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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Jardiance 10 mg tablets. Jardiance is a sodium-glucose cotransporter-2 (SGLT-2) inhibitor that is U.S. Food and Drug Administration (FDA) approved for management of type 2 diabetes. Data from the American Diabetes Association and the European Association for the Study of Diabetes has demonstrated that starting a SGLT-2 inhibitor can be beneficial to improve glycemic control in patients with established type 2 diabetes. In this case, the Health Plan has authorized alternatives to Jardiance including metformin, glipizide, glyburide, glimepiride and/or pioglitazone. This patient demonstrated intolerance to metformin therapy, thus its use is contraindicated. In addition, sulfonylureas are not first-line therapies for management of type 2 diabetes. Further, pioglitazone has a side effect profile including weight gain and pedal edema, thus is not suited as a first-line therapy. Given these findings, Jardiance 10 mg tablets are medically necessary for managing this patients type 2 diabetes.Final Result: The reviewer determined that the services at issue 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 has requested reimbursement for fertility preservation services. The patient was at risk of iatrogenic infertility due to treatment for breast cancer. An attempt of fertility preservation, specifically treatments necessary for oocyte retrieval and cryopreservation, is considered medically necessary for this patient since she will be undergoing chemotherapy that may cause irreversible/permanent changes to her reproductive organs that prevent natural childbearing options in the future. The American College of Obstetricians and Gynecologists have determined that oocyte cryopreservation, with appropriate counseling, is recommended for patients facing infertility due to chemotherapy or other gonadotoxic therapies. Per the American Society of Clinical Oncology, it is now standard of care to offer reproductive-aged patients with cancer a fertility preservation consult before administering gonadotoxic therapies. This discussion is crucial because fertility preservation can be accomplished with minimal to no delay in cancer treatment and many cancer treatments decrease fertility. The services in issue in this case include office visits, ultrasound testing, venipuncture, and assays of progesterone and estradiol. In this case, these monitoring and laboratory services were associated with oocyte cryopreservation, and as such, they were medically necessary to prevent iatrogenic infertility. Accordingly, the services in issue were medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services in 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 obstetrics and gynecology 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 platelet-rich plasma (PRP) injections. In patients with symptomatic osteoarthritis, PRP injections can result in significant clinical improvements up to 12 months post injection. Moreover, current data suggests that clinical outcomes are superior when compared to corticosteroids or viscosupplementation. This has been extensively studied in knees and also applies to hip osteoarthritis. In this case, the patient is unable to undergo total hip arthroplasty due to the severe muscle weakness and instability. Therefore, the goal of treatment is to achieve pain relief without surgical intervention. Among the options available, PRP has the highest probability of long-term pain relief without significant risk of complications. Moreover, this patients provider documented excellent results with prior PRP injections. As such, the requested PRP injections are medically necessary for management of the patients medical condition.Final Result: The reviewer determined that the services at issue 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing services (ThyraMIR, and ThyGenX). In this case, the submitted documentation does not support that the services in issue were medically necessary. First, molecular tests do not perform well on Hurthle cells. The patients biopsy of the suspicious right nodule noted that the specimen was sparsely cellular and that most follicular cells seen had Hurthle cell changes. The reading pathologist further commented that the sample in question may not have been representative of the targeted lesion and that the material collected for ThyGenX testing may not be sufficient. Therefore, it was questionable whether the molecular test was done on an adequate sample, thereby raising the question of whether its results can be trusted. Second, NCCN guidelines indicate that a clinician faced with a thyroid nodule without high clinical and/or radiographic risk of malignancy that shows structural abnormalities of undetermined significance, or follicular lesions of undetermined significance on fine needle aspiration, has four available options. These options are repeat FNA, observation, diagnostic lobectomy, or molecular diagnostics. None of these four options has been shown to be superior, since none has shown a difference in outcomes and/or a survival benefit. Molecular diagnostics, however, remains limited by the adequacy of the sample, hence the variability of its sensitivity and specificity for diagnosis. Under the circumstances of this case, where it was questionable whether the molecular test was done on an adequate sample, the treatment option of using molecular diagnostics is less appropriate than other treatment options. Accordingly, the gene testing services (ThyraMIR, and ThyGenX,) were not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services in 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 subspecialty certification in hematology and medical 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and coverage for intensive outpatient program (IOP) services received. 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, treaters 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) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.Regarding the six CALOCUS dimensions, the patient has a low risk of harm; he has not expressed any suicidal or homicidal ideation or intent (score = 1). Regarding functional status, the patient displays no limitation in the performance of activities of daily living (score = 2). There are no comorbidities noted (score = 1). The patients home environment appears to be moderately stressful (score = 2) and the patient has limited support at home (score = 3). The patient has also been responsive to treatment interventions (score = 1), has been active in and accepting of treatment (score = 2) with moderate acceptance/engagement from family (score = 3). For a CALOCUS composite score of 15, the recommended level of care is low-intensity outpatient therapy. Therefore, the IOP services provided were not and are not medically necessary for 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 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: Enrollee has requested reimbursement for the catheterization and coronary artery stent placement performed on 2/27/18. Per American Heart Association (AHA) criteria, cardiac catheterization is medically necessary for patients with intermediate or high-risk factors. High risk factors include diabetes, coronary artery disease (CAD) with prior myocardial infarction (MI) and hyperlipidemia. The AHA further indicates that stent placement is medically necessary for patients with diabetes, the presence of which increases risk of MI and percutaneous coronary intervention (PCI). Here, the patient has a medical history including high-risk factors such as diabetes, hyperlipidemia and CAD with prior MI. The patient therefore meets AHA medical necessity criteria for both cardiac catheterization and stent placement.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 internal medicine with sub-specialty certification in cardiovascular disease and I am 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 reimbursement and prospective authorization for 24-hour dialectical behavioral therapy (DBT) coaching as an element of intensive outpatient program (IOP) services from 5/07/2018 forward. DBT has been well established as an effective treatment for patients with borderline personality disorder, and 24-hour phone coaching is a common component of DBT. Researchers note that therapist availability by phone between sessions help[s] the patient apply skills [learned in therapy] when they are most needed (e.g., in a crisis). Researchers specify that access to 24-hour telephone coaching of skills learned during therapy sessions as a component of DBT has potentially clinically significant results when using DBT to treat anger and aggression. Here, the patient has been diagnosed with borderline personality disorder and has a history of aggressive outbursts. For a patient with this clinical presentation, 24-hour telephonic coaching is an effective and necessary component of the DBT services being provided through the subject IOP program from 5/07/18 forward.Final Result: The reviewer determined that the requested service 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 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. At the time of discharge from the residential treatment center on, the patient had not shown evidence of suicidality for several weeks, had participated actively in therapy, engaged in the treatment program, was motivated to make progress and was future oriented. Persistent problems involved the parent-child relationship. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the appropriate level of care. In terms of risk of harm, the records support a score of 2. Although he denied suicidal ideation for some time, the patient had a history of suicidal behavior with medical consequences. With regards to functional status, the records support a score of 1. The patient was functioning academically and socially. In terms of comorbidity, the records supported a score of 2. The patient had used cannabis the past, and parent-child relational problems persisted. With regards to level of stress of the recovery environment, the records supported a score of 2. The patient had a mildly stressful environment. The family home may be a trigger for memories of traumatic loss at the death of his mother. In terms of level of support for the recovery environment, the records support a score of 2. The patients father was engaged in treatment. With regards to resiliency and treatment history, the records support a score of 2. The patient had engaged and embraced treatment, demonstrated motivation, and continued to cooperate in treatment, even after the disappointment of being referred once again to a residential placement. In terms of acceptance and engagement of the patient, the records support a score of 1. The documentation noted optimal engagement and acceptance. With regards to acceptance and engagement of the parent, the records support a score of 2. The patients father demonstrated some resistance to having the patient outside of the residential setting. Thus, the patient has a composite score of 14. This score correlates with outpatient treatment. Therefore, residential treatment center services provided from 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 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: An enrollee has requested authorization and coverage for platelet-rich plasma (PRP) injections.Findings: Two of the three physician reviewers found that platelet-rich plasma (PRP) injections are not indicated under these circumstances. The ODG, a nationally recognized, evidence based set of medical guidelines, states that PRP is not recommended in foot and ankle conditions, with higher quality evidence showing that this treatment is no better than placebo. In addition, researchers conducted a Cochrane Database systematic review extensively covering patients from clinical trials for multiple conditions. Their systematic review included only a single randomized controlled trial for Achilles tendinopathy and another for post-surgical repair. The evidence for all primary outcomes was judged to be of very low quality. Lack of standardization and varying preparation techniques were areas of concern. Researchers concluded that there was insufficient evidence to support any platelet-rich therapies for musculoskeletal soft tissue injuries. Furthermore, in a systematic review of studies available on the clinical application of PRP for the treatment of foot and ankle pathologies, researchers concluded that no clear indications for PRP in the foot and ankle emerged. In sum, current evidence based medical literature does not support the use of PRP injections in foot and ankle conditions, noting that there was insufficient evidence and no clear indications. There is no compelling rationale presented, or extenuating circumstances noted, to support that platelet-rich plasma injections would be more beneficial for the treatment of the patients medical condition than any other standard treatment. Therefore, under these circumstances, platelet-rich plasma injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested treatment is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in orthopedic surgery 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for 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) is a utilization system to assess level of care needs for children and adolescents receiving psychiatric care. With regards to risk of harm, the records support a score of 1. With regards to comorbidity, the records support a score of 1. In terms of level of stress of the recovery environment, the records supported a score of 3. There was evidence of moderate stress in the patients home, as she was diagnosed with reactive attachment disorder. With regards to level of support of the recovery environment, the records support a score of 3. In terms of resiliency and treatment history, the records support a score of 1. With regards to acceptance and engagement of the patient, the records support a score of 2. In terms of acceptance and engagement of the caretaker, the records support a score of 2. The total equals 14, with no extreme outliers, indicating that the appropriate level of care was outpatient care. Thus, the patient could have been treated in a less restrictive environment. Therefore, services provided by treatment facility 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 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 authorization and coverage for a left lower extremity computed tomography (CT) scan. The American College of Radiology (ACR) has established appropriateness criteria to help physicians obtain imaging in the most efficacious and appropriate manner. In their recommendations for non-traumatic knee pain, the ACR describes multiple variants. The ACR considers x-rays to be the most appropriate study and CT scanning the least appropriate examination to perform. On occasion, if an MRI cannot be performed, the ACR will consider a CT arthrogram to be appropriate, but that is not being considered for this patient. Similarly, the ACR has established criteria for the evaluation of chronic hip pain, and again CT scanning is considered not appropriate. For chronic venous disease in the lower extremity, the ACR does not mention CT scanning as a possibility. In this case, the rationale for obtaining a CT scan of the patients left lower extremity is unclear. There are many possibilities which could explain the patients left leg and hip pain. For very few of them is a CT scan indicated. Diagnosing osteoarthritis, for example, is generally made by obtaining x-rays, and then correlating with physical examination. In some circumstances, an MRI is appropriate for diagnosing specific ligamentous abnormalities, such as a torn meniscus, but CT scanning is not an appropriate means to evaluate ligaments or cartilage. Similarly, a systemic arthropathy such as rheumatoid arthritis is not diagnosable by CT scanning. The patients chronic DVT could conceivably cause chronic leg pain due to venous congestion or inflammation, but this also is not diagnosable by CT scanning. In conclusion, CT scanning would not be an effective way to diagnose this patients chronic left leg and hip pain.Final Result: The reviewer determined that the requested service 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 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.