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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endometrial biopsy. As noted by the American College of Obstetricians and Gynecologists (ACOG), the primary role of endometrial sampling in patients with abnormal uterine bleeding is to determine whether carcinoma or premalignant lesions are present, although other pathology related to bleeding may be found. Moreover, the ACOG states that endometrial sampling also should be performed in patients younger than 45 years with a history of unopposed estrogen exposure (such as seen in obesity or PCOS [polycystic ovarian syndrome]), failed medical management, and persistent abnormal uterine bleeding. The ACOG further noted that, the decision to histologically evaluate the endometrium should be based on symptomatology and clinical presentation. On review of the patients documentation, there is a lack of an indication for an endometrial biopsy. The patient is premenopausal and has not reportedly failed medical management. In addition, she does not have any evidence of unopposed estrogen exposure or persistent abnormal uterine bleeding and she is not obese. Further, an ultrasound showed a normal endometrial stripe. All told, the requested endometrial biopsy is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient mental health hospitalization. The submitted documentation does not support the medical necessity of the services in issue. The submitted documentation reflects that on the dates of service in issue, the patient was cooperative, denied suicidal ideation or homicidal ideation, and denied hallucinations or delusions. The patient was cooperative with the treatment program and his vital signs were within normal limits. There was no indication of withdrawal from illicit drugs or alcohol. There is no indication in the patients medical records of any basis for 24 hour nursing care. The record does not explain why an inpatient hospital level of care was medically necessary. Therefore the inpatient mental health hospitalization provided on the dates of service in issue was not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services in 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 parent of a seven-year-old male enrollee has requested authorization and coverage for 12 hours per week of direct one-to-one applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that the sources reported that ABA is the most evidence based approach to address deficits displayed by patients with autism. Other sources indicate that service intensity should be dictated by the patients need and results of the assessment. This patient displays deficits in social communication that places him several months behind his peers. Thus, the requested 12 hours per week of direct one-to-one ABA therapy is supported 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 a board certified psychologist and is a board certified behavioral analyst 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 enrollee has requested reimbursement for 40 hours per week of applied behavioral analysis (ABA) therapy. Studies show that, the definition entails healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on the current medical literature and this patients clinical history and presentation, comprehensive ABA therapy was appropriate. However, there is a lack of objective data to suggest 40 hours of ABA would have led to more gains than 30 hours per week. Moreover, recent research on ABA therapy frequency suggests moderate gains can be made with less intensive services in some individuals. In this case, the goals targeted during the 2017 authorization period do not demonstrate that the patient exhibited behaviors or deficits in skills warranting 40 hours per week of medically necessary ABA therapy. All told, the 40 hours per week of ABA therapy were not medically necessary for treatment of the patients medical 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 a board certified psychologist and is a board certified behavior analyst 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 clarithromycin 500 mg tablets, two times per day for 30 days. The submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. Helicobacter pylori infection requires triple therapy, with the first line of treatment including a combination of clarithromycin and amoxicillin with a proton pump inhibitor. These medications are all dosed twice daily for a 14-day course. The medical evidence does not support the use of clarithromycin for 30 days. Therefore, clarithromycin 500 mg tablets, two times per day for 30 days is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 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 a Partial Hospitalization Program for eight (8) hours a day. The medical documentation does not support the medical necessity of the requested services. On the date of the request, the patient endorsed only passive suicidal ideation without a plan or intent. The assertion that her labs had deteriorated is somewhat of an exaggeration, given that the results that were out of range were within one point of the high/low limits, with only amylase being mildly out of range. These `deteriorations` are not a sufficient reason to step up to a higher level of care. They can be easily monitored on an outpatient basis by sending the patient to a lab for a repeat blood draw. The patient had no self-harm urges or behaviors. She was medically stable and her psychiatric medications did not require a structured setting. She had enjoyed an extended period of sobriety, and her alcohol cravings did not require a structured setting either, as she was attending AA and had a sponsor. Although the patient reported dizziness, her vital signs were stable and she was not orthostatic. She was engaged, cooperative, and within normal range in terms of ideal body weight and BMI. The medical documentation does not reflect that the patients eating disorder behavior requires a structured Partial Hospitalization Program setting. The documentation reflects that she is aware of how to use coping mechanisms, that she is working on triggers, that she has insight, and that she does not require intense, multiple times per day (8 hours/day, several times/week) interactive face to face treatment with staff. She is not reported to be over-exercising. Her treatment plan has not required frequent revision, she has been medication compliant, and her family has been noted to be supportive. Therefore, the requested Partial Hospitalization Program (PHP) for eight (8) hours a day is not medically necessary for treatment of the 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 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 Euflexxa injections. The submitted documentation supports the medical necessity of the requested services. The current literature supports the use of viscosupplementation for osteoarthritis of the knees. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Researchers noted intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function. Per researchers, viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. In this patients case, prior Euflexxa injections were beneficial. Therefore, the requested Euflexxa injections are medically necessary for the treatment of 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgeries to remove excess skin on the enrollees eyelids. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records document evidence of bilateral upper eyelid dermatochalasis. The patient complains of difficulty with her vision due to her excess upper eyelid tissue.  However, the degree of impairment directly related to the excess upper eyelid tissue and possible eyelid ptosis has not been adequately documented. A visual field analysis with taping and untaping of the eyelids has not been provided. The exact degree of ptosis of the upper eyelids cannot be adequately judged by the photographs provided. Therefore, the requested surgeries to remove excess skin on the patients eyelids are 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 plastic 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has chronic non-malignant pain which was previously treated with opiate analgesia. Clinical practice guidelines do not support restarting opiates for nonmalignant pain, such as chronic low back pain. The long-term outcomes for chronic low back pain are worse with opioids than other therapeutic approaches. Therefore, Norco 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 anesthesiology with sub-specialty certification in pain 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 a minor enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program services. Findings:  The physician reviewer found that IOP services were and are medically necessary for treatment of this patients behavioral health issues. The patient presents with no risk of harm behaviors. The patient has demonstrated a deterioration in his functional status and severe difficulties functioning in relationships with his peers, adults, and family. The patient has minor comorbidity with a history of substance use and psychiatric issues. The patients recovery environment is moderately stressful. However, the patients recovery environment is supportive. The patient has made minimal progress in treatment. Therefore, the composite score correlates with intensive outpatient services. Given these findings, the IOP services provided were and are medically necessary for treatment of this patients behavioral health issues. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the partial hospitalization program (PHP) services. This patients post-acute withdrawal symptoms were not severe in nature. Her level of anxiety and Clinical Institute Withdrawal Assessment (CIWA) symptoms could have been safely and effectively managed at a lower level of care. She was not a danger to herself or others. There were no emotional, behavioral, cognitive, or impulsive symptoms which would have interfered with her recovery. She was medically and psychiatrically stable. Her medication management was not complicated. There was no evidence of a high degree of impulsivity, agitation, depression, mania, or psychotic symptomatology. She was participating in her treatment plan and engaged in her program. She was motivated and demonstrated insight. She had support systems in place and a stable home environment. All told, the PHP services provided were not medically necessary for treatment of the patients medical 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 with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX procedure. Findings:  Two of the three physician reviewers found there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. In sum, the LINX procedure is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a pelvic floor electric stimulation device. Several randomized controlled trials have reported mixed results with electrical stimulation for treating fecal incontinence. One study evaluated patients with fecal incontinence treated with a home electric stimulation device for eight weeks. The authors found that there was no statistically significant difference between groups in patient reports of symptom changes. In addition, systematic reviews of randomized controlled trials have not revealed that electrical stimulation is superior to control interventions for treating fecal incontinence. All told, the requested pelvic floor electric stimulation device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested pelvic floor electric stimulation device is 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 requested equipment is 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned Decision of Health Plan

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Copaxone. Researchers noted that Copaxone has a lesser side effect profile, with demonstrated benefit, in the treatment of multiple sclerosis. They noted that compliance with treatment is critical for the best outcome of treatment. Other researchers found that Copaxone is an effective treatment for multiple sclerosis with a side effect profile that is better than comparable treatments for multiple sclerosis.  The records reflect that the patient has failed one therapy for multiple sclerosis. The patient notes concern for the side effect profiles, such as potential effects on end organs with other first line therapies supported by the Health Plan. As such, compliance with any new therapy is unlikely and will lead to poor response and failure if such treatment is instituted. Copaxone is an FDA approved treatment for multiple sclerosis and may be used when other treatment has failed. Therefore, Copaxone 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 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.