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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for 60-minute speech therapy sessions twice a week. Researchers reported that the results from 17 studies support the use of high-tech alternative augmentative communication devices to teach social-communication skills to individuals with autism spectrum disorder or intellectual disabilities and complex communication needs can be considered an evidence-based practice. The records provided for review establish that the current speech therapy services are successfully incorporating oral motor work, LAMP, and PROMPT approaches to improve this patients speech and language skills. Documentation by the providers report that the patient has been making good progress using these techniques. The LAMP device is the patients main form of communication. To remove access to ongoing therapy using the LAMP device would remove the patients primary mean of communication and lead to frustration and lack of developmental progress. Moreover, the records suggest that these services have not been available to the patient within the Health Plan. All told, the 60-minute speech therapy sessions twice a week were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child 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

The patient has requested reimbursement for residential treatment center (RTC) and prospective authorization and coverage for RTC services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC level of care services provided, and for an additional 28 days of RTC 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. Given the findings, the RTC services provided and 28 days of RTC level of care services, are consistent with the ASAM requirements for medically necessary mental health services. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for additional power features including tilt in space, recline, seat elevation, and power elevating leg rests for the approved Group 3 power wheelchair. A review of the literature supports the relationship between self-care and functionality of patients with multiple sclerosis as well as a multidisciplinary approach to managing and adapting to the needs of multiple sclerosis patients with disease progression. This patients DME evaluation indicates the appropriate power mobility device for this patient is a Group 3 power wheelchair with a single power option, such as tilt in space, and a pressure relief cushion. There is a lack of evidence in the documentation that the patients current medical needs and ADLs are unable to be completed without a seat elevation or power elevating leg rests. The patient does not have a history of extremity contracture or spasticity. The DME evaluation indicates that the patient requires minimum to moderate assistance for transfers without any seat elevation. In addition, the patient does not require a reclining feature to assist with bladder care or lower body dressing, as she is at minimum assistance for lower body dressing and toileting and has assistance 23 hours per day. Furthermore, the tilt in space option and pressure relief cushion on the approved Group 3 power wheelchair will address the patients medical needs as recommended in the DME evaluation. All told, the tilt in space power feature is medically necessary, while the remaining additional power features including recline, seat elevation, and power elevating leg rests for the approved Group 3 power wheelchair are not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested equipment 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for celiac plexus nerve block. A study concluded that the primary benefits celiac plexus blocks may be in reduced opiate dependence and opiate-associated side effects, which in turn improves quality of life. Celiac plexus block and neurolysis are safe and effective treatments for chronic upper abdominal pain and should be considered early in patients experiencing such symptoms. In this case, the patient has chronic abdominal pain related to multiple abdominal surgeries and has attempted non-interventional treatment in the form of cognitive behavioral therapy (CBT), a chronic pain management program, and physical therapy without substantial pain relief. She is currently taking Percocet for pain control with suboptimal results. The patients pain is severely impairing her quality of life with reports of poor sleep and the inability to sit for longer than 20 minutes. She reports having previous had celiac plexus blocks to manage her pain three to four times per year, with each injection providing several months of relief. In addition, the records indicate that the patient previously achieved adequate pain relief with celiac plexus blocks with good benefit and improvement in her quality of life. Based on the medical records available for review, the requested celiac plexus nerve block is medically necessary for 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 anesthesiology with subspecialty certification in pain management 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 Protopic (tacrolimus) 0.1% ointment. There are limited evidence-based data guiding the treatment of necrobiosis lipoidica diabeticorum, especially in children. While corticosteroids are the mainstay of therapy, they can have long-term unwanted side effects. Necrobiosis lipoidica diabeticorum can lead to ulceration and even skin cancer if not treated. Researchers reported that Protopic is an effective treatment option for patients with refractory chronic ulcerated necrobiosis lipoidica who do not want systemic oral therapy. In addition, the available data support the efficacy of Protopic 0.1% ointment after treatment with short-term corticosteroids. This patient has a diagnosis of necrobiosis lipoidica. Prior treatment with Protopic 0.1% was successful and did not produce any unwanted effects. Alternatively, the patients condition flared after changing to the 0.03% formulation of Protopic. Given these findings, the requested Protopic (tacrolimus) 0.1% ointment is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested mediation 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for individual therapy. The National Autism Center has identified effective, emerging, and unestablished treatments for autism spectrum disorder. Cognitive behavioral therapy (CBT) to treat anxiety symptoms in children with high functioning autism is an established treatment, providing support for the use of psychotherapy. The research supporting CBT as an established treatment has not included patients younger than age seven. Ung and colleagues conducted a meta-analysis on the effects of CBT on anxiety in patients ages 7-17 with high functioning autism. The authors found that CBT was effective in treating patients with autism and anxiety. According to Helps, the current data supports family psychotherapy in this clinical setting. Further, the Behavior Analyst Certification Board states that family involvement is a critical part of applied behavior analysis and that a consultative approach to therapy is appropriate for young patients with autism. In this patients case, the goals listed in the treatment plan are consultative in nature and involve the collaboration of the provider and his family. The records do not support an indication for individual therapy. Given these findings, the requested individual 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3 criteria for RTC 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 was intoxicated on admission and she was started on a 12-day Librium taper. She has continued to endorse agitation, anxiety, tremors, and sweating. The patients Clinical Institute Withdrawal Assessment (CIWA) scores have ranged from 5-12. The patient has a diagnosis of anorexia nervosa, and she is at risk of serious physical damage to her health. The patient previously required inpatient treatment six months prior to this admission due to her anorexia. The patient is noted to have psychosocial stressors of past sexual trauma and recent unemployment due to COVID-19, which place her at an increased risk of relapse. The patient has demonstrated a readiness to change, and per her relapse prevention planning, provided written documentation of insight into her condition and understanding of how her substance use affected her functioning. She has not been in opposition to treatment and is accepting responsibility for her use. The patient is in the early stage of readiness to change and is in need of engagement and motivational strategies. The patient is beginning to understand her addiction, but remains at risk of relapse in a less structured level of care. The records indicate that the patient demonstrates limited coping skills to address triggers and urges to use, and she remains at risk of relapse as result of a crisis. The patients recovery environment is not conducive to her recovery. The patient has significant stress at home due to the presence of her father in law who uses cannabis. She also works at a winery and is involved in the tastings. Based on these findings, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for Xifaxan. The enrollee has B-cell lymphoma, irritable bowel syndrome and gastroesophageal reflux disease. The enrollee was treated with a two-week course of Xifaxan one year prior for small intestinal bacterial overgrowth. On a return visit, the enrollee reported returning symptoms of bloating and diarrhea. A breath test was positive for small intestinal bacterial overgrowth. After treatment with Xifaxan (rifaximin) last year, her symptoms of bloating improved. After an endoscopy, the patient complained that her prior bloating issues have returned. Literature reports that Xifaxan (rifaximin) has been shown to normalize the hydrogen breath test and improve symptoms in small intestinal bacterial overgrowth. A governmental body has provided prescribing information for Xifaxan (rifaximin). For enrollees with irritable bowel syndrome, the dosage is 550 milligrams, three times a day, for 14 days. This enrollee has a diagnosis of irritable bowel syndrome and small bowel intestinal overgrowth. Xifaxan (rifaximin) has helped her in the past. The medical literature and prescribing information both support repeating the treatment in enrollees with relapse.  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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) services. Applying the CALOCUS framework, the patient met the criteria for the RTC services. The patient was at serious risk of harm (score 4) due to significant impulsivity and poor judgment and insight. The patients behavioral issues were significantly endangering to him as evidenced by suicidal threats and recent self-harm, as well as excessive substance use. The patient demonstrated moderate functional impairment (score 3) given his conflict with his parents, as well as recent gains made while in the structured environment of the RTC. The patient has significant comorbidities (score 3) considering his history of depression and anxiety as well as substance abuse. The patients recovery environment was moderately stressful (score 3) as the records report ongoing conflict with his family and possible abuse, bullying by peers, and struggles with parental expectations. The patients recovery environment was supportive (score 2) as his parents were active participants in his treatment and treatment planning. The patient has exhibited poor response to treatment (score 4) due to a lack of response to outpatient treatment and psychiatric hospitalization, as well as turmoil and distress caused by developmental pressures. The patients parents were constructive with treatment (score 2) given their participation in the patients treatment. This gives the patient a composite score of 21, which is consistent with medically monitored community based services. Due to a score of 4 on risk of harm, the patient qualified for Level Five, medically monitored residence based services. Furthermore, the patient met the requirements for Level 5B, intermediate stay medically monitored residence based services due to impulsivity and recent suicidal ideation, gains made in a structured setting, conflict with parents, co-occurring mental health and substance abuse, and lack of response to previous treatment. The typical length of stay at this level of care is up to 60 days. The patients stay at the RTC falls well below this upper limit. For these reasons, 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 subspecialty 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 patient has requested authorization and coverage for Xyrem 500 mg/mL solution, 4.5 grams, oral two times daily. A diagnosis of narcolepsy requires polysomnogram findings of no obstructive sleep apnea. The study should include sufficient sleep of at least six hours during the night, followed by a multiple sleep latency test (MSLT) with sleep latency less than eight minutes and two naps associated with sleep onset rapid eye movement (REM) associated with excessive daytime sleepiness. The records provided for review do not document a thorough polysomnogram or cerebral spinal fluid (CSF) orexin-A (hypocretin) level test to support a diagnosis of narcolepsy. Xyrem is indicated to treat appropriately diagnosed narcolepsy patients who have failed first-line of treatment. All told, the requested Xyrem 500 mg/mL solution, 4.5 grams, oral two times daily is not medically necessary for 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 internal medicine with subspecialty 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: 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 RTC 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. 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 subspecialty 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Xeljanz 5 mg tablets. The treatment for small vessel vasculitis includes initial immunosuppressive therapy and maintenance. In this patients case, there is no evidence of severe organ involvement and the patient appears to be in the maintenance phase. She has been treated with prednisone and rituximab as well as CellCept monotherapy and in combination with a prednisone burst. She has responded well to treatment with Xeljanz, which is a Janus kinase (JAK) inhibitor. However, there are limited studies demonstrating the safety and effectiveness of JAK inhibitors for the treatment of vasculitis. The current guidelines support treatment with azathioprine, rituximab, or methotrexate in this clinical setting. This patients records do not report that she has exhausted treatment or has a contraindication to treatment with azathioprine or methotrexate. Therefore, the requested Xeljanz 5 mg tablets are not medically necessary for 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 internal medicine with subspecialty certifications in allergy and immunology and rheumatology 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.