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

Nature of Statutory Criteria/Case Summary: A patient requested authorization and coverage for biofeedback peri/uro/rectal (units: six). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients medical condition. The submitted documentation supports the medical necessity of the requested services. Medical research by Alame (cited above) and Thapar (also cited above) has showed that there are a number of causes for constipation related to obstructed defecation syndrome, (per the symptoms in this case), and pelvic floor dysfunction, (per the testing in this case), such as rectocele, rectal intussusception, paradoxical muscular contraction, descending perineum syndrome, sigmoidoceles, or enteroceles. Some of these potential causes are structural anatomical issues. However, others potential causes are functional issues with normal anatomy. If functional abnormalities are present, lifestyle modification and biofeedback therapy can be effective. The American College of Gastroenterology (ACG) guidelines for the management of benign anorectal disorders recommend anorectal manometry to determine whether a functional disorder is present, and a physical functional performance test, such as a balloon expulsion test, is also warranted when evacuation or outlet disorder is suspected. In this case, this testing has  been performed and it showed dysfunction. Additionally, the patient has intermittent incontinence. The American Society of Colon and Rectal Surgeons clinical practice guideline for the treatment of fecal incontinence states that biofeedback should be considered as an initial treatment for patients with incontinence and some preserved voluntary sphincter contraction. The American College of Gastroenterology guideline for the management of benign anorectal disorders states that pelvic floor rehabilitative techniques, such as biofeedback are effective and superior to pelvic floor exercises alone in patients with fecal incontinence who do not respond to conservative measures. Medical literature supports the use of biofeedback as an effective therapy for fecal incontinence. For these reasons, biofeedback peri/uro/rectal (units: six) is 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 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: An enrollee has requested authorization and coverage for Nitro-Bid ointment. There is limited evidence to support the use of specific medications for chronic intermittent finger gangrene and lupus anticoagulant syndrome. Similar to other hypercoagulable states and collagen vascular disease, the use topical vasodilators are beneficial when there is tissue hypoxia similar to Raynauds syndrome. There is evidence for the use of calcium channel blockers in this case . Nitroglycerin is often used in the acute ischemic phase. In this case, the patient does not have any abnormal findings of the fingers on physical examination. The patient remains on aspirin and Nifedipine for prevention. However, there is no indication that Nitro-Bid ointment is superior to generic nitroglycerin or other formulations for use in this clinical setting.Therefore, the requested Nitro-Bid 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 family practice with expertise in wound management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for somatropin 1.5 mg. Based on the policy criteria, the GH is not medically necessary for a diagnosis of GH deficiency because the patient passed the GH stimulation test and had a peak of GH of greater than 10 ng/mL. However, the patient meets the criteria for GH therapy based on the criteria for GH treatment that require given his short stature is below standard deviations below the mean. Moreover, the patients condition is consistent with idiopathic short stature, which is known to be responsive to GH therapy and it is very likely he has some underlying genetic defect given the extreme short stature of his mother. In addition, based on practice clinical guidelines by the Pediatric Endocrine Society and based on U.S. Food and Drug Administration (FDA) approval for GH for extreme short stature this patient qualifies for GH treatment. Thus, the requested somatropin 1.5 mg is supported as medically necessary for treatment of this patients idiopathic short stature. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Helicobacter pylori antibody testing (CPT code 86677).Findings:  Three physician reviewers found there is a lack of support for the services at issue in this clinical setting. If there is concern that the patient may still have Helicobacter pylori infection or had reinfection, then there are three recommended ways to test. These methods of testing include biopsies via endoscopy, checking for stool antigen, or performing a urea breath test. An antibody level will be positive in patients who have been previously treated and cannot discern active infection. Therefore, Helicobacter pylori antibody testing (CPT code 86677) was not likely to be of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the 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: 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 gene testing (methylenetetrahydrofolate reductase mutation (MTHFR) testing).  Findings:  Three physician reviewers found that per the medical evidence, there is only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability in the treatment of depression. There is a lack of large randomized trials supporting its use. The existing studies have also indicated that there is no significant correlation between either genotypes or medication serum concentration and response to treatment. The current evidence does not support the use of genotyping when choosing an antidepressant. Therefore, MTHFR testing was not likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the 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: Physician reviewers 1, 2 and 3 are board certified in psychiatry 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for upgraded hearing aids. Hearing loss is the most common form of sensory impairment and hearing aids are a first-line of audiological intervention for many patients hearing loss with conditions that are improved with hearing aids. Age-related hearing loss is a multifactorial condition that affects more than one-third of the aging population. When left untreated, hearing loss can increase the risk of cognitive decline, dementia, social isolation, depression, and falls. This patient has mild to severe sensorineural hearing loss on the right and moderate to profound hearing loss on the left. This patients hearing loss documented by audiograms and is noted to have progressed. She has used hearing aids and would benefit from improved amplification. Given these findings, the requested upgraded hearing aids are medically necessary for this patient.Final Result: The reviewer determined that the requested equipment 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 otolaryngology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections.Findings:  Three physician reviewers found that there is sufficient support for the requested services in this patients case. Botox is an effective modality in the management of chronic migraine. Repeated Botox injections have been shown to be safe and well-tolerated. Botox has been approved by the U.S. Food and Drug Administration (FDA) for use in prophylactic management in chronic migraine. This patient fits the criteria for chronic migraine. Additionally, she has failed a large number of therapies. Therefore, the requested Botox injections are likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested services 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: Physician reviewers 1, 2 and 3 are board certified in neurology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a right leg lower limb replacement prosthetic. In this case, there is evidence of need for prosthetic socket adjustment and replacement of the patients foot component. The records do not include documentation that the socket, couple or shank need to be replaced. Given these findings, a new foot for the prosthetic is medically necessary and a socket adjustment or modification is medically necessary. However, a new socket, couple and shank are not medically necessary. Thus, a portion of the requested equipment is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for left total hip replacement. Findings:  The physician reviewer found that Osteoarthritis is a degenerative condition that commonly affects knees and hips. The treatment depends upon the severity of the subjective complaints such as severe groin pain with ambulation and nocturnal pain that is refractory to conservative measures, the objective findings of diminished range of motion with impairment of function, and radiographic findings of joint space narrowing, all of which are present in this case. The recommended total hip arthroplasty has a predictable result and has been shown to improve a patients physical and psychological well-being. Based on the history, physical findings, and imaging studies, the patient meets the indications for a total hip arthroplasty and is a good candidate for the same. Any additional physical therapy is not likely to relieve his pain or significantly alter the need for a total hip arthroplasty. Therefore, the requested left total hip replacement is 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for A-AVD (Adcetris). This patient with nodular lymphocyte predominate Hodgkin lymphoma is not likely to benefit from Adcetris since this agent has not been demonstrated to be active against lymphocyte predominant Hodgkin disease. According to the National Comprehensive Cancer Network (NCC) guidelines, patients with this condition have been shown to benefit from treatment with different regimens, primarily with a rituximab containing regimen. Thus, the requested A-AVD (Adcetris) is not 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 medication 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 authorization and coverage for allergy injections. Based on the available documentation, the requested immunotherapy does not meet the current guidelines for medical necessity. In this case, review of the chart showed insufficient documentation in several areas. Specifically, clinical information is not documented to demonstrate sufficient physiologic or functional limitations or level of incapacity of the patients condition, therapies tried and failed, list of therapeutic plan and goals to be achieved, and rationale for additional injection doses of immunotherapy. Per the Allergy Practice Parameters on dosing, immunotherapy level of efficacy can be determined by measuring objective and subjective parameters. In addition, the American College of Allergy, Asthma and Immunology has taken the position that any limits on coverage should not be less than 150 doses during the build-up year and not less than 90 doses thereafter for maintenance. However, in the case of this patient, medical chart documentation did not provide a rationale for additional injection doses of immunotherapy above Health Plans dose limitation policy. Thus, the requested allergy injections are not supported as 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 allergy and immunology 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: A 53-year-old female enrollee has requested reimbursement for gastric sleeve surgery.  Findings:  The physician reviewer found that This patient documents morbid obesity with a body mass index (BMI) of at least 35 kg/m2 and sleep apnea, which is a serious obesity related co-morbid condition. The patient has failed dietary efforts and completed a comprehensive multidisciplinary evaluation that did not reveal any obvious dietary or behavioral barriers to surgery. The patient meets standard nationally accepted criteria for bariatric surgery including the American Society for Metabolic and Bariatric Surgery. Thus, the gastric sleeve surgery (CPT 43775) was medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in surgery with sub-specialty certification in bariatric 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 reimbursement and prospective authorization and coverage for psychiatric residential treatment center (RTC) services. Overall the progress notes reflected repetitive concern over the patients relationship with boys and this appeared to be the main treatment focus. Residential treatment for adults is evidence based for reduction of serious psychiatric symptoms that are typically thought to be reversible in nature. The patient did not display serious psychiatric symptoms but rather interpersonal issues that could have been treated in a less restrictive setting. A large portion of the patients functional impairment appeared due to her borderline personality disorder traits. This is referenced by her fear of abandonment, affective instability, feelings of hopelessness and intense relationships. One of the mainstays of treatment for borderline personality disorder is dialectical behavior therapy, which can occur in a less restrictive setting once patients are free from safety concerns, which was the case for the patient.  Applying the Level of Care Utilization System (LOCUS), the RTC services provided to this patient were not and are not medically necessary. The patient has been at low risk of harm (score 2) due to a lack of current suicidal ideation. The patient has demonstrated moderate functional impairment (score 3) with overall fair functional level in school and with same sex peers. The patients co-morbidities are stable (score 2), and her recovery environment is mildly stressful (score 2). The patient has a supportive recovery environment (score 2), and limited response to prior treatment (score 3). The patient has been engaged and cooperative in treatment (score 2). This gives the patients presentation a composite score of 16, which correlates with high intensity community based services, such as intensive outpatient program (IOP) treatment. Accordingly, the RTC services provided were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that 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 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.