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

Nature of Statutory Criteria/Case Summary: A 19-year-old female enrollee has requested reimbursement for residential treatment center (RTC) services. Findings:  The physician reviewer found that The patient had one prior suicide attempt at the age of 16. The patient was not hospitalized at that time. The patient had an extensive psychological evaluation which noted that the patient was not cutting or threatening suicide. The provider recommended dialectical behavior therapy (DBT) and cognitive behavioral therapy (CBT). The patient underwent a suicide assessment at which time the patient did not report any thoughts of suicide. The patient had a bright affect and had a pleasant mood. She did not have auditory or visual hallucinations or delusions. The patient was cooperative with staff and was interactive with peers. Overall, the records indicate the patient was stable and was a candidate for treatment in a less restrictive treatment setting as an outpatient. Therefore, the RTC 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 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: A 39-year-old male enrollee has requested authorization and coverage for an ultralight wheelchair due to prior stroke with resultant hemiparesis.  Findings:  The physician reviewer found that Having wheelchair and prosthesis available is most likely to provide the patient with adequate mobility, benefits of functional rehabilitation, and upright gait, which is protective for the patients overall health. Given the support in the medical literature, the requested ultralight wheelchair is medically necessary for treatment of this patients medical condition. 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 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: An enrollee has requested authorization and coverage for Mavyret 100-40 mg. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret 100-40 mg. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. For these reasons, Mavyret 100-40 mg is 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 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 Mavyret 100-40 mg for eight weeks. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most 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 1a patients should be treated with Mavyret 100-40 mg for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg for eight weeks is 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. However, there is a lack of peer-reviewed published studies confirming the role of DecisionDx-Melanoma Gene Assay in this clinical setting. All told, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in dermatology and 3 is board certified in internal medicine with sub-specialty certification in medical oncology 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 reimbursement for proton beam radiotherapy. Findings:  Three physician reviewers found the medical evidence has not demonstrated that proton beam radiotherapy is superior to standard available therapy, photon-based intensity modulated radiation therapy (IMRT). The theoretical advantage of proton therapy is that it has a Bragg peak, resulting in decreased dose before and after the peak. This translates into a decrease in exposure of normal tissue in the low-dose to intermediate-dose range, but not in the high-dose range. Studies have shown a benefit in bladder and rectal exposure with this regard. However, this does not appear to translate into actual decreased clinical side effect. Cancer control rates are also reportedly similar between photons and protons. All told, proton beam radiotherapy was not likely to have been of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology 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: A patient has requested reimbursement for the acute hospital level of care services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for the treatment of the patients traumatic brain injury. The submitted documentation does not support the medical necessity of the services at issue. The patient was admitted to an acute inpatient level of care, after being hospitalized due to aggression at a psychiatric facility. The patient was readmitted for discharge planning without any decompensation of medical or neurological status. The patient did not have any acute infection, injury, or change in condition. Inpatient care is necessary when the patients signs, symptoms, and general medical condition can only be managed safely in an acute inpatient setting; when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. The acute inpatient level of care was not medically necessary. Therefore, acute hospital level of care services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for depo-testosterone, non-statin cholesterol medication, and a consultation with a urologist. Based on the available documentation, this patient should have ongoing follow-up for his symptoms with a urologist. However, there is a lack of documentation to support the need for testosterone treatment as there is no record of low testosterone levels in the records provided for review. In addition, there is a lack of evidence of statin intolerance. Thus, the requested depo-testosterone and non-statin cholesterol medication are not supported as medically necessary for treatment of the patients medical condition, while a consultation with a urologist is medically necessary. Final Result: The reviewer determined that a portion of the requested medications and services 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 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: The parent of a patient has requested authorization and coverage for Genotropin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients idiopathic short stature. The submitted documentation supports the medical necessity of the requested medication.  The patients weight for height ratio is normal, and other causes of short stature have been ruled out. This patient has not undergone provocative growth hormone (GH) testing. However, the patient meets criteria for a trial of GH therapy for treatment of idiopathic short stature. The U.S. Food and Drug Administration has approved GH therapy for children with short stature who are predicted to reach an adult height of less than 63 inches in males and less than 59 inches in females. 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 several of the following criteria; height is more than 2.25 standard deviations below the mean for age, or more than two standard deviations below the mid-parental height percentile; or growth velocity of less than the 25th percentile for bone age; bone age more than two standard deviations below the mean for age; low serum insulin-like growth factors-1 and/or insulin-like growth factor-binding protein 3; and/or other clinical features suggestive of GH deficiency. This patient meets a significant portion of the above criteria, and GH therapy for treatment of idiopathic short stature is medically necessary until epiphyseal fusion. Therefore, Genotropin 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 pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement and prospective authorization and coverage for residential treatment services. Prior to admission, the patients provider stated that patient required the RTC level of care due to the patient being unable to get out of bed and thus would be unable to attend any outpatient treatment including therapy and medication management. However, a lengthy note prior to admission stated that the patients depression was quite a bit reduced from what testing is showing. The records did not demonstrate that the patient was unable to function because she could not get out of bed. When the patient arrived, the patient was calm and cooperative. She was able to participate in treatment. She has no history of suicide attempts. The patient did not have substance use problems at the time of admission. The records indicate that the patient was capable of attending outpatient treatment. The patient does have medical issues, but these medical issues did not require 24-hour supervision. It is standard of care to treat the patient in the least restrictive environment possible. Based on the available documentation, the patient could have been set up in a group home situation and could have attended intensive outpatient treatment. For these reasons, the residential treatment services were not and are not medically necessary for treatment of this patients behavioral health issues. 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 with expertise 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: A enrollee has requested authorization and coverage for One Touch Blue Test Strips. Findings:  The physician reviewer found that based on the available documentation, there is no medical rationale for the One Touch System. The patient can download the Accucheck meter data as well if this helps him to comply with diet, medication adherence. However, there is a lack of documentation supporting the use of the One Touch as medically necessary for evaluation and treatment of this patients diabetes. Thus, the One Touch Blue Test Strips are not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested supplies 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 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: 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 neck and upper back. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient developed back and neck pain following a cupping procedure performed by an acupuncturist. Sources show for low back pain, and, as with cervical spine pain, MRI is not routinely recommended unless there are additional signs or symptoms.  The same can be concluded for thoracic back pain. Findings on MRI do not necessarily correlate with symptoms. The only reason to obtain an imaging study is if it will alter the course or type of therapy.  However, even if patients imaging demonstrates degenerative change, the management would include intensive physical therapy, anti-inflammatory medications, and other conservative measures. There is no indication that surgery is being considered. As such, the requested MRI of the neck and upper back is not medically necessary for the evaluation of this patient.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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for x-ray of the thoracic spine and magnetic resonance imaging (MRI) of the back. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the patients back pain. The submitted documentation does not support the medical necessity of the requested services. Evidence-based medical guidelines state that spine radiography should not be recommended in patients with low back pain in the absence of red flags for serious spinal pathology, even if the pain has persisted for at least six weeks. Guidelines recommend thoracic MRI in the setting of trauma with neurologic deficit. Evidence-based medical guidelines from the American College of Physicians and the American Pain Society indicate that clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain. Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe, progressive neurologic deficits are present, or when serious underlying conditions are suspected based on the patients history and physical examination. This patient presents with a reported 2-year history of mid-back pain. This patients pain was increased with prolonged sitting, bending forward or backward, twisting and turning, and twisting and bending. There is no documentation of radicular symptoms or a history of trauma. There is no clinical examination or evidence of focal neurologic deficits or findings suggestive of a red flag condition. The patient has reportedly failed to improve despite long-term nonsteroidal anti-inflammatory drugs use. There is no current indication to support the medical necessity of either a thoracic x-rays or MRI of the back in this clinical setting of nonspecific back pain and a lack detailed thoracic examination, clinical evidence of severe or progressive neurologic deficits, or suspicion of serious underlying conditions. Therefore, the x-ray of the thoracic spine and magnetic resonance imaging (MRI) of the back are not medically necessary for the evaluation of this patient.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.