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

The patient has requested reimbursement for Euflexxa injections in both knees. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history of significant benefit from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. The medical evidence supports the services at issue in this clinical setting. Therefore, Euflexxa injections in both knees 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 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

An enrollee has requested authorization and coverage for a hydrogen breath test. There is a paucity of peer-reviewed medical literature to support an indication for hydrogen breath testing to rule out small intestinal bacterial overgrowth (SIBO). Researchers did not find a statistically significant improvement in SIBO symptoms of nausea and stool frequency with probiotics versus prebiotics. There is a lack of data to support a role for hydrogen breath testing in this clinical setting. All told, the requested hydrogen breath test is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollees parent requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) gene mutation testing. The enrollee underwent methylenetetrahydrofolate reductase gene mutation testing. Her father had genetic testing, which was positive for the mutation in the methylenetetrahydrofolate reductase gene. The enrollees father reports the gene mutation test informs the enrollee of the need to avoid folic acid, which is commonly found in many processed foods and vitamin supplements. He concludes that carriers of this gene mutation have a 30% higher probability of certain cancers and must be screened appropriately based on this additional risk. Literature shows there is no indication for MTHFR mutation testing in routine clinical practice in any enrollee group. A professional society advises MTHFR genetic testing should not be ordered as part of the clinical evaluation for risk of blood clots or recurrent pregnancy loss. The presence of MTHFR mutations does not require any special treatment, such as supplementation with folic acid, vitamin B6, or vitamin B12, and no additional concerns arise because of it. This enrollee is not known to have any medical problems. Researchers report that no certain link to medical problems, such as recurrent pregnancy loss, thrombophilia, hypertension, stroke, or the risk for birth defects in offspring has been connected to MTHFR mutations.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in clinical cytogenetics and are 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: The patient has requested authorization and coverage for power wheelchair. The records indicate that this patient has sustained multiple strokes and presents with residual left-sided weakness. The records provided for review from October 2019 noted normal upper limb strength bilaterally and good lower limb strength bilaterally. She had functional active range of motion in the limbs. She demonstrated mild difficulties using her left hand. Based on the available records, the patient meets the criteria for a manual wheelchair. The patient may require a manual wheelchair with one-arm drive if her left upper limb motor function is too impaired, and the device should be fitted to allow for self-propulsion with the legs. The patient should be able to perform adequate pressure relief given that she can perform independent bed to wheelchair transfers. There are no indications in the records to establish that the patient would be bed or chair confined without a power mobility device. The patient should be able to attend college and medical appointments with a manual wheelchair. Moreover, the patient is noted to be obese. She would benefit from exercise, such as that afforded by regular use of a wheelchair propelled by her own body power. Obesity management requires comprehensive lifestyle approaches, including recommendations for exercise. Given these findings, the requested power wheelchair is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Remicade infusions at a hospital-based outpatient infusion facility with ultrasound-guided placement of intravenous (IV) lines every four weeks. Reliable IV access is required for administration of Remicade. This patient has responded well to Remicade and he has been in clinical remission. However, the patients providers have had difficulty in obtaining IV access on multiple occasions. Gupta and colleagues reported that over 40% of patients receiving Remicade require hospital-based infusions. In patients with challenging IV access, the success of IV placement can be improved or enhanced with the use of ultrasound guidance. This patient is in remission on his current dosing regimen of Remicade. Thus, he should continue with this regimen. However, given his documented poor IV access, it is appropriate for him to receive Remicade at a hospital-based infusion center with specialists trained with ultrasound assistance for IV placement. Given these findings, the requested Remicade infusions at a hospital-based outpatient infusion facility with ultrasound-guided placement of IV lines every four weeks is medically necessary for 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 with subspecialty 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Inspire hypoglossal nerve stimulator. The enrollee has severe and obstructive sleep apnea. The enrollee underwent a home sleep study, which revealed an apneahypopnea index of 60.3 events per hour and a lowest oxygen saturation value of 58 percent. The enrollee has failed continuous positive airway pressure. He has also tried the oral appliance therapy device but continues to suffer from daytime sleepiness, snoring and gasping. A five-year study by researchers indicated the treatment was effective and improved sleepiness, quality of life and respiratory outcomes. A position statement from a professional society reports upper airway stimulation can be an effective treatment of moderate-to-severe obstructive sleep apnea in individuals who do not benefit from positive airway pressure therapy. Multiple literature reviews show hypoglossal nerve stimulation is safe and effective for treating obstructive sleep apnea.Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in otolaryngology and are 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

The patient has requested reimbursement for residential treatment center (RTC) services.  Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient qualified for ASAM Level III treatment, similar to the services provided at the RTC. Given the severity of the patients illness, the RTC services were medically necessary for 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 expertise in addiction 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

The patient has requested authorization and coverage for abdominoplasty. According to the American Society of Plastic Surgeons (ASPS), when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. The ASPS noted that a cosmetic abdominoplasty is sometimes performed at the time of a functional panniculectomy or delayed pending completion of weight reduction. Abdominoplasty, typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. The medical records do not support an indication for abdominoplasty, which would not address a documented functional deficit due to the presence of the patients pannus. Therefore, the requested abdominoplasty is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement for inpatient psychiatric hospitalization level of care. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.This gives the patient a composite score which is consistent with medically monitored residence-based services. However, given the patients score for risk of harm, he qualifies for medically managed residence-based services, such as inpatient level of care. Accordingly, the inpatient psychiatric hospitalization level of care was medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested 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 expertise in addiction 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

The patients parent has requested authorization and coverage for 23 hours per week of direct applied behavioral analysis (ABA) services. The Behavior Analyst Certification Board (BACB) highlights that treatment intensity is influenced by variables, including the number, complexity, and intensity of behavioral targets and the clients own response to treatment. Based on the submitted treatment plan, this patient is engaging in low rates of challenging behaviors that are not severe in nature. The number of goals requested also does not require additional hours. Although problem behaviors are also targets, these issues are addressed as the opportunities arise. Moreover, the patient is making considerable progress, meeting 50% of the goals since the previous reporting period. According to medical literature medically necessary ABA services are required to meet the essential health needs of the patient; consistent with the diagnosis of the condition for which they are required; consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; required for purposes other than the convenience of the provider or the comfort of the patient; and rendered in the least intensive setting that is appropriate for the delivery of health care. Based on these guidelines, the patient does not meet criteria (c), as based on the treatment plan, the number of goals and severity of behavior do not warrant a more intensive level of service. All told, the requested 23 hours per week of direct ABA services 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 a licensed B.C.B.A. board certified in psychology 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

The patient has requested authorization and coverage for pulmonary rehabilitation for 36 visits. The role of pulmonary rehabilitation in the management of chronic obstructive pulmonary disease (COPD) is supported by substantial evidence. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) noted that, pulmonary rehabilitation improves symptoms, quality of live and physical and emotional participation in everyday activities. Based on the available documentation, this patients forced expiratory volume in 1 second (FEV1)-to- forced vital capacity (FVC) ratio was 0.65, confirming the presence of airflow obstruction. In addition, the frequency of exacerbations supports an indication for pulmonary rehabilitation. This patients exacerbation frequency places him in category C or D and qualifies him for pulmonary rehabilitation. All told, the requested pulmonary rehabilitation for 36 visits 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 internal medicine with subspecialty certifications in pulmonary disease and 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

The enrollee is requesting authorization and coverage for exome sequencing testing. The enrollee has a medical history of dysautonomia, Ehlers-Danlos syndrome, hypermobility syndrome, postural orthostatic tachycardia syndrome, and patellofemoral disorder.  She experiences fatigue, bruising, cool fingers and toes, oily stool and urine, arthralgias, and myalgias. She can tolerate physical activity for 30 minutes before experiencing moderate-to-severe pain and fatigue. A medical genetics consultation determined the enrollees clinical features were compatible with familial dysautonomia. A rheumatologists recommendations were for physical therapy, a gastroenterology evaluation, and additional studies for other conditions that may cause bleeding tendencies. Whole exome sequencing is a useful test for enrollees with neurodevelopmental disorders, including developmental delay, autism spectrum disorders and other genetic disorders. There is extensive literature support for the use of this test for these conditions. The clinical information reported for this enrollee does not include these findings. Studies support the use of whole-exome sequencing as a screening tool for these types of disorders. However, researchers report the optimal use of whole-exome sequencing in pediatric persons requires an understanding of who should be considered for testing and when it should be performed. Medical records do not provide information on why these tests were ordered. The medical records provide insufficient information regarding the enrollees developmental history, current intellectual functioning, or family history of similar disorders.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in clinical cytogenetics and clinical genetics 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

The enrollee is requesting authorization and coverage for breast reduction surgery. The enrollee has a history of type 2 diabetes mellitus, hypertension, high body mass index, and symptomatic macromastia. A surgical consultation reported the enrollee had breast hypertrophy, which was causing upper back pain and interfering with her ability to exercise. She has indentations in her shoulders and wears two bras for support. She reported pain in her shoulders, neck, and back, recurrent rashes, shoulder grooves, and poor posture. The enrollee reports she is unable to exercise the way she would like because her breasts are too large. The enrollee reports that if she could be more active, she could better manage her diabetes and blood pressure, and she would be able to lose weight. This enrollee demonstrates classic symptoms of macromastia, and medical treatments have not improved her symptoms.  Symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. Surgery provides the only real chance for symptomatic relief. Literature reports breast hypertrophy has a significant impact on womens health status and quality of life. In women requesting surgery, non-surgical measures were not effective in providing permanent relief of breast-related symptoms. However, both pain and overall health status were markedly improved by breast reduction. A study showed reduction mammoplasty can be a motivation for post-operative weight loss, and these individuals were more physically active, had better glucose control and improved self-confidence.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.