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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for RTC services.  The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Per CALOCUS, RTC level of care requires a composite score of at least 23.Regarding the six CALOCUS dimensions, the patient has a low risk of harm; has not expressed any suicidal or homicidal ideation or intent (score = 1). Regarding functional status, has had some issues with inappropriate peer relationships as well as a history of school refusal (score = 3). There are no comorbidities noted (score = 1). The patient has a positive recovery environment and a stable housing situation (score = 2) and the patients parents are involved and supportive (score = 2). The patient has had no documented treatment success (score = 3), participates in therapy but has poor coping skills and often will not comply with rules (score = 3) and has parents who work actively and constructively with clinicians (score = 2). For a CALOCUS composite score of 17, the recommended level of care is high-intensity outpatient therapy. Therefore, the RTC services provided were not medically necessary for this patient.Final Result: The reviewer determined that the requested services 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 specializes in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xyrem 500 mg/ml solution, 4.5 grams oral, two (2) times daily, 30-day supply. The submitted documentation supports the medical necessity of the requested medication regimen. Xyrem is FDA approved for treatment of two common symptoms of narcolepsy: excessive daytime sleepiness (EDS) and cataplexy. Alshaikh and colleagues have noted that narcolepsy patients on Xyrem have significant reductions in cataplexy and daytime sleepiness. Xyrem is well tolerated in patients with narcolepsy, and most reported adverse events were mild to moderate in severity. Boscolo-Berto and colleagues have also demonstrated, through meta-analysis of multiple peer reviewed studies, the effectiveness of Xyrem in treating major, clinically relevant narcolepsy symptoms and sleep architecture abnormalities. In this case, the medical records reflect that the patient has a long-standing diagnosis of narcolepsy that has been treated successfully with Xyrem since 2008. Records reflect that the patient has responded well and is well controlled on the medication. Under these circumstances, Xyrem 500 mg/ml solution, 4.5 grams oral, two (2) times daily, 30-day supply is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 Xeljanz.  Xeljanz has been shown to be of benefit to patients with AA. In a recent study, researchers found evidence for the effectiveness of tofacitinib in the treatment of AA. They compared the efficacy and tolerability of oral tofacitinib to conventional modalities for treating refractory alopecia. A total of 74 patients were included in the study. Of the 74 patients, 18 were treated with tofacitinib, 26 were treated with a conventional medication, and were 30 treated with another medication. After 6 months, 44.4% of patients in the tofacitinib group, 37.5% in the conventional oral treatment group, and 11.1% in the other group achieved 50% improvements in the Severity of Alopecia Tool score. It was concluded that oral tofacitinib was more effective and more tolerable than conventional oral treatment after 6 months of treatment.In this case, the patient has tried and failed other standard therapies, including steroid injections. The patient had recently started topical tofacitinib (Xeljanz) ointment with some improvement. The use of Xeljanz in this clinical situation is supported by recent medical evidence. Therefore, Xeljanz is medically necessary for 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for interspinous fixation (fusion) device, procedure codes 22869 and 22870. Findings:  Two of the three physician reviewers found that this patient presents with a history of low back pain with neurogenic claudication. Clinical examination findings have been consistent with imaging evidence of disc bulge, facet arthropathy, and ligamentum flavum thickening resulting in severe spinal stenosis with complete effacement of the cerebrospinal fluid and severe bilateral neural foraminal stenosis with mass effect on the exiting right L4 nerve root. There is evidence of 5-6 mm anterolisthesis of L4 on L5 with no instability reported on flexion/extension films. She has failed to improve despite at least six months of nonoperative treatment, including activity modification, medications, physical therapy, acupuncture, chiropractic care, and epidural steroid injection. The U.S. Food and Drug Administration (FDA) indications for the VertiFlex Superion Interspinous Spacer include moderate degenerative lumbar spinal stenosis. In this case, the patient has severe spinal and foraminal stenosis at the L4-5 level. Additionally, current evidence-based guidelines and peer-reviewed literature do not support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is no compelling rationale to support the spinal decompression device procedure over standard decompression with or without fusion in the setting of severe lumbar spinal stenosis. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device in this setting. In sum, interspinous fixation (fusion) device, procedure codes 22869 and 22870, is not likely to be superior over other available treatment options. Final Result: The reviewers determined that the requested device 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: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections. The submitted documentation does not support the medical necessity of the requested services. The patient has myofascial pain. The pathophysiology of myofascial pain remains uncertain, and multiple neurologic, myogenous, and psychological theories have been postulated. While there is strong anecdotal evidence supporting the use of Botox injections, many clinical trials have fallen short of producing conclusive results. Furthermore, studies supporting the use of Botox injections for orofacial dystonia are also inconclusive. Under these circumstances, Botox injections are 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 oral and maxillofacial 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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Enbrel SureClick 50 mg/mL, two times weekly. There is a lack of support for the requested medication dosage in this patients case. As noted by researchers, in the case of biologic agent treatment failure due to either adverse events or inefficacy, a large volume of observational data are now available supporting the conditional recommendation of switching either to an alternative biologic agent within a drug class or to a drug with a different mode of action. There is a lack of large phase III randomized controlled studies which demonstrate efficacy and safety or recommend accelerated dosing of a tumor necrosis factor inhibitor for the treatment of psoriatic arthritis. The medical evidence supports switching agents in this setting. Therefore, Enbrel SureClick 50 mg/mL, two times weekly is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 sub-specialty certification in 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a balloon dilation procedure.Findings: Two of the three physician reviewers found that the requested balloon dilation procedure was not likely to be more beneficial for treatment of this enrollees medical condition than any other standard therapy. Researchers reported that their study demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter [and] medical management compared to medical management alone to treat Eustachian tube dilatory dysfunction in adults.  Yet another study states that All current studies suggest that balloon dilation of the Eustachian tube can be a helpful treatment in patients with Eustachian tube dysfunction. However, placebo-controlled trials are still warranted. Husiman and colleagues recent study noted efficacy of this treatment for patients with abnormal tympanometric profiles.In this case, two of the three physician reviewers determined that the clinical findings do not support a diagnosis of Eustachian tube dysfunction. That diagnosis is usually made based on evidence of middle ear problems such as ear popping and pressure, infections and a flat tympanogram, often accompanied by a degree of conductive hearing loss. Thus, although balloon dilatation is promising as a therapy for Eustachian tube dysfunction, the reviewers concluded that this treatment would not likely be more beneficial for this patient than any other standard therapy.Final Result: Two of the three reviewers determined that the services in issue were not likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in otolaryngology, and all three 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nourish Pediatric Formula meal replacement. Pediatric Nourish meal replacement is a plant-based, gluten-free, corn-free, soy-free, casein-free formula made with real food ingredients designed for nutritional management of children with special medical needs, including failure to thrive, and G-tube dependence. It is recognized by the Centers for Medicare and Medicaid Services as an enteral formula for both tube and oral feedings and is produced in an FDA/USDA registered facility.Here, the patient has severe failure to thrive as a complication of her complex congenital heart disease and multiple surgical repairs. She is dependent on GJ tube feeds for nutrition and after fundoplication has continued to have retching and vomiting, even after trials of multiple elemental pediatric formulas and medications.  Nourish has been the only formula that she tolerates, and this formula currently provides her with 100% of her nutrition that is delivered via GJ tube. Nourish is thus a life-sustaining treatment for this patients failure to thrive and it is a medically necessary treatment.Final Result: The reviewer determined that the requested items 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 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 reimbursement and continuous coverage of a skilled nursing facility, level II care from 8/22/18 forward. Per a study, mild to moderate nonpurulent skin/soft tissue infections such as limb cellulitis are treated with intravenous and/or oral antibiotics. Another study note that lymphedema is a chronic condition that is managed with interventions such as manual decompression, limb compression pumps, compression wrapping/taping, compression sleeves and skin care The records in this case indicate that the patient was on oral antibiotics upon admission to the skilled nursing facility on 7/19/2018, with an order for a course of one week. Nursing evaluation did not note any significant wounds, skin lesions or other need for skilled nursing care with respect to his admission diagnosis of cellulitis. The patient was receiving topical creams on his legs twice a day. There were and still are no indications that the patient required skilled nursing facility level care on 8/22/2018 forward for treatment of cellulitis, leg swelling or lymphedema. From the therapy/functional standpoint, the patient underwent a prolonged therapy program and slowly made some gains in his functional status. As of mid-August 2018, he was requiring stand by assist for transfers and he was ambulating 75 feet with a cane at contact guard assist. He was contact guard assist for lower body dressing and toileting. This level of function constituted only a minimal level of improvement over the course of several weeks. He had dysphagia but made no progress from his initial swallowing status of pureed consistency for solids. There are no documented indications that the patient was not at or near his baseline functional status and/or his maximum level of functional potential. At the same time, there were no indications that further rehabilitative care could not be provided in the community setting with home care services and custodial level assistance. From the stand point of his functional rehabilitation, there were and are no indications that skilled nursing facility level care was or is medically necessary from 8/22/2018 forward.Final Result: The reviewer determined that the requested services were not and are 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 & rehabilitation 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 magnetic resonance imaging (MRI) of the pelvis and abdomen. Researchers note that ultrasound for pelvic pain `provides detailed information of the pelvis, is relatively inexpensive, widely available, and avoids ionizing radiation,` and that MRI is reserved for specific indications.  Researchers note that MRI may play a role in further evaluation of some adnexal masses already found on ultrasound (for example, differentiating a pedunculated uterine fibroid from an ovarian mass).Here, this patient has multiple pain conditions that are likely functional in origin, and an MRI will not help in diagnosing those conditions. A recent normal CT scan rules out the need for further evaluation of adnexal masses. This patient has no other indications for which an MRI might be necessary. Therefore, the requested MRIs of the pelvis and abdomen 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

enrollee has requested authorization and coverage for removal of three moles. This patient has abnormally enlarged moles which are documented to be painful.  Thus, removal to accurately diagnose the melanocytic nevi and to treat the functional impairment of pain is medically necessary. This patients condition constitutes an abnormal structure of the body. The records document enlarged, painful nevi, which are considered to be an abnormal structure. This condition is consistent with skin tumors/neoplasm. The requested services are likely to both improve function and create a relatively normal appearance to the extent possible. Based on the documentation submitted for review, the requested services are likely to provide more than a minimal improvement in the appearance of this patient. In sum, the requested removal of three moles is medically necessary and is reconstructive in nature.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing. Findings:  Three physician reviewers found that there are a number of serious medical disorders which are common in the Ashkenazi Jewish population. These are recessive genetic conditions. In order to reduce the incidence of these serious and lethal conditions in this population, genetic testing has been recommended by the American College of Obstetricians and Gynecologists. The results of this genetic testing allows the patient to make important reproductive decisions. Thus, gene panel testing was likely to have been more efficacious than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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.