Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intracept procedure. There is adequate peer-reviewed medical literature supporting the safety and efficacy of the Intracept procedure for treatment of this patients neck and back pain. Imaging revealed Modic endplate changes at L4-5 and L5-S1 and symptoms that have persisted for longer than six months. The current modalities for these patients are fusion or artificial disc replacement. Intracept offers a less invasive outpatient procedure that will maintain the structural integrity of the spine. Patients have been shown to have significant improvements in pain and overall return to high functioning levels with the Intracept procedure. For these reasons, the requested Intracept procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Intracept procedure 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Helicobacter pylori (H. pylori) serological antibody test (CPT 86677). Findings:  The physician reviewer found that the  American College of Gastroenterology (ACG) guidelines for dyspepsia support the use of H. pylori testing for evaluation of specific symptoms, as in this patients case. Current medical literature supports the use of H. pylori testing to rule out this infection as a cause for pain in well-selected patients. In this patient with dyspepsia and no documented prior treatment for H. pylori infection, the H. pylori immunoglobulin G (IgG) antibody would be expected to be elevated in the presence of ongoing infection. Use of the H. pylori serological antibody test can help avoid more extensive testing and facilitate treatment. In patients on proton pump inhibitors, the accuracy of alternatives such as breath testing or stool testing for H. pylori may be decreased. Furthermore, this provider noted that the patient is from Peru, which has an estimated 80% prevalence of H. pylori. For these reasons, the H. pylori serological antibody test (CPT 86677) was 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 H. pylori serological antibody test (CPT 86677) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for direct applied behavioral analysis (ABA) services. According to researchers, medically necessary ABA services are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Using this definition, ABA services are medically necessary for this patient. ABA therapy has been identified as the most evidence-based treatment for patients with autism, thus ABA is required to meet the essential health needs of the patient. To address the issue of dosage, the Council for Autism Service Providers recently released updated practice guidelines for healthcare funders, which indicate that recommendations for treatment intensity should be made by a BCBA given their expertise and formal training specifically in ABA for the treatment of autism. The patients lack of progress is not a contraindication for additional therapy. Studies of ABA treatment intensity that support a dose-response relationship between intervention intensity and outcomes for a wide age range. A lack of progress towards goals does not contraindicate the need for more ABA therapy. The research indicates that additional hours of therapy are likely to benefit the patient and lead to better long-term outcomes in functioning. Moreover, given the patients high level of problematic and at-risk behaviors including aggression, self-injury, and elopement, a reduction in hours would likely lead to an increase in these behaviors over time. Further, the maintenance of goals already mastered is a key component to any ABA program and losing recommended therapy time will likely result in not only less goals mastered, but also loss of previously acquired skills for the patient. For these reasons, the requested direct ABA services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is a licensed B.C.B.A, board certified in psychology, 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  proton beam therapy (CPT 77520, 77522, 77523, and 77525). This patient presents with a history of prostate cancer with recent recurrence. A prostate biopsy on 3/15/20 showed involvement of the prostate gland bilaterally by a combination of a Gleason 3+3 and 3+4 adenocarcinoma. The patients provider has recommended proton beam therapy in lieu of standard IMRT and other standard treatment modalities. Proton radiation therapy for prostate cancer in a patient previously treated with radiotherapy to the pelvis has not been demonstrated to be superior to prostatectomy or IMRT. Per the American Society for Radiation Oncology (ASTRO), the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. Thus, the requested proton beam therapy (CPT 77520, 77522, 77523, and 77525) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested proton beam therapy (CPT 77520, 77522, 77523, and 77525) is not 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, 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Apriso 0.375 gm. Findings:  The physician reviewer found that records provided for review document that this patient has a history of ulcerative colitis that has failed to improve with ciprofloxacin and Canasa suppositories. Treatment with Apriso, which is a formulation of mesalamine, has provided the patient with adequate symptom control for the past year. Mesalamine has been demonstrated to be effective for the treatment of ulcerative colitis in randomized double-blind multicenter clinical trials. Studies noted that the various formulations of mesalamine result in release at distinct times and locations in the gastrointestinal tract, which makes each preparation clinically distinct. Specifically, Apriso is different from alternatives such as Asacol, Lialda and Pentasa, as well as their respective generic formulations, each with release in different portions of the gastrointestinal tract and at different pH levels. Changing therapy for this patient is likely to result in inadequate symptom control with a different formulation since the new agent will direct the drug to a different part of the gastrointestinal tract. Additionally, ulcerative colitis flares can be induced by salicylate medications and changing therapies exposes the patient to this risk. Apriso is a recommended medication for the treatment of ulcerative colitis in this clinical setting. Therefore, the requested Apriso 0.375 gm is medically necessary for 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 internal medicine with subspecialty 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: The patients parent has requested authorization and coverage for whole exome sequencing . Whole exome sequencing analyzes a portion of a patients genome consisting of coding sequences to look for variants that may explain the patients phenotype. Clinical indications for whole exome sequencing are a suspected genetic disorder based on signs and symptoms with no known single gene condition fitting the phenotype. Researchers reported that the utility of whole exome sequencing in the clinical arena has been demonstrated, with a diagnosis made by exome sequencing in approximately 25% of patients referred for testing. In this case, persistently elevated creatine kinase is suggestive of a disorder of muscle. The patients episode of rhabdomyolysis supports a disorder of energy production in the muscle, such as a fatty acid oxidation defect or a mitochondrial disorder. Rhabdomyolysis is episodic in nature, so biochemical testing is oftentimes unrevealing. Whole exome sequencing is appropriate for diagnosis, and it would avoid the need for an invasive muscle biopsy. Confirming the patients diagnosis will prevent disability through the provision of disease-specific treatment and avoidance of precipitating factors. For these reasons, the requested whole exome sequencing is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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 genetics 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 conditio
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. There is insufficient data to suggest treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Researchers noted, There were no significant differences in rates of other morbidities or additional therapies between intensity-modulated radiation therapy (IMRT) and proton therapy. Per the researchers, among patients with nonmetastatic prostate cancer, the use of IMRT compared with conformal radiation therapy was associated with less gastrointestinal morbidity. Researchers found no significant difference in toxicity in patients with prostate cancer treated with IMRT and proton radiotherapy after one year. In this case, a photon-based treatment plan would not be contraindicated for a patient with hydronephrosis, and as the standard of care would be associated with a high level of safety and efficacy. Therefore, proton beam radiation therapy is not medically necessary for the treatment 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 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 authorization and coverage for magnetic resonance imaging (MRI) of the right knee. The American College of Radiology (ACR) appropriateness criteria for the evaluation of chronic knee pain notes that imaging assessment begins with conventional radiography, and if these demonstrate degenerative changes, MRI without contrast may be the next appropriate imaging study. In this case, the patient has a prior ACL reconstruction and symptoms of instability that were not explained by the radiographic findings. An MRI is medically indicated to evaluate for possible ligamentous or meniscus injury, and to evaluate the integrity of the ACL reconstruction. Therefore, MRI of the right knee is medically necessary for the evaluation of this patient. 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 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: The patient has requested authorization and coverage for weekly individual therapy services. To provide guidance in determining the appropriate treatment frequency for patients with depression, the American Psychiatric Association (APA) noted that the provider should consider multiple factors, including the specific type and goals of psychotherapy, symptom severity (including suicidal ideas), co-occurring disorders, cooperation with treatment, availability of social supports, and the frequency of visits necessary to create and maintain a therapeutic relationship, ensure treatment adherence, and monitor and address depressive symptoms and suicide risk. The APA supports the utility of marital or family therapy when indicated due to patient circumstances. In a 2020 review of psychological interventions for patients who have sustained intimate partner violence (IPV), Hameed and colleagues found evidence that psychological therapies probably reduce depression and may reduce anxiety symptoms for women who have experienced domestic violence (six to 12 months after the therapy). The authors noted that the evidence remains unclear whether psychological therapies improve other outcomes (self-efficacy, post-traumatic stress disorder, re-exposure to IPV, safety planning). In this case, the patient reports that she experienced a delay in connecting with psychotherapy services after her initial evaluation following after an incident of IPV. She reports difficulty in scheduling an appointment through the Health Plans network of providers. The records do not include documentation that the patient has undergone a recent evaluation to support an indication for weekly individual therapy services. The patient states that she need therapy for an incident that occurred in late 2019. Given the lack of current mental health assessment, the records do not support a current indication for weekly individual therapy services. Therefore, the requested weekly individual therapy services are not medically necessary for treatment 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 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: The patient has requested authorization and coverage for brand name medication, Tazorac Gel.   Findings: Guidelines state that tazarotene is a reasonable first-line treatment for palmar plantar psoriasis. The guidelines note, Topical tazarotene can be particularly helpful for palmar-plantar psoriasis and nail psoriasis. In this case, the patient has been prescribed Tazorac Gel to treat his plantar psoriasis. Per the submitted documentation, Tazorac Gel has been effective for this patient in the past. Therefore, brand name medication, Tazorac Gel, 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 dermatology 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 a high-frequency chest wall oscillation device. Reports recommend mucus clearance as the mainstay of therapy in bronchiectasis. Researchers listed several mucus clearance strategies such as flutter or Acapella devices, in combination with active breathing techniques, or a regimen of nebulized hypertonic saline solution. In this case, given the patients lack of mucus production, mucus impaction, and diffuse bronchiectasis, there is insufficient evidence to support a high-frequency chest wall oscillation device as medically necessary over other treatment options. Therefore, a high-frequency chest wall oscillation device is not medically necessary for the treatment of this patient. 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 internal medicine with sub-specialty in pulmonary disease and critical care 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 parent of the patient requested authorization and coverage of Aimovig 140 mg/mL auto-injector. A study describes erenumab as a monoclonal antibody against calcitonin gene-related peptide (CGRP) or its receptor that offers considerable improvements in migraine prophylaxis and is designed to act on the trigeminal pain system. Researchers reviewed  recommendations on the use of anti-CGRP monoclonal antibodies in children and adolescents with severe, refractory migraine. The researchers recommended an initial trial of anti-CGRP at the lowest available dose, and a higher dose if no improvement was seen. In this case, the patient had daily severe chronic migraines and a PedMIDAS score of 95, indicating severe disability. The patient had tried and failed several preventive treatments. Since starting Aimovig, the patient has reported improvement. Given the current medical literature and the providers recommendation to increase the patient's dosage to further increase the therapeutic effect, the requested dosage of the medication is medically indicated. Therefore, Aimovig 140 mg/mL auto-injector 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 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.