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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chiropractic care. There is sufficient support for the requested services in this patients case. The records document shoulder pain, neck pain and insomnia. The patient presented to her provider, and she was referred for chiropractic care. Prior x-rays revealed cervical subluxations. Based on the patients clinical presentation and prior imaging, chiropractic care is medically appropriate. The medical evidence supports the requested services in this clinical setting. Therefore, chiropractic care 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 chiropractic care 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 biofeedback therapy. The submitted documentation supports the medical necessity of the requested services. The records document fecal incontinence unresponsive to conservative therapy including medications and pelvic floor exercise. 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. The medical literature supports the use of biofeedback as an effective therapy for fecal incontinence. Therefore, the requested biofeedback therapy 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: A 29-year-old male enrollee has requested authorization and coverage for a Mueller wide-mouth sports water bottle. As noted in the medical literature, the incidence of feeding difficulties in patients with intellectual disability is high. Successful management of feeding and swallowing difficulties decreases morbidity. However, the requested Mueller wide-mouthed sports water bottle is not medically necessary for treatment of the patients medical condition. The specific water bottle cannot be regarded as an item of durable medical equipment. All told, the requested Mueller wide-mouth sports water bottle is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device 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 and neurology with special qualification in child 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a group 3 power wheelchair. The requested group 3 power wheelchair is not medically necessary. The documentation indicates that the patient has a mobility deficit. However, the documentation does not reveal that the patients mobility deficit cannot adequately be address with use of an appropriately fitted manual wheelchair. The durable medical equipment (DME) evaluation revealed that a group 3 power wheelchair is not appropriate for the patient. The DME evaluation noted that a manual wheelchair with tilt in space, rehabilitation seating with positioning components, and pressure relieving cushion, is appropriate for the patient to complete mobility related activities of daily living (MRADLs) in the home. The documentation does not demonstrate that a group 3 power wheelchair is medically necessary for this patient. Final Result: The reviewer determined that the requested equipment 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 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: A patient has requested authorization and coverage for testosterone 1 mL injections once every two weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients testicular hypofunction. The submitted documentation supports the medical necessity of the requested medication regimen. Low testosterone can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue. For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL. The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored every three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal, and the dose of testosterone replacement therapy should be adjusted accordingly. Therefore, the requested testosterone 1 mL injections once every two weeks are medically necessary for this patient.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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or 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 biofeedback therapy. The submitted documentation supports the medical necessity of the requested services. The records document fecal incontinence unresponsive to conservative therapy including medications and pelvic floor exercise. 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. The medical literature supports the use of biofeedback as an effective therapy for fecal incontinence. Therefore, the requested biofeedback therapy 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an oral device and associated services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees sleep apnea. Findings: In this case, the patients clinical presentation indicates a diagnosis of OSA and he is reported to be CPAP intolerant. The medical literature indicates that oral appliance therapy is an acceptable second line therapy option for CPAP intolerant patients with OSA (Epstein et al). Current practice guidelines from the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine support the use of oral appliance therapy in patients with mild or moderate OSA who are intolerant of or decline CPAP. The patient has been referred to a dental provider for an oral appliance. Accordingly, the potential provision of an oral appliance in this case would be within the currently accepted standards of medical practice for the treatment of this patients OSA. In this patients case, the request for an oral appliance has been demonstrated as medically necessary. Additionally, the patient would require a dental examination for the oral appliance. As such a consultation with a dental provider would be indicated to determine if the patient has an adequate dental status for provision of an oral appliance. However, with regards to diagnostic imaging, the request is premature at this time. Not all dental providers perform x-rays in this setting. Once the patient is evaluated by a dental provider, the provider can then determine if x-rays are clinically indicated. Therefore, with regards to diagnostic imaging, this diagnostic procedure has not been demonstrated as medically necessary at this time.Final Result: The reviewer determined that a portion of the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in neurology with sub-specialty certification in sleep 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: The parent of an enrollee has requested authorization and coverage for oral immunotherapy for treatment of the patients medical condition than any available standard therapy. Findings:  The physician reviewer found that oral immunotherapy has not been recommended by the guidelines due to the lack of data that the therapeutic benefits outweigh the risk of treatment. Oral immunotherapy may promote desensitization to peanut protein in children and adolescents with peanut allergy. However, oral immunotherapy has been associated with increased risk of adverse reactions. Oral immunotherapy with rush phase or build-up phase may improve peanut tolerance but may induce moderate-to-severe allergic response.  Oral immunotherapy is associated with higher rate of systemic adverse events compared with other forms of immunotherapy as well as a minor risk of eosinophilic esophagitis. For these reasons, oral immunotherapy is not considered within the standard of care. Accordingly, the requested oral amino therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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 is board certified in allergy and immunology and pediatrics and is actively practicing. Physician reviewers 2 is board certified in allergy and immunology with expertise in pediatric allergy and immunology and is actively practicing. Physician reviewers 3 is board certified in allergy and immunology and is 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 hyaluronate gel injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. However, this patients records document that after he completed a series of five hyaluronic acid injections, he presented with complaints of severe knee pain, indicating lack of efficacy in this case. Overall, the records indicate that this patient has undergone two series of hyaluronic acid injections in both knees without substantial relief. Thus, the requested hyaluronate gel injections are not supported as medically necessary for treatment of this patients osteoarthritis. 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 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 biofeedback.  Findings:  Two of the three physician reviewers found the submitted documentation fails to demonstrate the superior efficacy of the requested services. Per the medical literature, there is a lack of evidence of efficacy for biofeedback in the treatment of chronic, non-specific, low back pain.  There is some limited evidence supporting the use of biofeedback in rehabilitation, but the studies are sparse and methodologically flawed.  Ongoing trials that are investigating biofeedback applications in various clinical populations including chronic back pain may lend some clarity to this issue. However, at the present time, the evidence does not support the efficacy of biofeedback in the treatment of chronic low back pain. Therefore, the requested biofeedback is not likely to be more effective 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 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

An enrollee has requested authorization and coverage for Nutropin AQ NuSpin 20 mg/2 mL (10 mg/mL). The patient has normal stature, his bone age is not delayed more than 2 standard deviation (SD) below the mean for his age and gender.  His IGF-1 level is appropriate for pubertal stage and he has passed provocative GH testing on two occasions. The records do not indicate he has known morphological abnormalities of the pituitary gland. The most likely cause of the patients falls off in growth from the 75-25th percentile between ages 11 through 13 may be attributed to constitutional delay, likely exacerbated by the effect of stimulant medication and his underlying diagnosis of ADHD. He responded with a transient increase in growth velocity after a short course of testosterone, but growth slowed after discontinuation of testosterone as he was not far enough along in his puberty to expect a continued acceleration in growth. In addition, clinical notes indicate that he has remained on stimulant therapy for ADHD. According to  the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity < 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. Based on the records provided, this patient does not meet most of the above criteria, and his height is not short enough to consider GH treatment for a diagnosis of idiopathic short stature. Therefore, the requested Nutropin AQ NuSpin 20 mg 2 mL (10 mg/mL) has not been demonstrated as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive outpatient program services. Findings:  The physician reviewer found that in this patients case, the records support the medical necessity of a portion of the services at issue. The patient had a formidable addictive illness, and comorbid depressiveness and anxiety, which demanded chemical dependency specialty care. Per community standards, he progressed from more restrictive to less restrictive treatment settings during the episode of care as the acuity level lessened.  At the time of transition to intensive outpatient program level of care, the patient had made meaningful therapeutic progress. He was motivated for recovery.  He was able to identify effective treatment modalities and potential barriers unique to his case. His family was supportive. The treatment notes indicated that the patient was actively engaged in evidence-based treatment. However, the summary letters notwithstanding, there were no subsequent medical records submitted for review such as progress notes, physician statements or interpretative summaries articulating the medical necessity of the setting. The patient had nearly three months of sobriety. He was motivated for sobriety and better educated on his illness and treatments. He was not having a prolonged withdrawal syndrome, and he was not experiencing significantly impairing psychiatric symptoms. He was stable on psychotropic medications. The records do not demonstrate that comprehensive, evidence-based services provided a less restrictive treatment setting for this stable, motivated and otherwise healthy patient would have been insufficient or inadequate. In sum, intensive outpatient program services were medically necessary, but not the dates without evidence. Final Result: The reviewer determined that a portion of the services at issue was 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 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

An enrollee has requested authorization and coverage for Mavyret for 100/40 mg for eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100/40 mg tablets for eight weeks to treat hepatitis C is supported as medically necessary. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.