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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostate artery embolization (PAE) procedures. The first-line therapy for management of benign prostatic hyperplasia (BPH) includes medical therapy. This includes alpha-blockers, 5 alpha reductase inhibitors, phosphodiesterase inhibitors and anticholinergic medications. The standard of care for management of patients with BPH not responding to medical therapy is transurethral resection of the prostate (TURP). In patients with glands over 100 cc, as this patient, holmium laser enucleation of the prostate (HoLEP) and prostatectomy are recommended. Prostate artery embolization (PAE) is a novel approach for treatment of patients with BPH. Current medical literature on PAE is limited to case series and retrospective comparisons. There is a lack of randomized controlled clinical trials demonstrating the improved efficacy of PAE over TURP, HoLEP or simple prostatectomy. The medical literature does not support use of PAE over standard treatments. All told, the requested PAE procedures are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested PAE procedures, CPT code 37243 (vascular embolization and occlusion), 36247 (insertion of catheter/abdominal/L-external artery 3rd), and 36248 (insertion of catheter abdominal/L-external artery additional) are not likely to be more beneficial for treatment of the patients 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 urology 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

An enrollee has requested reimbursement for Amniotic membrane transplantation. The patient underwent excisional biopsy of a conjunctival lesion that was concerning for malignancy. Based on the information provided, the provider performed a wide resection of the lesion requiring a 6.5 mm x 6.5 mm amniotic membrane graft. Given the size of the defect, an amniotic membrane graft can be used to reconstruct the anterior segment. Based on various factors, including the patients ocular history, amniotic membrane graft is at least as beneficial as a conjunctival autograft in reconstructing a large conjunctival defect. All told, the amniotic membrane transplantation was 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 amniotic membrane transplantation was likely to be more beneficial for treatment 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 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 ophthalmology 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 authorization and coverage for weekly occupational therapy and intensive feeding therapy. This patient has been diagnosed with autism spectrum disorder, feeding aversion disorder, and fine motor delays. The patients providers have recommended ongoing occupational therapy to address the patients difficulty with fine motor tasks, and intensive feeding therapy for the treatment of his significant food aversion disorder. Baumer and Spence described that optimal treatment for patients with autism involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. Studies describe that severe feeding disorder and food aversion can result in malnutrition despite the patients weight being within a normal range. A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders by Sharp and colleagues concluded that, intensive, multidisciplinary treatment holds benefits for children with severe feeding difficulties. Given these findings, the requested weekly occupational therapy and intensive feeding therapy 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 neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nucala autoinjector 100 mg subcutaneously every 28 days. The records document that this patient has a known history of severe eosinophilic asthma and allergic bronchopulmonary aspergillosis, for which he was previously managed with systemic steroids leading to early osteoporosis. Based on the available information, the patient has also been treated with Singulair and Xolair. He was started on Nucala in 2018, resulting in an excellent treatment response based on improved clinical symptoms and normalization of peripheral eosinophilia. Nucala is U.S. Food and Drug Administration (FDA) approved for the treatment of severe, persistent eosinophilic asthma. Moreover, the medical literature supports Nucala for use in this clinical setting. This patient is at risk for relapsed asthma and worsening steroid-induced bone disease without adequate control of his condition. Therefore, Nucala autoinjector 100 mg subcutaneously every 28 days 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 pulmonary disease 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 reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. 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. Based on CALOCUS criteria, this patient meets the criteria for IOP treatment. The patient has been at significant risk of harm to others (score 3) as evidenced by the patients past suicidal ideation with plan, as well as episodic impulsivity and distress. The patient has demonstrated moderate functional impairment (score 3) given his difficulty connecting with peers, social isolation, absences from school, and gains made in the structured setting of the IOP. The patient has no significant comorbidities (score 1) due to the absence of medical illness. The patients recovery environment is moderately stressful (score 3) as evidenced by bullying by peers as well as the patients struggles to cope with school. The patients recovery environment provides limited support (score 3) due to his parents struggles to accept and respond to the patients autism spectrum diagnosis. The patient has shown poor resiliency and response to treatment (score 4) based on the patients continued symptoms even with prolonged treatment, and distress in response to developmental pressures. The patient has been constructive in treatment (score 2) as the patient has attempted to fully participate in the program. The patients parents have been obstructive with the patients treatment (score 3) as his parents are participating actively in program but struggling to accept and address the patients autism spectrum diagnosis. This gives the patient a composite score of 20, which meets the criteria for medically monitored community based services. This level of care can include IOP and home-based wraparound care. Houston and colleagues noted that the ideal treatment setting for adolescents is at home with their families. A child or adolescent with mental illness should be treated in the safest and least restrictive environment and needed services should be wrapped around to provide more intensive home or community-based services. Given these findings, the IOP 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation (RFA) (CPT code 47382). The patient has oligometastatic breast cancer with persistent right upper quadrant pain due to her liver lesion. Pain alleviation is an acceptable standard of care goal for cancer care. Focal therapy is likely to be effective, without the risk of complications or side effects from systemic therapies. There are multiple accepted modalities for focal treatment of tumor to provide symptom management. Radiofrequency ablation (RFA) is an effective palliative local therapy that can achieve symptom management due to progressive disease (Kwapisz). Additionally, there is data to support improved disease control and long-term survival with RFA of oligometastatic breast cancer (Kwapisz). Given these findings, the requested RFA (CPT code 47382) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested RFA (CPT code 47382) 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 internal medicine with subspecialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a temporomandibular joint appliance, x-rays (CPT codes 70350, 70355, and 76102), and follow-up office visits (CPT code 99214 x 4). Oral appliance therapy has been shown to be beneficial in patients with TMJ disorder and myofascial pain. TMJ appliances are associated with a decrease symptoms in 70-90% of patients. There are various types of splints used to treat myofascial pain. A single maxillary or mandibular splint is supported for use in this clinical setting. Given this patients history and clinical examination findings, the requested TMJ appliance is medically necessary. The well-accepted standard for the diagnosis of TMJ disorder and orofacial pain is patient history and clinical examination and when indicated, select TMJ imaging. Obtaining TMJ radiographs to determine whether the condyles translate during jaw opening is not indicated as this information can be obtained from physical examination. Therefore, x-rays (CPT code 70355) is medically necessary, while x-rays (CPT codes 70350 and 76102) are not medically necessary for this patient. In addition, the requested four follow-up visits are appropriate to assess the patients response to therapy. Moreover, these appointments will allow the provider to adjust the patients appliance as needed. Thus, the follow-up office visits (CPT code 99214 x 4) are also medically necessary. Final Result: The reviewer determined that a portion of the requested services are 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 oral and maxillofacial 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: The patients parent has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. Applying CALOCUS, this patient meets the criteria for PHP level of care services. The patient has been at significant risk of harm (score 3) due to episodic inability to care for herself as demonstrated by the patients difficulties with eating and hygiene while at home. The patient has demonstrated moderate functional impairment (score 3) given the strained relationship with her mother, deteriorating hygiene, and disordered eating, and refusal to attend school. The records document significant comorbidity (score 3) due to recent medical hospitalization, as well as nausea and vomiting. The patient continues to exhibit behaviors that require frequent and significant intervention. The patients recovery environment is moderately stressful (score 3) considering her mothers severe depression and recent loss of a close friendship. The patients recovery environment is supportive (score 2) given her mothers participation in the patients program. The patient has shown limited response to treatment with continued symptoms despite multiple attempts at treatment at higher levels of care (score 3). The patient has been obstructive in treatment (score 3). The provider noted the patient has frequently missed or been late to PHP sessions, and has demonstrated a lack of adherence with her medication at home. The patients parent has been constructive with treatment (score 2) as her mother has been willing to participate in treatment despite her own struggle with depression. This gives the patient a composite score of 22, which is consistent with Level 4, medically monitored community based services, such as PHP. Given these findings, PHP 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 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 Motegrity 2 mg daily (QD) for six months. Motegrity is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic constipation. Motegrity has been demonstrated to be safe and effective for the treatment of constipation and associated symptoms, including abdominal pain, with greater efficacy than placebo in randomized controlled clinical trials. The American College of Gastroenterology (ACG) guidelines for constipation recommend the use of advanced laxatives such as Motegrity after failure of stimulant and osmotic laxatives. In this case, the patient has chronic constipation symptoms despite treatment with a stimulant laxative and osmotic laxative. For these reasons, Motegrity 2 mg QD for six months 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 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: Upheld Decision of Health Plan

The patient has requested reimbursement for air ambulance transportation.  According to the American College of Emergency Physicians and National Association of Emergency Medical Services (EMS) Physicians guidelines, patients requiring critical interventions should be provided those interventions in the most expeditious manner possible. The guidelines note that, patients who require high-level care during transport, but do not have time-critical illness or injury, may be candidates for ground critical care transport. In this case, the patient sustained a severe right acetabular fracture requiring care at a medical facility with orthopedic surgical expertise. He was transferred to a high-level rehabilitation facility. The patient was transferred by air ambulance almost two weeks postoperatively to a lower level of care to be closer to home. There is no indication that the patient was unstable or had a condition that could not have been managed at the initial facility. The submitted records do not document that the patient required air transport over ground transport or that the patient had any medical conditions that precluded ground transport. All told, the air ambulance transportation was not medically necessary for treatment of this patient.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 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: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care 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 including: (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. For dimension 1, the patient has been at moderate to severe withdrawal per Clinical Institute Withdrawal Assessment (CIWA) scores. The patient does not meet the criterion for dimension 2. For dimension 3, the patient has comorbid post-traumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD), depression, and agoraphobia. Dimension 4 is satisfied as the patient is willing to change, but is not ready as evidenced by his variable engagement and his lack of coping strategies. For dimension 5, the patient has a history of multiple brief periods of abstinence followed by relapses. His history of multiple relapses in an uncontrolled environment is a strong risk factor for recurrent relapses in the absence of adequate supervision and appropriate direction. For dimension 6, the patient reports difficulty with trusting in interpersonal relationships leading to potential lapses in support in his recovery environment. He continues to be unemployed without a path to reemployment. The patient requires a safe and stable living environment in order to develop his recovery skills. Thus, the patient qualifies for ASAM Level III treatment similar to what the patient has received at the current RTC. Given the severity of the patients illness, RTC 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 board certified in psychiatry with expertise in addiction 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.