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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) level of care mental health services. At the time of admission, the patient did not meet the American Psychiatric Association (APA) requirements for treatment at the PHP level of care. She was not suicidal, homicidal or psychotic, and her level of functioning was not deteriorating. The patients mood has improved and she has responded well to medications. The patients current symptoms can be safely and adequately addresses in the outpatient venue. DBT is the first-line treatment for self-harm and borderline personality traits. In addition, intensive family therapy is indicated for the treatment of the patients reactive attachment disorder. All told, the PHP level of care mental health services were 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 expertise 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 authorization and coverage for Orthovisc. The submitted documentation supports the requested medication in this clinical setting. The medical literature supports the use of viscosupplementation for osteoarthritis of the knees. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors noted that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Per the authors, viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Therefore, Orthovisc 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 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 authorization and coverage for cryoablation of the metastatic tumor at the right chest wall. In a peer-reviewed medical literature reported on percutaneous ablation of musculoskeletal metastases. The authors noted that this treatment modality may result in significant pain palliation, prevention of morbidity from skeletal-related events, and local tumor control. The authors concluded that this minimally invasive approach has unique advantages compared with surgery or radiation therapy. In addition, `many studies have shown that percutaneous ablation of a painful bone metastasis can significantly and sustainably reduce symptoms. Thus, the literature does support the use of cryoablation for bone metastasis for the purpose of palliating bone pain and local tumor control. Given this support, the requested cryoablation of the metastatic tumor at the right chest wall is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested cryoablation of the metastatic tumor at the right chest wall is 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 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:  One reviewer is board certified in diagnostic radiology and is actively practicing. One Reviewer is board certified in diagnostic radiology and is actively practicing.  One Reviewer is board certified in diagnostic radiology 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 almotriptan malate 12.5 mg tablets, 30 pills every 30 days.  The submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. The treatment of chronic migraine should be centered on prophylactic therapy and lifestyle modification with limitation of acute headache medications. Chronic use of acute migraine therapies predisposes a patient to medication overuse headache. There is evidence to suggest effectiveness of a large number of medications including, but not limited to, topiramate, onabotulinumtoxinA, propranolol, amitriptyline, valproic acid, gabapentin, memantine, zonisamide, and candesartan. Medication overuse headache describes a headache occurring 15 or more days a month and developing as a result of overuse of acute headache medications for an extended period of time. Triptan overuse is one of the most common causes of medication overuse headache. There is a lack of evidence supporting the requested medication quantity in this clinical setting. Therefore, almotriptan malate 12.5 mg tablets, 30 pills every 30 days is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lynparza (olaparib) 150 mg, twice daily. Olaparib is FDA approved for the maintenance treatment of recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer in patients who are in a complete or partial response to platinum-based chemotherapy. This is also supported by the NCCN guidelines. This patient has received second line, platinum-based therapy and meets criteria. She was on a previous PARP (poly [ADP-ribose] polymerase) inhibitor for such a short amount of time that it would likely not be considered significant. The use of olaparib in this patient is reasonable and medically necessary. Therefore, Lynparza (olaparib) 150 mg, twice daily is medically necessary for 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 medical oncology and hematology 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 Afrezza. Findings: Two of the three physician reviewers found that Afrezza inhalation powder is a rapid-acting Technosphere insulin administered via a breath-powered oral inhaler to patients with diabetes requiring prandial insulin.  Although it achieved the pre-specified non-inferiority margin of 0.4% as compared to injections of rapid acting insulin in a recent trial, patients with type 1 diabetes who received Afrezza demonstrated less reduction in hemoglobin A1c levels per the review by researchers. In this patients case, the records do not establish the superiority of Afrezza as compared to injectable insulin. Therefore, Afrezza is not likely to be of greater benefit than other available treatment options. Final Result: The reviewers determined that the requested medication 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 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for pulsed dye laser treatment to the left lower lip. The submitted documentation fails to demonstrate the medical necessity of the requested services. The medical records indicate that the lesion has been asymptomatic and has not bled. Therefore, the requested pulsed dye laser treatment to the left lower lip is not medically necessary. An angioma is not considered to be an abnormal structure of the body. The lesion is not causing any functional impairment, and the requested services will only provide a minimal improvement in the appearance of the patient. Therefore, the requested services are not reconstructive in nature. In sum, the requested pulsed dye laser treatment to the left lower lip is not medically necessary and is not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in dermatology 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: A 26-year-old female enrollee has requested authorization and coverage for weekly individual outpatient therapy. Findings:  The physician reviewer found that the American Psychiatric Association (APA) noted that regardless of the type of depression-focused psychotherapy that is selected, the clinician should carefully and systematically monitor the patients response to treatment, which can be facilitated by the use of clinician and patient rated scales at regular intervals. If 4-8 weeks of treatment do not yield at least moderate improvement (20% diminution in symptoms), the clinician should thoroughly review and reappraise the treatment plan. In this case, the patient has improved with treatment. She has also expressed her preference for outpatient services rather than more restrictive PHP, which is not indicated at this time. In terms of outpatient therapy, current mental health practice is focused on aggressive treatment of psychiatric illness in the acute phase of illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Thus, weekly sessions are oftentimes indicated, particularly following psychiatric hospitalization. Psychotherapy is a first-line intervention for depression, anxiety, and eating disorder, especially in this clinical setting. Thus, weekly therapy is appropriate and reasonably expected to help the patient consolidate her recent treatment gains and prevent a more serious episode of illness. The medical records support an initial eight week course of weekly individual outpatient therapy as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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 reimbursement for residential mental health treatment services.  The submitted records fail to demonstrate the medical necessity of the services at issue. Although still ill and in need of comprehensive care delivered in accordance with a multidisciplinary treatment plan, the clinical note described a calm patient with reasonable insight. She was having mild ideas of reference and delusional thinking, but her thought processing was linear and organized. She was not gravely disabled. Her mood was good. She did not have any suicidal ideations or homicidal thoughts. There was no mention of aggressive or disruptive behavior, or an inability to attend to her activities of daily living. She was clean and sober, and taking her psychotropic medications, including a new antipsychotic that helped reduce her paranoia.  She did not have medical issues that would warrant service delivery at the residential level of care. The records indicate that the patient had quickly reconstituted from a brief exacerbation of symptoms in context of chronic mental illness and possible medication non-adherence.  There was no evidence that partial hospitalization in a supportive living environment would have been unsafe or inadequate at the time. Thus, residential mental health treatment services were not medically necessary for the 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for services. The records indicate that the patient had a long history of mental illness that included a history of autism spectrum disorder. The progress notes indicate that the patients sedation was well-documented by his psychiatrist. He presented to a second psychiatrist to reevaluate his medications due to sedation. The second psychiatrist made other medication changes. There is no indication in the records that there was any emergency condition discovered. The patient was on two medications that are well-known for causing sedation. The records do not demonstrate an emergent need for evaluation. Rather, the patients symptoms appear to be standard side effects that would occur with these particular medications at the doses that were listed in the chart. Psychosis, self-harm and suicidal or homicidal ideation are typically considered emergencies in psychiatric care. There was no indication of dangerous symptoms which required inpatient psychiatric acute-care. The services at issue were not necessary for treatment of a psychiatric emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the services at issue were not psychiatric emergency medical services.Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 14-year-old female enrollee has requested reimbursement for the adolescent mental health residential treatment. According to the medical literature and best practice guidelines, residential treatment is used for acute stabilization and is not evidenced based for long-term type treatment. The American Academy of Child and Adolescent Psychiatry (AACAP) noted that residential treatment is appropriate when the provider has considered less restrictive resources and determined that they are either unavailable or not appropriate for the patients needs. In this patients case, less restrictive resources were available to safely and adequately address the patients needs. The patient was engaged in DBT and reported to her provider that she would continue DBT after she left residential treatment. All told, the adolescent mental health residential treatment was not medically necessary for treatment of the patients medical 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 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 authorization for hand prosthetics. Upper limb prostheses are used for amputations at any level from the hand to the shoulder. The need for a prosthesis can occur for a number of reasons, including trauma, surgery, or congenital anomalies. The primary goals of the upper limb prostheses are to restore natural appearance and function. In this case, the requested prosthesis is not purely for cosmetic reasons. The patient has partial preservation of their thumb and would be expected to be able to perform opposition with the digits of the prosthesis. The patient currently does not use their hand when in public and uses an assistive device in their right hand. Providing a partial hand prosthesis is within the standard of care for treating the patients condition and considered medically necessary.Furthermore, the patients condition constitutes an abnormal structure of the body. The amputation is an abnormality due to trauma, and a prosthesis would be expected to improve the patients function, create a normal appearance to the extent possible, and provide more than a minimal improvement in the appearance of the patients hands. Therefore, the requested hand prosthetics is medically necessary to treat the patients medical condition.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 physical medicine & 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the split night sleep study (procedure code 95811, polysomnography) and reimbursement and prospective authorization and coverage for the related continuous positive airway pressure (CPAP) supplies. The submitted documentation fails to demonstrate the medical necessity of the split night sleep study (procedure code 95811, polysomnography). In this patients case, the medical documentation noted a diagnosis of OSA dating back to 2008. A copy of the patients prior sleep test results were available and the medical records provided for review did not indicate why a repeat diagnostic sleep study was ordered for this patient. The medical records provided for review do not indicate that the patient had significant changes in her health that would have led to a change from her prior diagnosis of OSA. There was no indication of significant weight loss or an upper airway surgical procedure that would have been expected to ameliorate the patients sleep related breathing disorder. In this setting, there was no clear indication for the performance of repeat diagnostic sleep testing. Such testing would have otherwise been duplicative of services that were previously provided.However, the submitted documentation demonstrates the medical necessity of related continuous positive airway pressure (CPAP) supplies. In this patients case, the medical records noted a long-term history of CPAP use. It is usual and customary for CPAP accessories, to be replaced on a periodic basis. It is well established within current practice guidelines that CPAP supplies should be replenished on a periodic basis. This is in part to maximize patient therapy with the devices. Replenishment is generally recommended for patients who have been compliant with therapy.  Per the records, this patient was noted to have continuously used her CPAP.Final Result: The reviewer determined that a portion of the services at issue and equipment at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in neurology with a sub-specialty in sleep 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.