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

Nature of Statutory Criteria/Case Summary: The records document that this patient has been diagnosed with relapsing remitting multiple sclerosis (RRMS). Currently there are several treatment options available for the treatment of this progressively neurodegenerative disease process. The available medications include therapies that are injections, oral therapies, as well as infusion therapies. Oral therapies are often better tolerated in patients due to reduced side effects and the ability to avoid daily injections. Interferon therapies such as Avonex and Betaseron are known to cause a flu-like reaction. Other injectable therapies such as Copaxone are known to cause lipoatrophy and can lead to disfiguring dimple like changes at the site of the injections. Oral medications are often better tolerated and do not cause these types of side effects thereby increasing compliance. Dimethyl fumarate (Tecfidera) is a U.S. Food and Drug Administration (FDA) approved oral therapy for the treatment of RRMS. Tecfidera has demonstrated better relapse reduction rate than traditional interferons and Copaxone. In this particular case, the patient is likely to benefit from taking this therapy. Thus, the requested Tecfidera is supported as medically necessary for treatment of this patients RRMS. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma. Findings: The physician reviewer found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the treatment of the patients melanoma. Thus, its use is not expected to affect the treatment or outcome of the patients melanoma. Therefore, DecisionDx-Melanoma test was not likely to have been more effective than other options for evaluating this patients medical condition. Final Result: All three reviewers determined 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: All three reviewers are board certified in dermatology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program services. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Findings:  The documentation provided does not support the medical necessity for the services at issue in this clinical setting. There were no significant post-acute withdrawal symptoms and the patient denied same. The patient reported that his main complaint was sleep disruption. He denied cravings except for cannabis. The patient was not a danger to himself or to others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant IOP level of care. There was no evidence of a high degree of aggression, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with this patients care at a lower level. The patient was medically stable and psychiatrically stable during the dates in question. The patients medication regimen did not require close monitoring at IOP level of care.  There were no new problems that had arisen. Additionally, the records reflect that this patient demonstrated a lack of motivation and noncompliance throughout his treatment, as he did not fully participate in programs being offered. The patients partner was supportive, and the patient could have availed of psychotherapy, substance abuse counseling, and other forms of support and recovery if the patient did not choose to participate in a 12 step program. The patient required treatment and counseling. However, the patient could have received treatment on an outpatient basis. For these reasons, IOP level of care was not and is not medically necessary.Final Result: The reviewer determined the services at issue were not and 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 psychiatry with sub-specialty certification in addiction psychiatry and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for electrical stimulation and ultrasound therapy. Based on the available documentation, the requested transcutaneous electrical nerve stimulation (TENS) and ultrasound therapy are not medically necessary for treatment of the patients low back pain. A recent literature and meta-analysis found that TENS may provide short-term functional benefit but not pain relief. Medical literature reported short-term functional benefit with therapeutic ultrasound. The records indicate that this patient has complaints of low back pain treated with chiropractic care. However, this patients provider has not provided a rationale for the use of TENS or ultrasound in a proposed treatment plan. Overall, the requested electrical stimulation and ultrasound therapy are not medically necessary for treatment of the patients low back pain based on review of the literature and medical records. 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 physical medicine and rehabilitation with sub-specialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement the surgical mesh, Strattice, utilized during hernia surgery. Findings:  Biologic mesh is derived from human or porcine dermis, after having been processed into acellular, porous extracellular matrix scaffolds of collagen and elastin. The theoretical advantages of biologic mesh over synthetic mesh include reduction of chronic inflammation and foreign body reaction, stiffness and fibrosis, and mesh infection. However, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) notes that there is a lack of data regarding the performance of biologic mesh in the setting of primary or recurrent ventral or inguinal herniorrhaphy in the non-contaminated and previously uninfected field. At this time, the medical evidence has not demonstrated the superior effectiveness of the services at issue. All told, the surgical mesh, Strattice, utilized during hernia surgery was not likely to have been of greater benefit than other available treatment options.Final Result: Two of the three reviewers determined that the services at issue were 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 reviewers are board certified in surgery and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 57-year-old female enrollee has requested authorization and coverage for physical therapy. Findings:  The physician reviewer found that the documentation does not support the medical necessity of the requested PT services for treatment of this patients foot and ankle pain as well as the right shoulder. The guidelines of PT practice support an initial evaluation, daily treatment notes, and periodic reassessments to support the efficacy of interventions. There should be an initial evaluation which supports the need for therapy. The documentation does not reveal clinical documentation by the providers revealed deficits that require continued skilled PT. The notes from the provider reveals the patient has improved ADLs, no significant pain or discomfort, and has improved strength. There are no physical examination deficits of the foot that require skilled therapy. The documentation does not reveal a treatment plan or evaluation prior to the most recently requested therapy indicating a plan of care or deficits that require skilled therapy for either the shoulder or the foot. Given these findings, the requested PT is not medically necessary for treatment of this patients medical condition. 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 physical medicine and rehabilitation with sub-specialty 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 parent of an enrollee has requested authorization and coverage for 38 hours per week of direct applied behavior analysis (ABA) services for at least six months is medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, the patient has made steady progress in many areas. However, the patient continues to require a high level of support. Failure to master these skills puts the patient at an increased risk for injury, and makes it increasingly difficult for him to be successful in more generalized environments. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Given the support provided by the medical records provided in conjunction with current-peer-reviewed literature, the requested services are medically necessary for treatment of the 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 in pediatrics with sub-specialty certification in developmental-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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ketamine infusion for treatment of the enrollees complex regional pain syndrome (CRPS). Findings:  The physician reviewers found that There is a lack of medical literature supporting the requested service in this clinical setting. There is no high quality evidence available evaluating the efficacy of ketamine for CRPS and all manuscripts examined in this review were of moderate to low quality. Therefore, there is currently only weak evidence supporting the efficacy of ketamine for CRPS. There is also concern for possible toxicity with the use of ketamine infusion that needs to be further assessed.  Given the lack of support in the peer-reviewed literature, the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three 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:  Different SpecialtiesOne reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. One Reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  One Reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services.  Findings:  The physician reviewer found that upon presentation, the patient was intoxicated and at high risk for an alcohol withdrawal syndrome. He had been drinking regularly for about eight months and consuming up to two bottles of wine per day for the previous week. He was mildly hypertensive and tachycardic. Based on this clinical data, admission for supervised detoxification was safe, appropriate and consistent with good medical practice. However, although chemical dependency specialty services were indicated, the medical records do not demonstrate the necessity of the RTC level of care following detoxification. On admission, the patient had a normal mental status examination. He had no acute psychiatric issues or medical comorbidity that would warrant service delivery in a RTC setting. His alcohol related medical sequelae were non-emergent and would not be expected to improve to any greater degree in a RTC setting as opposed to the outpatient venue. He expressed motivation for recovery and he was committed to treatment and his spirituality. The patients wife and children were supportive and he had safe housing. The patient had good success in the past with outpatient services and community-based programming. Further, he had no prior treatment during the episode of illness, such as anti-craving medications, sober living environments, IOP or partial hospitalization program treatment. In sum, the records do not reflect that comprehensive, evidence-based services provided in a less restrictive treatment setting would have been unsafe or inadequate. Thus, the RTC services were not medically necessary for treatment of this patients behavioral health condition. 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 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 enrollee has requested authorization and coverage for Nutropin AQ NuSpin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature.The submitted documentation does not support the requested medication in this clinical setting. The submitted records do not indicate that this patient has undergone provocative GH testing.  The records appear to indicate that the patient is underweight for his height but has normal growth factors. In addition, the records do not show the patient has known morphological abnormalities of his pituitary gland or midline structures to raise concern for GH deficiency. His growth pattern and preliminary laboratory data are not consistent with classic GH deficiency. Additionally, there are no chronic medical conditions noted in the records submitted. For these reasons, Nutropin AQ NuSpin is not medically necessary for treatment of this patients medical condition.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 pediatrics with sub-specialty certification in pediatric endocrinology 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 a computed tomography (CT) scan or magnetic resonance spectroscopy (MRS) or angiography and magnetic resonance angiography (MRA) scan. The Health Plan has denied this request indicating that the requested diagnostic procedures are not medically necessary for evaluation of the enrollees dizziness.  The requested for CT scan, MRS or angiography and MRA scan are not medically necessary for evaluation of the patients medical condition. In this case, the patient has a history of dizziness without evidence of other neurologic deficits. Symptoms have been present for at least four years, and the patient has been seen by a neurologist, who did not detect an underlying disease.  In addition, the patient underwent an MRI of the brain in 2016 which was negative. Moreover, several studies have evaluated the utilization of CT scanning to evaluate dizziness. Astudy fount that Consistent with the American College of Radiology appropriateness criteria and the literature, this study suggests a low diagnostic yield for CT in the evaluation of acute dizziness. In addition, there is a lack of utility for the requested MRS. MRS is utilized primarily to measure biochemical changes in the brain in known tumors. MRS is utilized when the etiology of a lesion in the brain is unclear, and has no utility in the evaluation of what is likely idiopathic dizziness. In addition, the patient has requested an angiogram or a MRA. The American College of Radiology (ACR) does not recommend MRA in this clinical setting. An angiogram or MRA is appropriate to evaluate a patient for an aneurysm. However, in this case there are no specific symptoms of an aneurysm. In conclusion, the requested diagnostic procedures are not indicated for evaluation of the patients medical condition. For the reasons provided, the requested diagnostic procedures have not been established as medically necessary for evaluation of the patients medical condition Final Result: The reviewer determined that the requested diagnostic procedures are 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 diagnostic radiology 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 reimbursement for a hospital stay. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees status post motor vehicle accident with intracranial hemorrhage.The hospital stay was not medically necessary for treatment of the patients medical condition. In this case, the patient was stable. He was awake and ambulating.  The documentation does not support that he had any complications, active infection, seizures or change in mental status. He was tolerating an oral diet without any swallowing difficulties. He had a thromboembolic work-up for the stroke and was receiving rehabilitation services. His strength was at a functional level and he did not appear to require any new assistive devices. He could have been safely discharged to receive further services at a lower level of care.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 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.