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

An enrollee has requested reimbursement for mental health residential treatment center services. The submitted documentation supports that mental health residential treatment center services were medically necessary. Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient has met the criteria for Clinically Managed High-Intensity Residential Services. The patient required Clinically Managed High-Intensity Residential Services to maximize his chance of survival, which was contingent upon sobriety. In addition, given the patients age and the known physiological changes that come with age, he was at increased risk of falls and exacerbation of his diabetes mellitus if he continued to drink. Given the severity of the patients illness, residential treatment center services were clinically appropriate for the patient's illness. Therefore, mental health residential treatment center services were medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested authorization and coverage for one-on-one therapy appointments with the same provider twice per week for six months, or in the alternative, one-on-one therapy appointments with the same provider once per week for six months. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment; (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. This gives the patient a composite score which is consistent with high intensity community-based services. The chart documents that the patient has already participated in traditional IOP and PHP, yet she continues to have significant symptoms. Given the patients nonverbal learning disorder and her history of trauma, consistency in her treatment plan will be important for her recovery. Her care needs to be trauma-informed and sensitive to the ways in which her nonverbal learning disability may affect comprehension and communication. Given these findings, the requested individual therapy twice per week with the same provider is medically necessary for this patient. After her symptoms improve, the frequency could be reduced to one time per week. Although it is difficult to predict the required length of care, given the patients combination of trauma, mood symptoms, as well as academic difficulties, it is reasonable to expect that patient will require ongoing weekly therapy for at least six months at a frequency of twice per week. Therefore, the requested one-on-one therapy appointments with the same provider twice per week for six months are medically necessary for 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 psychiatry with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. Proton radiation therapy has not been demonstrated to be superior to photon intensity modulated radiation therapy (IMRT) for the treatment of neurofibromatosis syndrome. There is a lack of data in the medical literature demonstrating that proton radiation therapy yields improved clinical outcomes for a patient with neurofibromas, as compared to a regimen of photon-based intensity modulated radiation therapy (IMRT). The American Society for Radiation Oncology (ASTRO) policy supports use of proton beam radiation therapy for patients with documented neurofibromatosis. This patients records do not document results of genetic testing demonstrating findings of neurofibromatosis. In this clinical setting, the standard of care remains IMRT. Accordingly, the proton beam radiation therapy was not and is not medically necessary for treatment of this patient.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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Applying ASAM criteria, the RTC services were medically necessary for treatment of this patient. The patient has a treatment history of failure and rapid relapse on drugs and alcohol following discharge. He has been unable to stop using substances on his own or with prior treatment. The patient is at elevated risk with continued substance abuse given his diagnosis of hepatitis C and promiscuous behavior while intoxicated. The patients mental status was overall sufficient to permit participation. He was initially unable to consent to treatment due to psychosis. Treatment with Risperdal and Invega Sustenna were an integral part of patients treatment given his continued and progressive psychotic symptoms as noted by active persecutory delusions and hallucinations. He was later able to relate his desire to change despite his struggles with inattention, distraction, and hyperactivity in groups. The patient demonstrated limited insight into his need for continued treatment. The records document that the patient has shown limited understanding on the effects of his substance use on coping and functioning. The patient has been at imminent danger of relapse as result of a crisis. The patients parents have enabled his behavior. The patient has been at risk of returning to dangerous impulsive behavior in the context of poor coping, low premorbid functioning, and delusions. The patients recovery environment was too chaotic for the patient to succeed in his treatment goals. His family enables his addiction and his aggression towards them leads them to be fearful. Given these findings, RTC level of care services were medically necessary for 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 with expertise in addiction 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 panitumumab in liquid intravenous (IV) form. Panitumumab is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with wild-type RAS metastatic colorectal cancer, either as first-line therapy in combination with folinic acid, fluorouracil, oxaliplatin (FOLFOX) or as a single agent following disease progression after prior treatment with fluoropyrimidine, oxaliplatin, and irinotecan containing chemotherapy. Panitumumab is not indicated for the treatment of patients with RAS-mutant metastatic colorectal cancer or for in patients with an unknown RAS mutation status. This patient has no documentation of KRAS or NRAS mutation status. In addition, his performance status does not support treatment with additional chemotherapy. All told, panitumumab in liquid IV form is not medically necessary for treatment of this patient.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 internal medicine with subspecialty certifications in medical oncology and hematology 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 enrollees parent has requested authorization and coverage for genomic exome sequencing analysis (CPT 81415 and 81416). This patients genetic condition, 4q deletion syndrome, is a phenotypically variable syndrome with a wide range of clinical presentations. Specific abnormalities are associated with terminal deletions, including cleft palate and congenital heart disease. Fogel and colleagues noted that clinical exome sequencing is rapidly becoming the new standard for sequencing in genetic diagnostics, as all 21,000 genes in the human genome can be evaluated in an essentially unbiased manner. The authors noted that in instances where phenotypic presentation does not yield a diagnosis, rather than embarking on a series of diagnostic tests, exome sequencing could abbreviate or stop the diagnostic testing cascade by establishing the specific rare diagnosis genetically. Currently, exome sequencing is indicated for undiagnosed neurologic disorders with nonspecific or clinically heterogeneous phenotype, following expert evaluation with detailed history and examination, and genetic testing when deemed appropriate. In this patients case, there is concern about use of growth hormone to address her short stature and stimulation of cancer-causing genes given the predisposition to certain blood cancers. Therefore, the requested genomic exome sequencing analysis (CPT 81415 and 81416) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested genomic exome sequencing analysis (CPT 81415 and 81416) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in genetics and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certification in pediatric critical care 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: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Applying CALOCUS, this patient does not meet the criteria for RTC services. The patient has been at significant risk of harm (score 3) due to past suicide attempts, current passive suicidal ideation, and non-lethal self-harm related to acute distress. The patient has demonstrated moderate functional impairment (score 3) given her prior frequent purging, with reduction in purging and stabilization in the structured RTC setting. The patient has significant comorbidities with probable Crohns disease (score 3), which was likely exacerbated by the patients food choices and water loading. The patients recovery environment is mildly stressful (score 2) considering a shift in custody arrangement and missed school due to RTC services. The patients recovery environment has been supportive (score 2) as the records report that both of her parents have made an effort to participate in the patients treatment. The patient has shown poor response to treatment (score 4) due to her struggles with behavioral issues, continued self-harm, and difficulties adhering to the meal plan despite continued RTC services. The patient has been incompletely engaged in treatment (score 3) as she struggles to adhere to her meal plan and continues to engage in self-harm. This gives the patient a composite score of 20, which is consistent with medically monitored community-based services. This level of care includes partial hospitalization program (PHP) services, in which patient could attend daily sessions and have many or all of her meals monitored, but she would still sleep at home. These programs should also have 24-hour support available for urgent support. All told, the RTC services were not and are not medically necessary for treatment of this patient. 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 subspecialty 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

The patient has requested authorization and coverage for a Monovisc injection in the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has osteoarthritis of the right knee. Further treatment with Monovisc provided adequate pain and symptomatic relief. Given the patients prior benefit with Monovisc and the lack of alternative treatment options, the requested Monovisc injection in the right knee is medically necessary for 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 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

The enrollee requested reimbursement for the DecisionDX-Melanoma gene assay. The enrollee has a malignant melanoma with superficial spreading. The Castle Biosciences report indicates the DecisionDx-Melanoma class was 1 and sub-class was 1A, and for enrollees 55 years and older with T1-T2 tumors, a class 1A result is associated with a low probability of a positive sentinel lymph node. The enrollees dermatologist reports the result of the test enables her to provide risk-specific surveillance and management for this enrollee. Literature shows a professional societys staging system has served as a foundation for clinical classification, and the particular impact for the DecisionDx-Melanoma gene expression profile test is still incompletely defined. Impacts such as prediction of tumor behavior will require additional clinical trials and long-term clinical follow-up. The DecisionDx-Melanoma gene expression profile test is not currently recommended by any standard treatment guidelines. Based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this enrollee.Final Result: The reviewer determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is board certified in dermatology and are actively practicing.  The reviewer is 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 Nutropin AQ Nuspin.The submitted documentation supports that the requested medication is medically necessary. The patients report for MRI of the sella (pituitary) noted that the patient has thin infundibulum and ectopic pituitary. This MRI impression is consistent with the patients diagnosed growth hormone deficiency. The patient also has very poor growth velocity for his age and sex, and he has had two failed growth hormone stimulation tests. Under these circumstances, Nutropin AQ Nuspin is medically necessary to treat the patients medical condition.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 subspecialty 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

An enrollee has requested authorization and coverage for a Synvisc-One (hyaluronan) injection in the left knee. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, there is a history of substantial benefit from prior viscosupplementation with Synvisc-One. Furthermore, their options are clearly limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. Under these circumstances, a Synvisc-One (hyaluronan) injection in the left knee is medically necessary to treat the medical condition.Final Result: The reviewer determined that the requested service 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested reimbursement for the DecisionDX-Melanoma genetic testing. The enrollee has a malignant melanoma on his left leg. The DecisionDX-Melanoma class was 2 and sub-class was 2A. A Class 2A signature is associated with an increased risk of recurrence within 5 years, relative to class 1. The enrollees surgical oncologist states the result of the test enables him to provide risk- specific surveillance and management for his enrollee. The DecisionDX-Melanoma gene panel may be used in clinical practice, but it is not currently recommended by any standard treatment guidelines. The DecisionDX-Melanoma has not had sufficient testing prospectively, and in a randomized controlled study, to make it standard of care. There is no evidence that this test will benefit the enrollee beyond standard of care, which is monitoring, and lymph node biopsy and excision.Final Result: The reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The reviewers are board certified in dermatology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.