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 for residential treatment center services provided.  Findings:  The physician reviewer found that : Residential treatment center services provided  for the dates in question were not medically necessary for treatment of the patients behavioral health condition. The patient had no documented post-acute withdrawal symptoms. There was no evidence of suicidality or homicidal ideation. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the residential level of care. She was medically and psychiatrically stable and she did not require a 24-hour facility for the remainder of her care. Although her baseline was anxious, there was no evidence of a high degree of agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with her care in a less restrictive treatment setting. She was motivated and appeared to be working the program. The patient no longer required the restrictive residential setting, her recovery efforts could have continued on an ambulatory level of care with 12-step community support and a sponsor, along with outpatient counseling. Thus, the services at issue were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewers determined that the services at issue were not medically necessary for treatment of the patients medical condition. Credentials/Qualifications: Physician reviewer number two is board certified in psychiatry with sub-specialty certification 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a female enrollee has requested reimbursement for the allergy testing performed. Findings:  The physician reviewer found that In the case of the patient, serum IgE testing for food hypersensitivity can be an appropriate test for evaluating atopic dermatitis according to the standard guidelines for the diagnosis and management of food allergy and the current literature on allergy diagnostic testing . However, IgG4 and IgG4 subclass antibody testing for evaluating food allergy and food allergy related conditions such as atopic dermatitis, do not have clinical relevance, are not validated, and lack sufficient quality control  Thus, the serum IgE food sensitivity testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy while the IgG4 food sensitivity testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that a portion of the testing 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 partially overturned. Credentials/Qualifications: Physician reviewer number1 is board certified in pediatrics with sub-specialty certification in allergy and immunology and is actively practicing. Physician reviewer number 2 and 3 are board certified in internal medicine with sub-specialty certification in allergy and immunology and are  actively practicing
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The parent of 10-year-old male enrollee has requested authorization and coverage for social skills group speech therapy. Findings:  The physician reviewer found that a study reviewed social skills groups for people aged 6 to 21 with autism. The authors reported that there is some evidence that social skills groups can improve social competence for some children and adolescents with autism, however more research is needed to draw more robust conclusions, especially with respect to improvements in quality of life. Another systematic review noted that Social skills interventions presently appear modestly effective for youth with [autism spectrum disorder] ASD, but may not generalize to school settings or self-reported social behavior. In this case, the patients pragmatic skill delays are due to behaviors associated with an autism spectrum disorder and likely further complicated by ADHD. His scoring on standardized measures of less than 1.5 standard deviations below the mean does not support speech therapy treatment, which is typically reserved for individuals scoring two standard deviations below the mean. The Health Plans recommendation for ABA to address the patients social communications skills is medically reasonable and appropriate. Based on the documentation submitted for review, the request for social skills group speech therapy has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral 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 parent of an enrollee has requested reimbursement for partial hospitalization program (PHP) treatment level of care services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the PHP treatment level of care services provided was medically necessary for treatment of the patients medical condition. During the dates in dispute, the patient had recurrence of symptoms that included anxiety, panic, paranoia and psychosis. Continued treatment at the PHP level of care was medically indicated due to the degree of the patients symptoms. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anterior optical coherence tomography (OCT) performed.  Findings:  The physician reviewers found that the standard test for evaluating the anterior chamber angles is gonioscopy. Anterior segment optical coherence tomography is a newer imaging modality that can be used to visualize and document the extent of narrow angles . In clinical practice, anterior segment optical coherence tomography is used in addition to gonioscopy and not instead of gonioscopy. Thus, without documentation of the results of gonioscopy to first determine the degree of narrow angles, the anterior segment optical coherence tomography was not clinically indicated. Therefore, the anterior optical coherence tomography performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in ophthalmology 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 authorization and coverage for Epclusa-sofosbuvir-velpatasvir tablet 400/100 mg for 12 weeks. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies to all patients, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment naive, genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate (98%) with this regimen . AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, Epclusa-sofosbuvir-velpatasvir tablets 400/100 mg for 12 weeks for the treatment of this patients hepatitis C infection is medically necessary. 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 for the partial hospitalization program (PHP) services provided at The Ranch on the Piney River, Inc., and the psychiatric residential treatment center (RTC) services provided at McLean Hospital. Findings:  The physician reviewer found that based on the available documentation, the PHP services provided at The Ranch on the Piney River, Inc., were medically necessary for treatment of this patients medical condition as she required a comprehensive, multi-disciplinary, multimodal course of treatment, including routine observation and supervision as well as behavioral intervention to maximize functioning and minimize risks of relapse. However, the psychiatric RTC services provided from at McLean Hospital were not medically necessary as there is a lack of clinical evidence that the patient could not have been treated at a lower level of care such as outpatient treatment following discharge from the PHP. Thus, the PHP services provided at The Ranch on the Piney River, Inc., were medically necessary and the RTC services provided at McLean Hospital were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty. Findings:  Three physician reviewers found that the records fail to demonstrate the superior effectiveness of the requested services.  In this case, the pulmonary function tests are not diagnostic of obstructive lung disease alone and show a mixed pattern with restriction on spirometry with evidence of hyperinflation. The bronchodilator response does not show improvement in forced expiratory volume 1 (FEV1) alone, but instead both the FEV1 and forced vital capacity (FVC) increase proportionately. Most concerning is the low diffusing capacity of the lungs for carbon monoxide (DLCO), which is not characteristic of asthma alone and may represent other alveolar processes, such as chronic fixed airways obstruction. There is a lack of history provided prior to 2015 detailing the patients asthma history, medication use, symptoms, steroid use and frequency of exacerbations, which are important in determining if patient is a candidate for bronchial thermoplasty. This patient has numerous other comorbidities which may explain the persistent symptoms, including morbid obesity, obstructive sleep apnea, diabetes and chronic sinusitis.  The severity of the obesity is concerning and may play a significant role in patient symptomology. Additionally, the presence of tracheobronchopathia osteochondroplastica (TBOP) with mild obstruction of lower lobe and middle lobe airways and history of recurrent pneumonias is likely to be a relative contraindication to bronchial thermoplasty.  The medical evidence does not support the requested services in this clinical setting.  In sum, the requested bronchial thermoplasty is not likely to be of greater benefit than other treatment options. Final Result: 2 of 3 reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Belsomra tablet 20 mg. Findings:  The physician reviewer found that : current practice guidelines have long recommended non-pharmacological therapy for the treatment of insomnia . There are indications for the use for pharmacotherapy for patients with insomnia in certain situations . While studies have been completed in individual drugs that have been approved for the treatment of insomnia, there is a lack of comparative evidence of efficacy. A study  noted that the comparative effectiveness and long-term efficacy of pharmacotherapies for insomnia are not known. Recently published guidelines form the American Academy of Sleep Medicine (AASM) on pharmacotherapy in insomnia also failed to provide evidence of superiority of any specific agent for insomnia with all of the drugs receiving a weak recommendation. Ultimately, the current literature does not demonstrate that Belsomra is more effective than zaleplon and there is no documentation that the patient has been tried on and failed, or has a contraindication to treatment with zaleplon. Therefore the requested Belsomra tablet 20 mg is not supported as medically necessary for treatment of this patients insomnia. Final Result: The reviewer determined that the requested medication 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 with sub-specialty certification 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator. Findings:  The physician reviewer found that review of the submitted documentation indicates the patient has an AHI of 51.8. Although the U.S. Food and Drug Administration (FDA) indicates hypoglossal nerve stimulator implantation may be appropriate for patients with moderate to severe OSA with an AHI of 20 or more, but less than or equal to 60, there remains insufficient scientific data from independent researchers demonstrating the requested service is superior to standard therapy. While some studies suggest that hypoglossal nerve stimulation in treatment of OSA can provide a beneficial outcome with minimal adverse events, most of these studies are funded by the manufacturer. At this time, there is inadequate data from independent, well-designed, blinded studies comparing this therapy to standard available treatment options. As such, there is a lack of data demonstrating that hypoglossal nerve stimulation is superior to standard available therapy for patients with OSA. Given these findings, the requested hypoglossal nerve stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The  2 of 3 reviewers determined that the requested service 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 & 3 are board certified in otolaryngology and are 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 eight sessions of occupational therapy. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested services in this clinical setting. The medical studies indicate that oral aversion develops in many children, including in healthy children.  Rates are higher in the setting of a relevant medical condition or developmental disability. There are few high-quality studies of these disorders in children whose oral aversion is not sufficiently severe enough to require a feeding tube, as in this patients case.  The patient is well grown and there is no mention in his history of chronic respiratory problems which might indicate chronic aspiration of food or liquid.  There is no laboratory data to demonstrate the presence or absence of micronutrient deficiency, such as iron or vitamin D, which can occur with restricted dietary range. There is also no description of any speech impairment. Moreover, there is a statement in the provided documentation that he had a feeding evaluation performed which indicates that the patient can eat and drink safely.  It is unclear whether the evaluation performed included a fluoroscopic evaluation as well as a bedside/clinic evaluation. In this patients case, the documentation does not demonstrate that he is malnourished or has inadequate oral motor skills, or that he has mucosal damage from frequent vomiting.  In the absence of such findings, eight sessions of occupational therapy is 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 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 Makena in weekly dosage starting at 24 weeks to 36 weeks of pregnancy for treatment of the enrollees high risk pregnancy. Findings: The physician reviewer found that as noted by the American College of Obstetricians and Gynecologists (ACOG), in its practice bulletin, a woman with a singleton gestation and a prior spontaneous preterm singleton birth should be offered progesterone supplementation starting at 16-24 weeks of gestation, regardless of transvaginal ultrasound cervical length, to reduce the risk of recurrent spontaneous preterm birth. However, the ACOG further noted that progesterone treatment does not reduce the incidence of preterm birth in women with twin or triplet gestations and, therefore, is not recommended as an intervention to prevent preterm birth in women with multiple gestations. Thus, the ACOG supports progesterone treatment for the prevention of preterm birth in patients with a history of preterm delivery, in singleton gestations only. The records indicate that this patient has a twin gestation. Therefore, the requested Makena in weekly dosage starting at 24 weeks to 36 weeks of pregnancy does not meet the standard of care. Final Result: The reviewer determined that the requested medication 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 obstetrics and gynecology 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.