Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for applied behavioral analysis (ABA) assessment and direct 1:1 ABA, 12 hours per week for 3 months, and then 6 hours per week for 3 months; parent and caregiver training, 8 hours per month for 6 months; case management/supervision, 8 hours per month for 3 months, and then 5 hours per month for 3 months; assessment/indirect treatment planning 5 hours per month for 3 months, and then 2.5 hours per month for 3 months. ABA encompasses a wide-variety of techniques commonly used in the treatment of ADHD, oppositional defiant disorder, conduct disorder, and various anxiety disorders. More specifically, behavioral management training is an evidence-based treatment for problem behavior supported by extensive research for children diagnosed with ADHD and disruptive behavior disorders (Kazdin, et al.). Further research in this area indicates that behavioral treatments produce reliable and significant reductions in oppositional, aggressive, and antisocial behavior among children with behavior disorders (Kazdin, et al.). Based on this support, along with the growing breadth of research demonstrating the successful use of ABA therapy in the treatment of disorders other than autism, ABA is an appropriate treatment modality to address this patients behavioral health issues. Additionally, given the patients documented history of success with ABA therapy, ABA is the most effective available treatment for the patients diagnoses, even when compared to any available treatment modality. Therefore, the ABA assessment and direct 1:1 ABA, 12 hours per week for 3 months, and then 6 hours per week for 3 months; parent and caregiver training, 8 hours per month for 6 months; case management/supervision, 8 hours per month for 3 months, and then 5 hours per month for 3 months; assessment/indirect treatment planning 5 hours per month for 3 months, and then 2.5 hours per month for 3 months, provided from 1/1/19 and forward, were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is a licensed B.C.B.A, board certified in psychology and is actively practicing. One Reviewer is a licensed B.C.B.A, board certified in psychology and is actively practicing.  One Reviewer is a licensed B.C.B.A, board certified in psychology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 38-year-old male who has been diagnosed with gastroesophageal reflux disease and dysphagia. On 12/11/18, the patient reported acid reflux symptoms and dysphagia. The treatment plan included esophagogastroduodenoscopy (EGD). In the pre-anesthesia evaluation on 2/13/19, the patient did not have any significant cardiac or pulmonary medical history. He did not have any history of sleep apnea, and he denied any history of problems with anesthesia. He did not have any documented problems or complications with previous endoscopy or colonoscopies, and he also denied any tobacco or alcohol use. The patients body mass index was 29. His airway, cardiovascular, and pulmonary systems were evaluated and found to be normal. His airway was rated as a Mallampati class two. The patients American Society of Anesthesiology (ASA) anesthesia score was two. On 2/13/19, the patient underwent an upper gastrointestinal endoscopy with monitored anesthesia care (MAC) and administration of propofol. The patient has requested reimbursement for MAC that was provided during an endoscopy on 2/13/19. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether MAC that was provided during an endoscopy on 2/13/19 was medically necessary for the treatment of the patients medical condition. The guidelines for sedation and anesthesia in gastrointestinal endoscopy state that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA class one, two, or three. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and patients undergoing a procedure that is expected to be uncomplicated or routine. Lim and colleagues concluded that moderate sedation showed comparable safety and effectiveness to deep sedation in uncomplicated endoscopy cases. In this case, the patient did not have any cardiac or pulmonary history, and he did not have any prior complications with anesthesia administration. His Mallampati airway score and ASA score were rated as two. The physician reviewer found that the guidelines for sedation and anesthesia in gastrointestinal endoscopy do not support the use of monitored anesthesia care and general anesthesia for a patient who does not have significant health conditions or airway concerns. The medical evidence does not support the services at issue in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Korlym. The enrollee has obesity, uncontrolled diabetes and hypertension. Their blood sugar became difficult to manage with the medication regimen and the endocrinologist suspected they might have hypothyroidism or Cushings syndrome. A follow-up thyroid function test (blood work) and a standard 1mg dexamethasone suppression test were ordered. While the enrollees thyroid function test resulted in normal values, the enrollee was found to have mildly suppressed cortisol and ACTH levels. The physician indicated the enrollee's dexamethasone suppression test was positive and a CT scan of the adrenal gland was to be performed to see if the enrollee had a tumor; if not, the enrollee was to be put on Korlym. Notes indicate the enrollee was taking Jardiance, Trajenta and Fenofibrate medications.  The CT scan was negative and Korlym, medication, was prescribed. Korlym is an approved glucocorticoid receptor (GR2) antagonist used to treat adults with Cushings syndrome with concurrent hyperglycemia who have failed surgery, or are not surgical candidates. In addition to improvement in glucose metabolism, Korlym has been shown to decrease body weight and improve quality of life. Clinically, the enrollees morning cortisol levels are consistent with Cushings syndrome. However, there is a false positive rate of 20%, which improves to 5% if the cut-off is increased. This explains the need for a second test to improve the accuracy of the diagnosis. Guidelines indicate that due to the rarity of Cushings syndrome, the high prevalence of conditions, such as diabetes mellitus and obesity, and the limitations of the screening tests, the risk of false-positive test results is high. False-positive results are reduced if case detection is limited to individuals with an increased pretest probability of having the disorder, such as this enrollee. The testing strategy places higher value on reducing the number of false-positive test results, particularly in enrollees with very mild disease in whom the benefits of intervention are unproven. This enrollee has a level suggestive of, but not diagnostic of, Cushings syndrome because there is no evidence in the record of a confirmatory second test prior to her diagnosis of Cushings syndrome.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology, diabetes and metabolism 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an implantable loop recorder device. Implantable loop recorders can be helpful in evaluating patients with recurrent infrequent syncope of undetermined cause. Based on the records provided for review, this patient has a longstanding history of intermittent palpitations. There is no documentation of prior syncope. Attempts at monitoring with a Holter device while the patient was experiencing symptoms did not demonstrate significant dysrhythmias. The results of the event monitor should provide some data regarding the patients cardiac rhythm during symptoms. Overall, the records support that a long-term off-line event monitor would have been sufficient to evaluate the patients palpitations. In the absence of recurrent unexplained syncope or significant arrhythmias on Holter monitor during symptoms, an implantable loop recorder device was not indicated. Therefore, the implantable loop recorder device was not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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 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: The patient has requested reimbursement for inpatient detoxification services. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether inpatient detoxification services that were received were medically necessary for the treatment of the patients medical condition. ECT involves inducing a controlled seizure in a patient. Sedatives like clonazepam prevent seizures. A patient taking significant doses of sedatives can therefore not achieve the seizures needed for ECT to be successful. The American Society of Addiction Medicine (ASAM) criteria is the most widely used and comprehensive set of guideline for placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions. There are six dimensions of ASAM level 3.5 criteria. For acute intoxication and/or withdrawal potential, the patient reported experiencing withdrawal symptoms, including hallucinations. For biomedical conditions/complications, the patient was medically unstable given her hallucinations. For emotional/behavioral/cognitive conditions and complications, the patient was diagnosed with depression and was being treated with ECT. The patient also reported suicidal ideation and had a history of a previous suicide attempt. For readiness to change, the patient was noted to be apprehensive about detoxification. For relapse/continued use/continued problem potential, the patients relapse potential is high due to her depression. For recovery environment, the patient reported marital stress. Her husband did participate in her treatment. In this case, the patient was experiencing benzodiazepine withdrawal with hallucinations. This was a medical emergency requiring inpatient admission for detoxification. The medical evidence supports the services at issue in this clinical setting. Therefore, inpatient detoxification services that were received were medically necessary for the treatment of the patient. Final Result: The reviewer determined that the requested services 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 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

The authors noted that viscosupplementation was not superior to the use of a corticosteroid injection. Maheu and colleagues recommended intra-articular hyaluronic acid (IAHA) injections as a treatment option in the management of knee osteoarthritis, tailored by disease stage and patient phenotype. The authors indicated that future research efforts should focus on identification of osteoarthritis patient subgroups that demonstrate a more robust response to IAHA, determination of long-term effects of repeat IAHA injections on patient-reported outcomes and total knee replacement-sparing effect, further elucidation of disease-modifying effects, and the potential for combination therapy with other pharmacologic and non-pharmacologic therapies to optimize the management of knee osteoarthritis.This patient presents with left knee pain that interferes with activities of daily living. Clinical examination findings are consistent with radiographic evidence of minimal to mild medial and patellofemoral compartment osteoarthritis. Her prior conservative treatment has included a corticosteroid injection on 4/02/19, with no documentation of response. Over-the-counter nonsteroidal anti-inflammatory drugs have not been beneficial. The physician reviewer found that the current literature does not support the use of viscosupplementation in the setting of mild knee osteoarthritis. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has not been submitted. Thus, Euflexxa injections in the left knee are not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested authorization and coverage for combined superficial temporal artery (STA)-middle cerebral artery (MCA) and indirect bypass surgical procedures. Moyamoya disease is a progressive occlusive vasculopathy that involves the supraclinoid internal carotid arteries and Circle of Willis, and results in the formation of collateral vessels at the skull base. The progressive nature of this disease leads to cerebral ischemia and possible intracerebral hemorrhage. The physician reviewer found that  treatment of moyamoya disease is mainly surgical revascularization, using revascularization techniques that include direct, indirect, and combined strategies. This patient is symptomatic. A magnetic resonance imaging (MRI) scan demonstrated severe right supraclinoid ICA stenosis and left internal carotid artery (ICA) occlusion. Therefore, the requested combined STA-MCA and indirect bypass surgical procedures are medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a four-dimensional (4D) computed tomography (CT) scan of the neck. Primary hyperparathyroidism is often found in clinical practice with resultant hypercalcemia. Imaging tests help to confirm the condition, but a negative scan does not rule out the diagnosis. Sestamibi scintigraphy is an acceptable method for localizing a solitary parathyroid adenoma. However, the technique alone does not reliably predict multi-glandular disease. The utility of sestamibi parathyroid imaging is limited by an approximate 20% false-negative rate and is less accurate for detecting abnormal parathyroid tissue in patients with small adenomas, multi-glandular disease, superior adenomas, or preoperative normocalcemia. In this patients case, a 4D CT scan has higher sensitivity in terms of localizing a parathyroid adenoma. Therefore, the requested 4D CT scan is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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 certification diabetes, endocrinology and metabolism 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 enrollees parent is requesting reimbursement for Intensive Outpatient Program (IOP) Services. The enrollee has diagnoses of major depressive disorder, recurrent episode, severe; generalized anxiety disorder, and seizure disorder. The enrollee has diagnoses of major depressive disorder, recurrent episode, severe; generalized anxiety disorder and seizure disorder. She attended the IOP and was discharged to an outpatient level of care, which she attended for about two months. However, she was readmitted to the same IOP due to increased anxiety and depression. Admission documentation describes her as depressed, irritable and impulsive, with poor self-care. Documentation also notes passive suicidal ideation.  Discharge summary notes indicate towards the end of her stay, the enrollees participation and engagement in groups was variable. She was generally calm in groups, but had low frustration tolerance and would leave if she became upset. No self-harming behaviors were noted. Child and Adolescent Level of Care Utilization System (CALOCUS) applied in this case  The enrollees composite CALOCUS score is 16, which correlates with low intensity, community-based services.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 33-year-old male who was diagnosed with chronic hepatitis C. Laboratory results dated 10/20/18 revealed the patients viral load was 1,450,000 IU/mL. On 2/28/19, the provider noted the patient was diagnosed with hepatitis C, genotype 3 infection in October 2018, and he has never been treated for hepatitis C. On 2/28/19, serum fibrosis testing was consistent with F0, lack of fibrosis. The patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan denied the requested and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Mavyret for eight weeks is medically necessary for the treatment of the patients medical condition. The American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommend treatment for all patients diagnosed with chronic hepatitis C virus (HCV) infection, except those with a short life expectancy that cannot be remediated by HCV treatment, liver transplantation, or another directed therapy. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines support an eight-week regimen of Mavyret for the treatment of non-cirrhotic, treatment-naive, genotype 3 patients. Testing for nonstructural protein 5A (NS5A) resistance variants is not recommended. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment with Mavyret in treatment-naive, non-cirrhotic, genotype 3 patients with chronic HCV (Foster, et al.). The medical evidence supports the requested medication in this clinical setting. Therefore, Mavyret 100 mg-40 mg for eight weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested authorization and coverage for treatment by an oncologist who specializes in amyloid light-chain (AL) amyloidosis. Amyloidosis is a neoplastic disorder characterized by the deposition of amyloid in multiple organs, such as the kidneys, marrow, liver and heart. Treatment includes relatively aggressive forms of chemotherapy, or high dose chemotherapy followed by stem cell rescue. The survival results have significantly improved with current chemotherapy and stem cell transplant protocols. Many providers have limited experience with this disease and will refer the patient to a stem cell transplant center for evaluation and consultation about stem cell transplant. In this case, the records document that the patient is planned to undergo evaluation and treatment by the Health Plans transplant team. This is considered the standard of care and does not require further direction from an independent oncologist. Therefore, the requested treatment by an oncologist who specializes in AL amyloidosis 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 internal medicine with subspecialty certification in medical oncology 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.