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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for intensive outpatient services and partial hospitalization program services. The enrollee has a history of eating disorder symptoms and a diagnosis of anorexia nervosa. The enrollee was at high risk of relapse and further decompensation with discharge to an outpatient treatment program. Although her weight was healthy, she needed assistance to continue to monitor her deficits, mood, impulse regulation, self-esteem and behavior problems.  Findings:  The physician reviewer found that the medical literature supports the use of intensive outpatient therapy for this enrollee.  According to the  medical literature, services for treating eating disorders can range from intensive inpatient programs (in which general medical care is readily available) to residential and partial hospitalization programs to varying levels of outpatient care. Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Psychiatry and AddictionPsychiatry 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 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 epidural injections (facet injections). Findings:  The physician reviewer found that the American Society of Interventional Pain Physicians (ASIPP) updated recommendations support the clinical utility of the requested cervical facet injections in this patients care. ASIPP noted that, diagnostic cervical facet joint nerve blocks are recommended in patients with somatic or non-radicular neck pain or headache and upper extremity pain, with duration of pain of at least three months, without preponderance of evidence of discogenic pain, disc herniation, or evidence of radiculitis. The ASIPP guidelines also state that once conservative management for cervical facet joint pain has been exhausted, appropriate diagnosis with controlled diagnostic blocks is essential. Following this, therapeutic cervical facet joint interventions may be indicated. In this case, the patient has longstanding neck pain without any significant radiation into the upper extremities for over one year. She has MRI findings of multilevel cervical disc disease as well as listhesis of C3 on C4. There was no report of canal stenosis in the MRI. The patient has tried and failed conservative management with NSAIDs, Norco and a home exercise program. She has reportedly experienced benefit from previous injection therapy. Based on the current guidelines, the requested epidural injections (facet injections) are medically necessary for treatment of this patients neck pain. 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 subspecialty certification in pain management 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 authorization and coverage for routine intravenous (IV) saline infusions every two to three weeks.Findings:  The physician reviewer found that based on the records provided, the patient has POTS and presyncope symptoms refractory to several medication trials. The patients condition has transiently improved after saline infusions. Hydration may be an effective treatment for POTS. However, there is no documentation in the records provided for review that this patient cannot tolerate oral hydration. In addition, there is increased risk of infection with IV saline hydration as opposed to oral hydration. There is a lack of scientific literature supporting the routine use of IV saline in the management of POTS. Therefore, the requested routine IV saline infusions every two to three weeks are not medically necessary for treatment of this patient. 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 internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Venclexta 100 mg tablets and Imbruvica 420 mg tablets. The use of Venclexta, alone or in combination with Ibrutinib, for T-cell prolymphocytic leukemia (PLL) is not within the current standard of care. A case report of two patients with T-cell PLL reported anti-tumor activity with Venclexta (Boidol, et al.). The U.S. National Institutes of Health (NIH) announced a clinical trial to evaluate the combination of Venclexta and Imbruvica in T-cell PLL. Therefore, Venclexta 100 mg tablets and Imbruvica 420 mg tablets are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication regimen 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:  One reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in medical oncology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for physical therapy. Autism is a complex neurological disorder characterized by restricted repetitive patterns of behavior, as well as variable deficits in speech/language and social interaction. Deficits in fine/gross motor skills and processing of sensory and motor information are also common. Many approaches have been used to facilitate development of adequate communication and interpersonal skills in children with autism. Typically, children on the autistic spectrum require interventions in multiple areas, including speech therapy, occupational therapy, and behavioral therapy. Deficits in fine and gross motor skills and sensory integration dysfunction are common in this population of children. Physical therapy, with its focus on gross motor skills, ambulation, balance, strength, and coordination, is ideal to facilitate development of a normal gait pattern in children with deficits in these areas. At the only formal physical therapy assessment performed, this patient was noted to have weaknesses in stationary standing, dynamic balance, and walking. Based on the submitted records, the requested services are medically necessary. Therefore, the requested physical therapy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: The patient is a 29-year-old transgender female who has been diagnosed with gender dysphoria. Findings:the provider noted that gender affirming surgery is medically necessary for the patient. The records noted that the patient had been treated with estrogen and spironolactone. The patients breasts had developed but were small and in the range of at 32-34 A cup. The patient has requested authorization and coverage for bilateral breast augmentation. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether bilateral breast augmentation is medically necessary for the treatment of the patients medical condition. The Health Plan denied the request for bilateral breast augmentation due to the patient having developed breast tissue with hormone therapy. The presence of breast growth due to estrogen treatment does not negate the patient's gender dysphoria. The World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People states that the expected maximum effect of hormones on breast growth is two to three years. The patient has been treated with hormone therapy since 2013. WPATH also states that the criteria for breast surgery for an adult includes well-documented gender dysphoria, capacity to consent, and that any co-occurring medical and mental illnesses are reasonably well-controlled. Gender affirming/confirming treatments and surgical procedures have proven to be beneficial and effective for patients with transsexualism or gender dysphoria (WPATH). The medical evidence supports the requested services in this clinical setting. Therefore, bilateral breast augmentation is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 authorization and coverage for transcranial magnetic stimulation. Findings:  Two of the three physician reviewers found that the submitted documentation supports the requested services in this patients case. One study reported in a multicenter prospective trial that the use of single pulse transcranial magnetic stimulation has a beneficial effect in reducing the number of headache days and headache intensity for patients with migraine headaches. Other medical literature stated that transcranial magnetic stimulation was an effective treatment for migraine. The study noted that this treatment modality had the added advantages of being safe and well-tolerated by patients. The use of single pulse transcranial magnetic stimulation is likely to be beneficial in this clinical setting. This patient has experienced reduced frequency and intensity of migraine headaches with transcranial magnetic stimulation. Thus, transcranial magnetic stimulation is likely to be of greater benefit than other treatment options.Final Result: The two of the three physician reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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 reimbursement for intensive outpatient services. The progress notes during the disputed period indicate that the patient was minimally cooperative in treatment. Per the records, the patient had limited insight into her need for treatment. During the disputed timeframe, the patient was not expressing active suicidal ideation. She showed minimal commitment to therapy and also exhibited counterproductive behaviors. The patient continued to have symptoms of depression and anxiety. Overall, the submitted documentation indicated poor judgment and insight and impulsive behaviors. The records indicate that she was at continued risk for substance use as well as relapse. In cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 2 due to recent impulsive behaviors. With regards to functional status, the records support a score of 2 due to some problems in interpersonal interaction and school issues secondary to anxiety and substance use. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 3. The records documented overall medical stability with mental health issues including anxiety and depression. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living environment but strained relationship with family. In terms of level of support of the recovery environment, the records support a score of 2 due to supportive resources. With regards to treatment and recovery history, the records support a score of 3 due to minimal recent treatment response in the intensive outpatient program but consideration of continued depression and possible substance use. In terms of engagement and recovery status, the records support a score of 3 due to fair cooperation in treatment but limited ability to accept responsibility for recovery. Thus, the patient has a composite score of 17. This score correlates with intensive outpatient program level of care. Therefore, intensive outpatient services were medically necessary for the 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 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: The patient has requested reimbursement and prospective authorization and coverage for hyaluronan injections to the bilateral knees every six months. An exhaustive review of medical literature pertaining to the viscosupplementation at issue reveals mixed results. Evidence suggests that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown as to which patients will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. Current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons (AAOS) indicate that the evidence is not conclusive. As such, the AAOS does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, guidelines reserve viscosupplementation for patients with a history of lasting benefit from prior injections and in carefully selected cases where treatment options are limited. In this case, the patient reports excellent results from viscosupplementation since 2014, with reduced need for taking non-steroidal anti-inflammatory drugs and discontinuation of opioids. Furthermore, the remaining treatment options are limited, with the alternative being a total knee arthroplasty. As such, hyaluronan injections received to the bilateral knees, every six months, were and are medically necessary for treatment of osteoarthritis of the patients knees. Final Result: The reviewer determined that the 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Aimovig and Botox (taken together). To date, there is a paucity of literature evaluating the use of Aimovig or any CGRP-based agents in patients concurrently receiving Botox injections. The trials of Aimovig and other CGRP agents have evaluated patients who did not receive Botox for a few months prior to the start of therapy. Furthermore, recent practice guidance from professional societies does not support the use of the CGRP drugs with Botox. Guidance from the American Headache Society suggests that there may be a role for the use of Aimovig or other CGRP drugs in combination with oral prophylactic therapies. However, the AHS was silent on the use of multiple injectable agents in the treatment of migraines. Therefore, the requested Aimovig and Botox (taken together) are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested medication regimen 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:  One reviewer is board certified in neurology and is actively practicing. One Reviewer is board certified in neurology with subspecialty certification in sleep medicine and is actively practicing.  One Reviewer is board certified in neurology and subspecialty certification in pain management 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the the gene test. Mutations associated with the clinical diagnosis of NF1 disrupt the function of the NF1 gene. Due to the large size of the gene and the heterogeneity of mutations, molecular testing includes sequencing of all of the coding exons as well as tests for deletions or rearrangements of a portion or the entire gene. Molecular testing has been reported to find the causative DNA mutation in approximately 95% of patients who carry the clinical diagnosis of NF1. As there are several conditions that can present with features similar to NF1, but require different strategies and have different recurrence risks, a diagnosis is critical. If the NF1 mutation testing is negative, then the provider may perform mutation testing to evaluate for Legius syndrome. If both are negative, then the provider may recommend genetic testing of the four mismatch repair genes or Noonan syndrome. Medical literature supports molecular testing of the NF1 gene in this case as the best evidence-based practice. Therefore, the gene test was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in pediatrics with subspecialty certification in genetics and is actively practicing. One Reviewer is board certified in pediatrics with subspecialty certification in genetics and is actively practicing.  One Reviewer is board certified in pediatrics with subspecialty certification in genetics 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.