month of applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the request for 15 therapist hours per week and 10 supervisor hours per month of ABA services is not medically necessary for the treatment of the patients medical condition. Numerous scientific organizations have concluded that ABA-based therapies are highly effective in the treatment of autism. However, in this case the Health Plan has authorized a three-month bridging period of ABA therapy with their in-Plan ABA provider. There is a lack of support in the medical records to support the medical necessity for ABA from the out-of-Plan ABA provider. 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 child 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.