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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prenatal genetic testing. The Health Plan has denied this request indicating that the services at issue were not medically necessary for management of the enrollees prenatal care.Findings: The documentation provided does not demonstrate the medical necessity for the genetic testing in this clinical setting. Patients who are 35 years of age or older, at the expected time of delivery, are considered in a high risk setting. The American College of Obstetricians and Gynecologists Committee (ACOG) endorses the discussion and use of NIPT testing in this patient population. As such, she does not fall within the high risk category identified by ACOG. At this time, ACOG has not provided a definitive recommendation that all patients in the low risk setting be offered NIPT testing and it is not currently identified as a standard of care for low risk maternal age women. ACOG addressed the issue of the use of cell free DNA testing in the Committee Opinion #640, conventional screening methods remain the most appropriate choice for first line screening for most women in the general obstetric population. This patients records do not demonstrate that she falls within the high risk category. Therefore, the medical necessity for the prenatal genetic testing has not been established.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 internal medicine with sub-specialty certification in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient was status post psychiatric hospitalization. She did well on her medications. On step down, she denied suicidal or homicidal ideation. She was not self-harming. She was not gravely disabled. She was compliant with her medication regimen. She was cognitively intact with coherent thought processes, and there were no behavioral or impulsive abnormalities. She did not have command hallucinations. She was reported to be mildly anxious and reported sleep disturbance. During the residential stay, no significant medication changes were made that could not have been done in an ambulatory setting. None of her essential functions were impaired. Her treatment could have safely been continued in an ambulatory setting, such as partial hospitalization program level of care. Therefore, the residential treatment center services were not medically necessary for the 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 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 parent of a male enrollee has requested reimbursement for acute inpatient psychiatric services. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. Applying the child and adolescent level of care utilization system criteria to determine the appropriate level of care, the patient demonstrated some risk of harm (score 2) due to his history of aggression. The patients functional status was moderately compromised (score 3) given his issues with role performance due to psychiatric symptoms. The patient did not have any medical, addictive, or psychiatric co-morbidity (score 1). His recovery environment was mildly stressful (score 2) and he was noted to have a stable living environment. The patients recovery environment was supportive (score 2), he demonstrated resilience to prior treatment (score 3), and was constructive and engaged in treatment (score 2) although he was also noted to engage in attention seeking behaviors and was non-compliant with staff. The patients parents were constructive (score 2) and worked actively with providers. This gives the patients presentation a composite score of 17, which correlates with intensive outpatient services. The records provided for review document that this patient was initially admitted to the acute inpatient setting due to a reported failure of prolonged residential treatment. The progress notes indicate that during the initial portion of the stay the patient did not have many behavioral outbursts and his mood was often described as euthymic. As his stay progressed, the patients behavior worsened and he became defiant with treatment and exhibited numerous attention seeking behaviors. Progress notes indicated that he had intermittent passive suicidal ideation. The progress notes do not document any significant improvement in the patients behavior while he was at the inpatient level of care. Accordingly, the inpatient psychiatric services were not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female has requested reimbursement for the genetic testing. Cell free fetal DNA testing has been proven to be beneficial in certain high risk populations. In addition, cell free fetal DNA technology may be appropriate based on a patient. However, in this case, the patient does not have any risk factors such as advanced maternal age, or personal, familial, or ethnic risk factors for the disorders tested. All told, the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology and is 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross-linking procedure, on the left eye and prospective authorization and coverage, procedure code 0402T, on the right eye. The Health Plan has denied this request indicating that the procedures at issue were and are considered investigational for treatment of the enrollees keratoconus.Findings:  There is support in the medical literature for the efficacy of the corneal crosslinking in this patients case. Cross-linking is a U.S. Food and Drug Administration (FDA) approved procedure for keratoconus and post refractive ectasia. The FDA approved this procedure in 2016. The primary purpose of crosslinking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus. The procedure involves soaking the corneal stroma with riboflavin and then using UV light to create chemical bonds between collagen fibrils within the stroma.  This stiffens the cornea and halts the thinning.  Prior to this treatment, patients with keratoconus who failed medical treatment (glasses, contact lenses) and whose disease continued to progress would go on to surgical management with corneal transplantation. There have been multiple studies published which demonstrate that patients who underwent corneal cross-linking showed an improvement in keratometry values, uncorrected visual acuity and best corrected visual acuity in contrast to control group.  There is mounting evidence of the benefit of this treatment in younger keratoconic patients with evidence of disease progression. This patient has severe keratoconus with poor best corrected visual acuity.  Corneal cross-linking was medically beneficial treatment to slow the disease progression for this patient. All told, the corneal collagen cross-linking procedure, on the left eye and prospective authorization and coverage, procedure code 0402T on the right eye was and is likely to be more effective than the available standard therapy for treating this patients medical condition.Final Result: All three reviewers determined that procedures at issue were and 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:  All three reviewers are board certified in ophthalmology 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy, 25 mg daily. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B.Findings: Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared to alternatives for the treatment of chronic hepatitis B (Terrault, et al). In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for treatment of hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. As such, the request to switch the patient to Vemlidy to reduce the risk of tenofovir-related nephrotoxicity and loss of bone density is medically reasonable and appropriate. For these reasons, Vemlidy 25 mg daily is medically necessary for the treatment of this patients 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 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 Epclusa 400-100 mg tablets for 12 weeks. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Epclusa for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested requested authorization and coverage for Spinraza medication therapy. Findings:  The physician reviewer found that Spinraza is the only U.S. Food and Drug Administration (FDA) approved therapy for the treatment of SMA. In addition, the medication Spinraza has been shown in clinical studies to be effective for SMA of all types. Per FDA approval, Spinraza is indicated for the treatment of SMA in pediatric and adult patients. In addition, there is a lack of available therapies for treatment of SMA. The natural history of the disorder is progressive weakness, progressing to respiratory failure. Spinraza, which has FDA approval, has been shown to alter the disease progression. In sum, Spinraza has been demonstrated as likely to be more effective for treatment of the patients medical condition than any available standard treatment options.Final Result: Two of the three reviewers determined that requested medication is 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: All three reviewers are board certified in neurology 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for partial hospitalization program (PHP) services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.  Findings: The documentation submitted supports the medically necessity of the services at issue in this clinical setting. The patient has a longstanding history of eating disordered behavior.  Per the documentation provided, since discharge from the residential facility, the patient has re-engaged in eating disordered behavior by restricting meals. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP, 2014). The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services. Based on the patients clinical history provided and documentation as outlined above, this patient meets CASII criteria for Level 4 intensive integrated services without 24 hour psychiatric monitoring. This level of care is higher than intensive outpatient services.  The patients clinical status, in addition to current medical literature, support treatment at a partial hospital program level of care. Accordingly, the requested partial hospitalization program 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 internal medicine with sub-specialty certification in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right knee Orthovisc injections. The current medical evidence supports the requested services in this clinical setting.  This patient presents with significant right knee pain that is limiting activities of daily living. Clinical examination findings are consistent with right knee osteoarthritis. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective. Given the previous response and to assist in delaying total knee replacement, repeat viscosupplementation injections are indicated. Therefore, the requested right knee Orthovisc injections are medically necessary for the 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the foot. The patients injury was at least six months prior to the presentation to the provider and the patient continues to have disabling pain. The patients physical examination and radiographs demonstrate soft tissue abnormal findings laterally corresponding to the area of clinical complaint. Since there was no fracture on initial radiograph, the injury is at least six months old, and the patient has radiographic and clinical findings which are positive, the next procedure of choice is MRI. Accordingly, the requested MRI of the foot is supported as medically necessary for evaluation of this patients lateral foot pain.Final Result: The reviewer determined that the requested diagnostic procedure is 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C infection.According to the recent guidelines, all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. Moreover, the guidelines recommend that non-cirrhotic, treatment naive, genotype 2 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage.  A trial showed a 99% cure rate with eight weeks of treatment. Guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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 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.