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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance abuse residential treatment center services, including detoxification for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. This particular patient had significant comorbidity.  She was diagnosed with bipolar disorder and multiple substance use disorders. Based on the documentation provided, the patient was not responding well to psychiatric services in the outpatient setting.  Further, the patient had treatment ambivalence while her motivation for recovery was poorly consolidated. Indeed, she walked away from treatment days before the disputed admission and skipped many treatment sessions early in the treatment course.  Finally, the strained parent-child dynamics posed a significant barrier to safe housing options and community-based service delivery.  The services and setting were safe, appropriate and consistent with good practice. Additionally, the services provided were reasonably expected to improve her condition and prevent a more serious episode of illness, while the duration of care was consistent with community standards. In sum, considering the clinical presentation and the relevant peer-reviewed literature, substance abuse residential treatment center services, including detoxification, were medically necessary for the treatment of this patient. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) mutation testing  for evaluation of the enrollees neuro immune syndrome. Findings:  The physician reviewer found that the use of the MTHFR gene mutation testing is commonly used in patients who need to be assessed for hypercoagulability disorder. Based on the documentation provided, there is no evidence that the patient presents with symptoms concerning for hypercoagulable state. The patient has been diagnosed with Lyme disease, anxiety, fatigue and Streptococcus group A. There is a lack of medical literature which supports the use of MTHFR mutation testing in patients that have been diagnosed with this patients diagnoses. As such, the patient was not likely to benefit from the testing at issue. For the reasons provided, the MTHFR mutation testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was 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 reviewer number one is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
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 for treatment of the enrollees thoracic back pain. Fulfills Findings:  The physician reviewer found that the request for Botox injections are not medically necessary for treatment of the patients medical condition. There is a lack of medical literature supporting Botox injections in this clinical setting. The review did not support the use of Botox in myofascial pain syndromes. Similarly, the contradictory results regarding the efficacy of botulinum toxin A in [myofascial pain syndromes] MPS associated with neck and back pain do not allow this treatment to be recommended or rejected. In addition, there is no documentation the patient has trialed anticonvulsant medications such as Lyrica, undergone a neurosurgical consultation or has underwent evaluation with computed tomography (CT) scan of the thoracic spine as recommended in the interpretation of the MRI. For the reasons provided, the requested services have not been established as medically necessary for the 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stereotactic body radiation therapy for treatment of the enrollees prostate cancer. .Findings:  The physician reviewer found that The physician reviewer found that stereotactic body radiation therapy (SBRT) is not likely to be more beneficial than available standard therapy, conventionally fractionated intensity modulated radiation therapy (IMRT). Outcome data for SBRT at this time is limited to five to six years follow-up. In a pooled analysis of separate phase II trials from eight institutions (1100 patients) by King and colleagues, the authors noted that the five-year biochemical disease-free survival was 84% for intermediate-risk patients treated with SBRT. Overall, the outcome data appear similar to conventionally fractionated radiotherapy, but do not demonstrate that SBRT is likely to be more beneficial. Additionally, longer follow-up would be optimal due to the long natural history of prostate cancer. The idea of SBRT being equivalent to conventionally fractionated IMRT is summarized by the most recent National Comprehensive Cancer Network guidelines which note extremely hypofractionated image-guided IMRT/SBRT regimens (6.5 Gy per fraction or greater) are an emerging treatment modality with single institutional and pooled reports of similar efficacy and toxicity to conventionally fractionated regimens. They can be considered as a cautious alternative to conventionally fractionated regimens at clinics with appropriate technology, physics, and clinical expertise. Overall, the requested SBRT is not likely to be more efficacious than other available treatment modalities. 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 reviewer number one is board certified in radiation oncology 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 genetic testing for frontotemporal dementia for evaluation of the enrollee, who has a family history of frontotemporal dementia. Findings:  The physician reviewer found that the physician reviewer found there is a lack of support for the requested services in this patients case. Genetic testing can detect various mutations associated with familial frontotemporal dementia. However, there is a lack of therapeutic implications relative to the results of the requested testing. The diagnosis remains a clinical one, with treatment generally directed at behavioral issues associated with the disease regardless of the genetic testing results. Accordingly, the requested genetic testing is not likely to confer benefit to the patient clinically. Therefore, genetic testing for frontotemporal dementia is not likely to be superior over other methods of evaluating this patient. Final Result: Two of three reviewers determined that the requested services are 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 reviewer number one is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that the physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients.  A delay in treatment may result in decreased survival. For these reasons, Epclusa for 12 weeks is medically necessary for the treatment of 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency ambulance services. Findings:  The physician reviewer found that the services at issue were necessary for treatment of an emergency medical condition. In this case, the patient was discharged from the hospital but remained significantly ill and required oxygen. The complexity of the patients chronic illness coupled with multiple evolving serious complications required ongoing hospitalization which was not an option in Mexico. Readmission to the local hospital for further care would have wasted valuable time given the patients serious medical issues. The patient had an evolving emergency medical condition with the oxygen requirement at a minimum, requiring emergent transport. The complexity of the patients chronic condition with evolving serious complications made the most appropriate receiving facility one in which his already familiar, multi-specialty team of providers would be present to address this evolving multi-organ system emergency, particularly in the context of such a long-distance transport. Transport to any other facility would have resulted in a delay in definitive care as well as an inevitable second transport. In addition, the patient required IV pain medication and breathing treatments during flight and these interventions are not routinely available on commercial flights. In sum, the ambulance services provided were emergent, and could not have been provided by treatment locally or transport to any other closer facility. Thus, the ambulance services provided were for emergency services. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for Vemlidy 25 mg po daily (30 tabs with 11 refills for treatment of the enrollees chronic hepatitis B virus. Findings:  The physician reviewer found that Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend Baraclude and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with Viread, which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. For this reason, the request for Vemlidy 25 mg po daily (30 tabs with 11 refills) is medically necessary for the treatment of this patients chronic hepatitis B. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for significant wrap around services through a comprehensive transitional program that specializes in young adults with special needs that would allow the enrollee to live at home and that would work with the enrollee on maintaining the enrollee stability while also working on the enrollees independent living skills through a multidisciplinary clinical setting that incorporates vocational, educational, health, independent living, social and recreational goals for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the comprehensive services requested by this patient are safe, appropriate and medically necessary. The treatment components requested in this dispute comprise of core elements of both patient centric and evidence based care that are consistent with current practice standards.  The studies have shown that a multidisciplinary array of clinical interventions will optimize this patients autonomy and reduce a risk for readmission. The patient had been admitted to a residential treatment facility at age 15 but had a recrudescence of symptoms that prompted a second residential admission. The literature supports the recommended multidisciplinary transitional approach to maintain this patients successful transition to the community setting.  Thus, the request for coordinated services in context of a patient specific, multidisciplinary treatment plan is indicated in this clinical setting.  For these reasons, wrap around services through a comprehensive transitional program that specializes in young adults with special needs that would allow the patient to live at home and that would work with the patient on maintaining his stability while also working on his independent living skills through a multidisciplinary clinical setting that incorporates vocational, educational, health, independent living, social and recreational goals are medically necessary for the treatment of this patients behavioral health 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xyrem 500 mg/mL for treatment of the enrollees narcolepsy. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The records provided for review do not support a diagnosis of type 1 or type 2 narcolepsy. The records indicate that the patient has a diagnosis of obstructive sleep apnea for which the patient has been prescribed and initiated on CPAP. The medical records do not contain the results of a multiple sleep latency test (MSLT) conducted in accordance with current practice guidelines that is required to establish a diagnosis of narcolepsy. The records provided for review do not include reports of any hallmark symptoms of narcolepsy besides the mention of excessive daytime sleepiness. As such a diagnosis of narcolepsy is unable to be established based on the documentation provided for review. Xyrem is U.S. Food and Drug Administration (FDA) approved for the treatment of narcolepsy, and it is not supported for patients with excessive daytime sleepiness. Given that the records provided for review do not establish a diagnosis of narcolepsy based on current diagnostic criteria the use of Xyrem cannot be determined to be clinically appropriate for this patient. Therefore, the request for Xyrem 500 mg/mL has not been established as medically necessary for treatment of the 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Care Assist Bed System with a P500 air mattress. for treatment of the enrollees Duchenne muscular dystrophy. Findings:  The physician reviewer found that a review of the literature and Care Assist Bed System with a P500 air mattress reveals that this bed and mattress has features which do not primarily serve a medical need, rather convenience items. The documentation indicates that the patient is at risk for pressure ulcers but does not reveal physical examination findings of the patient with current evidence of pressure ulcers or skin breakdown. The records do not document failure of current conservative repositioning and skin care/wound prevention routine. Durable medical equipment (DME) is primarily used to serve a medical purpose and the requested equipment exceeds the patients needs based on the available documentation. There is no evidence that the patients current needs cannot be met with a standard hospital bed and air loss mattress. Thus, the requested Care Assist Bed System with a P500 air mattress is not medically necessary.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.