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

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient treatment for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that In this clinical setting, the services at issue were not and are not medically necessary. The patient was not a danger to himself or to others. He was medically stable and he was not on any psychiatric medications. He did not demonstrate symptoms of delusions, hallucinations, paranoia, or mania. He did experience social anxiety. He remained sober and had . There were no emotional, behavioral, cognitive, or impulsive behaviors that would warrant intensive outpatient program level of care. His activities of daily living were intact. He was actively engaged in the program and demonstrated motivation by attending four Alcoholics Anonymous meetings per week, obtaining a sponsor, working on relapse prevention, using his workbook, and completing assignments. The documentation notes that he had improved and there was no evidence to suggest that treatment at a lower level of care would exacerbate his condition or lead to a relapse. He no longer required the structured setting of multiple days per week/multiple hours per day in an intensive outpatient program level of care. He could have continued his recovery in an outpatient setting with community support in 12 step meetings, his sponsor, and other outpatient services such as counseling. For these reasons, the intensive outpatient treatment was not and are not medically necessary for treatment of this 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 psychiatry with sub-specialty certification in addiction 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Botox injection performed Findings:  The physician reviewer found that the patient is  under evaluation and management for pelvic floor dysfunction.  the patient has constipation and significant straining with defecation.  This was evaluated with a dynamic magnetic resonance imaging (MRI) which suggested dysmotility and demonstrated mucosal prolapse with straining. Colonoscopy was unremarkable.  He achieved some benefit with anal manometry directed biofeedback.  A colonic transit study was normal.  The patient has requested reimbursement for Botox injection performed on 8/31/16.  Per the Health Plan, the services at issue were investigational for the treatment of this patient. This patient apparently is experiencing dyssynergic defecation. In patients with dyssynergic defecation, ineffective defecation is associated with a failure to relax, or inappropriate contraction of, the puborectalis and external anal sphincter muscles. This narrows the anorectal angle and increases the pressures of the anal canal so that evacuation is less effective.  Relaxation of these muscles involves cortical inhibition of the spinal reflex during defecation; thus, this pattern may represent a conscious or unconscious act.  The pathogenesis of dyssynergic defecation is not completely understood, but it is probably multifactorial.  It is thought to be an acquired, learned dysfunction rather than an organic or neurogenic disease.  Manometric diagnostic criteria for dyssynergic defecation include inappropriate contraction of the pelvic floor or less than 20 percent relaxation of basal resting sphincter pressure with adequate propulsive forces during attempted defecation.  Ultimately, treatment rests on biofeedback to retrain the pelvic musculature.  This is performed in a motility lab. Biofeedback is combined with laxatives, either osmotic or stimulant.  There is a lack of support for the services at issue in this clinical setting.  All told, Botox injection performed on the date of dispute was not likely to have been superior over other treatment options. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are expert sin 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: ean nrollee has requested authorization and coverage for Zepatier 50/100 mg at a quantity of 28 per 28 days for 12 weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies regardless of fibrosis score. The guidelines recommend that treatment naive genotype 1b patients should be treated with Zepatier for 12 weeks, regardless of NS5A resistance testing results. These guideline recommendations are based on high quality clinical trial data. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for oral nutritional supplement, Neocate Junior. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity for requested nutritional supplement in this clinical setting. EoE is an atopic disorder leading to inflammation of the esophagus and associated symptoms of dysphagia, nausea, and abdominal pain with associated poor weight gain.  Although there is some support in the medical literature that an elemental diet can be an effective management of EoE, more focused elimination diets lead to remission in up to 45 percent of cases. In this patients case, the documentation indicates that his dysphagia and esophageal eosinophilia have resolved with avoidance of peanut, soy, and wheat.  Although, this patient continues to have slow growth and evidence of mild malnutrition based on his growth charts, he is able to take food with dairy and is noted to consume milk daily. He does not have dysphagia to solids. As such, the patient should be able to tolerate high-calorie dairy foods as well as other high-calorie foods that do not contain peanut, soy, or wheat.  Additionally, the provider describes early satiety and so a trial of an appetite stimulant may be indicated.  Furthermore, it may be reasonable to consider an avoidant restrictive food intake disorder or other contributing factors for the patients inadequate caloric intake. Final Result: The reviewer determined that the nutritional supplement is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential rehabilitation for treatment of the enrollees behavioral health conditions.Findings:  The physician reviewer found that by report, the patient had difficulty maintaining sobriety on his own.  He was not a danger to himself or others, and was not manic.  He showed no signs of psychosis.  He was medically stable.  In 2016, he had failed multiple outpatient detoxification attempts.  His motivation was questionable, and he was in need of education and assistance in learning coping skills to maintain sobriety.  His relapse risk was high, and he had been authorized to receive care at transitional residential treatment.  However, the patient opted for the day treatment program, at which he did quite well, successfully graduating.  He developed motivation and received education regarding relapse prevention, and at that point he could have continued his recovery at an outpatient level of care with community support such as a 12-step program with a sponsor.  The records do not provide a rationale for the contention that he would have required the level of care or services, which was a dual diagnosis facility; either prior to starting the day treatment program or after graduation. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 digital breast tomosynthesis for the evaluation for her breast cancer screening. Findings:  Three physician reviewers found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, considering the prior history of calcifications and that this study was performed in part to evaluate those calcifications, it was reasonable to perform tomosynthesis to separate out the overlapping structures.  In spite of the fatty density of her breasts, especially when the prior mammogram was not immediately available for comparison, tomosynthesis allows the possibility of demonstrating an otherwise occult tumor, by better delineating the calcifications and excluding an associated mass. Final Result: The reviewers determined that the service 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: Physician reviewers 1, 2 and 3 are board certified in diagnostic radiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of her breast screening mammogram. Findings:  Two physician reviewers found that the report revealed fatty tissue but no evidence of malignancy was noted. The Health Plan has denied reimbursement for digital breast tomosynthesis. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two dimensional imaging alone.  Thus, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely of greater benefit to the patient than had her examination been performed using two dimensional imaging alone. Final Result: The reviewers determined that the service 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: All three reviewers 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: An enrollee has requested reimbursement for partial hospitalization program (PHP) mental health treatment  for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that the documentation does not support the medical necessity for the services at issue in this clinical setting. This patient had no post-acute withdrawal symptoms. She was not a danger to herself or others. She was medically stable. Moreover, her psychotropic medications did not require PHP level of care for management. She was not manic or psychotic. She was actively engaged in her treatment plan, and awaiting anticraving medication. She was motivated for recovery and future oriented. Her family was supportive. She had an extensive treatment at intensive outpatient program (IOP) from April 2016 through her admission at the end of November 2016, which amounted to approximately six months. The services at the IOP level of care would have given her a strong educational platform from which to build her coping skills and relapse prevention. Although, the patient continued to struggle with her emotions and presented a risk for relapse, treatment to help her further develop coping skills could have been accomplished at a lower level of care such as resumption of IOP services. 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 with sub-specialty certification in addiction 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 12 weeks for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the most 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. The current guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient psychiatric treatment for treatment of the enrollees delusions and hallucinations. Findings:  The physician reviewer found that based on the available documentation, the services could not have reasonably been delivered effectively at a less restrictive setting. The patient had a serious underlying formal thought disorder as evidenced by her hospitalization two months prior and complicated by her substance use, non-adherence with medications, and lack of family support. The patient was guarded, suspicious and delusional. The patient was deemed to be gravely disabled due to an inability to provide self-care secondary to her psychosis. The patient required antipsychotic medication for her agitation and three days later she was described as more disorganized. A conservatorship was approved and the patient was started on a long-acting injectable antipsychotic medication. An additional oral antipsychotic medication was added due to her persistent psychotic burden and delusional thought process. The patient was paranoid and hallucinating. The patient was agitated and disorganized and her delusions were more prominent. The patient believed that people could read her mind and she threw a chair at another person which prompted emergency treatment with an antipsychotic and benzodiazepine. Her oral antipsychotic was increased that day as well. The patient was less agitated with no aggressiveness. In sum, the inpatient stay more than likely prevented undue morbidity, unnecessary risk to the community and prompt re-admission to the hospital. Considering the severity of her illness burden, retaining this patient in the inpatient setting until the establishment of conservatorship and formalization of aftercare planning was appropriate. Further, the acute inpatient setting remained safe, appropriate, consistent with good medical practice in the U.S., and is reasonably expected to both improve the patients condition and prevent a more serious episode of illness. Overall, the patient should be afforded the opportunity to stabilize and consolidate the treatment gains before transitioning to an appropriate, less restrictive treatment setting. 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 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 authorization and coverage for admission to an acute neurorehabilitation treatment facility. Findings:  The physician reviewer found that this patient has received two weeks of acute level inpatient rehabilitation and ten days of skilled nursing facility level rehabilitation. The documentation indicates that this patient has progressed functionally with his therapies. However, the submitted records indicate that this patient only had minimal functional gains at the skilled nursing facility (SNF) level of rehabilitation. His function upon admission to SNF was similar to what it was when he discharged from acute rehabilitation. While this patient has persistent functional deficits and significant safety concerns, the medical literature does not support the requested services at an acute neurorehabilitation facility. This patient will benefit from skilled level outpatient physical therapy, occupational therapy, and speech therapy to work on safety, endurance, ambulation, balance, and ADLs. The outpatient therapies will also benefit his mild cognitive deficits. For these reasons, the requested authorization and coverage for admission to an acute neurorehabilitation treatment facility is not medically necessary 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 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.