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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two individual therapy sessions per month with a Psychiatry Department therapist for the treatment of depression. Findings:  The physician reviewer found that According to the American Psychiatric Association, patients with co-occurring depression and substance use disorder are more likely to require hospitalization, more likely to attempt suicide, and less likely to adhere to treatment than patients with affective illness uncomplicated by substance abuse. In this case, the patient has not fully responded to the standard intervention provided by the Health Plan, and it appears that he has not been referred to a psychologist or psychiatrist for a diagnostic evaluation during this episode of illness. The patient has expressed a reasonable preference for psychotherapy to augment his chemical dependency treatment services. There is support for the requested services in this clinical setting. Specifically, a time-limited course of an evidence-based therapy is safe, appropriate, consistent with practice standards, and is reasonably expected to improve the patients condition. In sum, a course of eight individual therapy appointments delivered once every other week with systematic monitoring and re-assessment of clinical needs upon conclusion of the treatment episode is medically necessary. 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: The parent of an enrollee has requested reimbursement for residential treatment center (RTC) services. At the time of admission to the residential facility, per the nursing assessment, the patient was documented as having a neat appearance, cooperative behavior, appropriate thought process, apprehensive and depressed mood, appropriate speech and affect, and no hallucinations or delusions. The last documented substance use was in April 2016.  The provided documentation from admission to the residential facility did not contain recent reports of suicidal or homicidal ideation, aggression, self-injurious behavior, abnormal vital signs, documentation of withdrawal from substances, non-response or adverse response to medications, frequent medication changes, or difficulty with attending to activities of daily living.  The patient was documented as having an anxious and low mood at times. However, he was more frequently documented as having a good mood and attitude with cooperative behavior. He was consistently documented as having a euthymic mood in the psychiatric progress notes. There was no documentation of significant adverse effects to the medications, and there were few documented medication changes. The American Academy of Child and Adolescent Psychiatry (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth. The CASII utilizes dimensions that are relevant to the patients clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services.  Based on the patients clinical history, at the time of admission to the residential facility, the patient met CASII criteria for intensive outpatient services. Based on the provided documentation and current medical literature, treatment at the residential level of care was not medically necessary. Therefore, residential treatment center 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 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 and coverage for three uninterrupted cycles of residential treatment center services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health conditions. The submitted documentation supports the medical necessity of a portion of the requested services. Considering this case in its entirety, in particular the severity of symptoms and poorly developed sense of self, a time-limited course of residential treatment is medically necessary at this time. In the absence of a meaningful intervention, the distress stemming from the patients multitude of unresolved intrapsychic conflicts will more than likely culminate with a crisis-related hospitalization.  However, this should be framed as a brief, sub-acute, stabilizing intervention that prepares the patient for long-term outpatient care, coordinates multidisciplinary aftercare planning and facilitates a sustainable supportive living residence. In sum, it would be premature to approve a three-month residential admission at the outset. An initial four-week residential admission would be safe and reasonably expected to improve the patients condition. A longer admission would be contingent upon clinical reassessment, patient needs and appropriateness of the requested services in the context of evidence-based practice standards. Therefore, four weeks of residential treatment center services are medically necessary for the treatment of this patient.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan (Synvisc) injections - 2 units, in both knees. In the peer-reviewed medical literature, researchers concluded that hyaluronic acid as a pharmacologic intervention for knee osteoarthritis was superior to injected placebo or injected corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. The study reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. This patient presents with severe bilateral knee pain that interferes with ambulation and activities of daily living. Clinical examination findings have been consistent with x-ray findings of moderate medial compartment narrowing and patella osteophytes. Enrollee has failed to improve despite physical therapy, activity modification, and corticosteroid injections. Overall, the evidence based medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Therefore, the requested hyaluronan (Synvisc) injections - 2 units, in both knees is medically necessary for treatment of this patients bilateral knee osteoarthritis. 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a hysterectomy. The patients symptoms of pain and heaviness, feeling of a knot or ball in the vagina and discharge are consistent with pelvic organ prolapse. She has several risk factors including morbid obesity, chronic cough, and four previous vaginal deliveries. Given her morbid obesity and other comorbid factors, she is unlikely to achieve benefit from conservative medical management of her prolapse. Considering the patients degree of uterine prolapse and symptoms, it is likely she also has weakness of the surrounding vaginal walls and such an anterior and posterior repair discussed, she is a candidate for surgery. These are a variety of surgical options depending on which and to what degree of pelvic organ prolapse exists. The provider noted the patients cervix is described as at the introitus and the provider noted a grade two prolapse. The provider noted the patients morbid obesity and need to address vaginal prolapse while staying out of the abdomen support a vaginal hysterectomy as the safest surgical approach. As this patient is morbidly obese with several comorbidities, multiple surgeries should be avoided if possible. Addressing her pelvic organ prolapse in totality seems most appropriate for this specific patient. Given these findings, the requested hysterectomy is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 36 visits of cardiac rehabilitation. Findings: The physician reviewer found that based on the records provided, this patient has been diagnosed with coronary disease including recent coronary stent placement. In this circumstance of a recent coronary stent placement, cardiac rehabilitation is reasonable, appropriate and considered standard accepted practice in the medical community. There is support in the medical literature for cardiac rehabilitation after a coronary stent placement. The guidelines for patients who undergo percutaneous coronary intervention such as this patient also recommend formal cardiac rehabilitation. Therefore, 36 visits of cardiac rehabilitation has been established as medically necessary for treatment of this 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret for eight 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection, regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, Mavyret for eight weeks is medically necessary for the treatment of this patient. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc.  Findings:  The physician reviewer found that Nationally recognized evidence-based medical guidelines state that hyaluronic acid injections in the knee, such as Orthovisc, are recommended as a possible option for severe osteoarthritis for patients who have not responded adequately to recommended conservative treatments (exercise, nonsteroidal anti-inflammatory drugs or acetaminophen), to potentially delay total knee replacement. Per the current medical evidence, if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to perform another series. In this patients case, the records document a history of left knee osteoarthritis with severe pain. Clinical examination findings are consistent with reported imaging evidence of severe osteoarthritis. He had apparently failed conservative treatment, including corticosteroid injection, exercise, and nonsteroidal anti-inflammatory drugs. He had also reportedly failed prior viscosupplementation with Synvisc. The peer-reviewed literature generally supports the use of viscosupplementation for treatment of osteoarthritis of the knee. However, prior viscosupplementation had not provided significant improvement in symptoms for six months or more to support the medical necessity of another series of this type of injection. Therefore, Orthovisc is not medically necessary for the treatment of this patient. 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for DecisionDx-Melanoma testing. Findings:  The three physician reviewers found the prognosis of cutaneous melanoma has classically been determined by applying the staging system. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 or class 2, which represents the statistical risk of metastasis over five years. Most importantly, it is not clear if the assay can be used to make clinical decisions. The medical evidence has not established the superior efficacy of the services at issue. Therefore, DecisionDx-Melanoma testing was not likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 sub-specialty certification in medical oncology 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 reimbursement for anesthesia. The Health Plan has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollee, who underwent a colonoscopy. Per the medical evidence, monitored anesthesia care is warranted in prolonged or painful procedures, such as complex polyp resections, endoscopic retrograde cholangiopancreatography, endoscopic dilation, or endoscopic resection. Additionally, monitored anesthesia care may be necessary in patients with a failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, increased aspiration risk, American Society of Anesthesiologists (ASA) class III or higher, or morbid obesity. In this patients case, the records do not support the medical necessity of monitored anesthesia care. All told, anesthesia was 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 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 residential treatment center services. The submitted documentation supports the medical necessity of a portion of the services at issue. Modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. In this patients case, he was motivated for care. He self-referred for treatment and had safe housing. Prior to the admission, he had just started counseling and was going to see the therapist individually as well. This patient reported a history of complicated alcohol withdrawal. Thus, an extended period of observation at the outset was reasonably expected to prevent a more serious episode of illness. The patient rated his alcohol craving. His craving went down.  The patient was discharged from detoxification sub-specialty services. In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been unsafe or inadequate. Thus, a portion of the residential treatment center services at issue were medically necessary.  Final Result: The reviewer determined a portion of the services at issue was 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 authorization and coverage for allergy injections. Allergy shots may be indicated for persistent symptoms on a seasonal and/or perennial basis for patients with an inadequate or partial response to environmental control and medications. In this case, the medical records do not demonstrate a failure to respond to the new medication regimen, cetirizine and Flonase. The records do not establish that allergen immunotherapy is warranted at this time. As noted by colleagues, the immunotherapy build-up schedule (also called updosing, induction, or the dose-increase phase) entails administration of gradually increasing doses during a period of approximately. In conventional schedules a single dose increase is given on each visit, and the visit frequency can vary from one to three times a week. The authors noted that the maintenance phase begins when the effective therapeutic dose is reached. Once the maintenance dose is reached, the intervals between allergy injections are increased. The dose generally is the same with each injection, although modifications can be made based on several variablesthe intervals between maintenance immunotherapy injections generally range from four to eight weeks for venom and every two to four weeks for inhalant allergens but can be advanced as tolerated if clinical efficacy is maintained. In this patients case, the request is for weekly allergen immunotherapy during the maintenance phase, which is in excess of the current recommendations. As such, the request for allergy injections is not medically necessary.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 allergy and immunology 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.