Persius/hicric huggingface dataset:
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 30 hours per week of direct applied behavior analysis (ABA) services by a paraprofessional (Code H2019). To determine the medical necessity of ABA, research by Papatola and Lustig provides guidelines. According to the authors, the definition entails healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms; and 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. Based on the presenting information, this patient meets the medical necessity criteria for direct ABA services. The requested services are specifically tailored to meet the needs and deficits of this patient. In addition, the National Autism Center has identified ABA as the most effective evidence based treatment for children and adults on the autism spectrum. Thus, the requested services are required to meet the patients essential health needs and is consistent with the patients diagnosis of autism. With regard to treatment intensity, the Behavior Analysis Certification Board (BACB) outlined guidelines, which incorporate the presenting concerns of the patient. Treatment intensity and duration is unique to these presenting concerns and are based on progress and remaining skill deficits. This patients provider has listed over 30 goals in the current treatment plan. Further, the treatment plan outlines discharge criteria, indicating the providers have identified a level of skill acquisition for the patient to no longer require ABA therapy. Overall, the records suggest that these services are not for the patients convenience and are being provided in the least restrictive setting available to deliver appropriate health care. The patient has demonstrated progress, meeting 35 of 49 goals in one authorization period and 7 of 39 goals during the following authorization period. Given this information, 30 hours per week of direct ABA services by a paraprofessional (Code H2019) 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
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patients parent has requested authorization and coverage for Guanfacine HCL ER 1 mg. The American Association of Pediatrics (AAP) recommends evidence-based parent and/or teacher-administered behavior therapy as the first-line of treatment for preschool aged children with ADHD. The physician reviewer found that the AAP further states that a provider may prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-to severe continuing disturbance in the childs function. In addition, Guanfacine falls in the non-stimulant medication category, which is not Food and Drug Administration (FDA) approved for use in patients under the age of six years of age. The records provided for review do not document that the patient has tried or failed any methylphenidate formulations, consistent with the recommendations from the AAP. Therefore, the requested Guanfacine HCL ER 1 mg is not medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Skilled Nursing Facility (SNF) services.The submitted documentation does not support that the Skilled Nursing Facility (SNF) services at issue were medically necessary. Spine surgery may be indicated in cases of refractory back pain with indication of pathology that is amenable to surgical intervention. Multidisciplinary rehabilitation is often indicated postoperatively when there are issues such as significant functional decline, poorly controlled pain, and wounds that require close monitoring.In this case, the patient underwent multiple spine surgeries for chronic back pain. Patient had multiple complications and had persistent lower limb weakness with functional decline. The patient was transferred to a skilled nursing facility for reconditioning and ongoing wound care. patient participated in therapies and made some progress, but  plateaued at a level where help for basic self-care tasks were needed. The patients mobility was limited, and required supervision at least, if not physical assistance at times. Given underlying impairments and plateau in functional gains, patient would not have been expected to improve further functionally in a predictable and significant manner that would have altered the amount of assistance required in the community on a practical basis. The patient had a back wound that was chronically requiring wound VAC dressing care, but there were no indications that this could not have been continued on an outpatient basis. The patient otherwise had multiple chronic medical conditions, but none that required ongoing inpatient level medical and nursing care. The patient had plateaued at a level where further care was custodial and Skilled Nursing Facility (SNF) services were not medically necessary. Further rehabilitation efforts could have been provided in the community, or at a custodial level facility, if needed due to environmental barriers and/or insufficient caregiver availability, willingness or ability. Accordingly, the Skilled Nursing Facility (SNF) services at issue were not medically necessary to treat the patients medical condition.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 physical medicine and rehabilitation 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:  The enrollees parent requested authorization and coverage for optometric vision therapy. The enrollee has refractive amblyopia in both eyes. She has anterior visual midline shift syndrome (VMSS) and requires yoked prism in her lenses to center the VMSS.  These lenses are a form of vision therapy and will change as her visual system improves and becomes more integrated.  The optometrist has recommended neuro-optometric vision therapy, designed to increase the visual sub skills necessary for proper educational intervention.  The individualized vision therapy program will emphasize binocular work to improve eye-teaming efficiency and depth perception; visual-motor tasks to improve body awareness and control, visual direction of gross and fine motor skills, eye-hand coordination; inter-sensory integration skills through visual-auditory-verbal matching; and reintegration of spatial-visual processing and its relationship to the proprioceptive base of support. The enrollees diagnoses are esotropia, amblyopia, and high myopia.  Review of the literature indicates standard treatments for these conditions include eye muscle surgery; with or without occlusion/cycloplegic therapy, and spectacle correction.  A literature search failed to generate any studies comparing standard treatments to vision therapy. There are various non-standardized testing results to indicate dysfunction in the enrollees visual pursuit.  Literature does not support the efficacy of eye exercises, behavioral vision therapy, or special tinted filters or lenses for improving educational performance in these pediatric neurocognitive conditions.  These approaches lack scientific evidence of efficacy and are not endorsed. Convergence insufficiency as the only diagnosis for which vision therapy has been proven beneficial in randomized clinical trials. Convergence insufficiency has been associated with reading impairment and poor academic performance. However, these associations do not prove a causal relationship between these conditions.  Additionally, there is no evidence the enrollee has convergence insufficiency. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for a special bed alarm-HCPCS: enuresis alarm, using auditory buzzer and/or vibration device x1.  The enrollee has Tourettes syndrome, obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), anxiety and autism-like symptoms. His urologist indicates the enrollee has a history of possibly two episodes of epididymitis, as well as bedwetting. The most likely etiology for this condition is voiding dysfunction.  A follow-up note indicates the enrollee needed an authorization for diapers because he is unable to hold his urine and stool.  An enuresis alarm for the enrollee was prescribed. The enrollees parent indicates the alarm would wake the enrollee when wet and will help train him not to urinate in his sleep. Review of the record indicates while the enrollee exhibits nocturnal enuresis (bedwetting), he also has daytime urinary incontinence, fecal incontinence and lower urinary tract symptoms, such as urgency and postponement that require wearing diapers. According to a literature review, these incontinence symptoms associated with the enrollees nocturnal enuresis are consistent with the enrollees comorbidity, autism spectrum disorder. Findings: Literature support for an enuresis alarm device for nocturnal enuresis is limited to highly motivated individuals with primary monosymptomatic (a single principal symptom) nocturnal enuresis (PMNE) and family support. However, this is not the case for this enrollee. Unlike individuals with PMNE, this enrollee exhibits other lower urinary tract symptoms, such as daytime incontinence, urgency and holding maneuvers. He has multiple comorbidities, including ADHD and autism-like symptoms that limit his ability to cooperate with parental support and make the most effective use of the alarm device. Even for qualifying enrollees with PMNE, literature recommends short-duration treatment trials and/or intervals because of the high level of burden on the parents to support this treatment. While literature supports the superiority of an enuresis alarm over other pharmacologic treatment for PMNE, literature support for non-monosymptomatic nocturnal enuresis is lacking. This enrollees comorbidities compromise his ability to cooperate with the treatment.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in urology 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Guardant Health Laboratory Tests. The enrollee has breast carcinoma originally diagnosed as multifocal infiltrating lobular cancer node negative classic type. She had aggressive chemotherapy at that time, went into menopause and then developed a local recurrence in her late 50s.  Lymph nodes were removed, she had radiation therapy to her axilla and she has been on tamoxifen with no evidence of systemic relapse.  Her tumor DNA has been non-detectable after she was started on tamoxifen.  Her routine bloodwork indicated a normal CA 15-3 but the circulating tumor DNA showed a re-appearance of the BRCA mutation shown initially on her first test.  Thus, the DNA test was repeated. The Guardant360 report indicated somatic alterations were detected in the circulating cell-free DNA isolated from the enrollees blood specimen.  The genomic alterations were cancer-associated somatic variants, some of which have been associated with either increased or reduced clinical response to specific treatments. According to the literature, liquid biopsies can be performed when tissue biopsy is inaccessible or unavailable. While the current focus is dominated by DNA, additional components of a liquid biopsy include ribonucleic acids (RNA), circulating tumor cells (CTCs), extracellular vesicles (EVs), and tumor educated platelets (TEPs).  The latter components are mainly of research interest.  As more translational research is performed, these additional components of a liquid biopsy may have increasing clinical use in the future.  Although liquid biopsy may be an attractive tool for cancer screening in asymptomatic enrollees, such applications will need to be carefully and thoughtfully considered to avoid excessive anxiety due to false positive results, and the research in ongoing.  The Guardant360 test or a similar test to detect the circulating cancer cells in this enrollee with breast carcinoma is not recommended in the textbooks or the national guidelines. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in medical oncology. One review is board certified in clinical cytogenetics and clinical genetics. All 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

The enrollees parent is requesting  reimbursement for residential treatment services. The enrollee has a history of major depressive disorder (MDD), post-traumatic stress disorder (PTSD), gender dysphoria, obsessive compulsive disorder (OCD), generalized anxiety disorder (GAD), and Tourettes. The enrollee reported gender dysphoria with eventual identification as a male. Using the CALOCUS system, the total composite score correlates to Level 5. Residential care is appropriate for this enrollee. The literature supports a psychiatrist should determine the most appropriate level of care and that treatment for depression may occur in a variety of settings. The determination of an appropriate setting for treatment should include consideration of the enrollee's symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Lorazepam, (Ativan) prescribed for anxiety with associated diagnoses of panic attacks and insomnia. The enrollee had anxiety every time she went to health plan providers. When she requested a refill of Ativan, it was noted she did not take it regularly as her last prescription for 20 tablets was given four to five months prior to the request. A psychiatric outpatient initial adult diagnostic evaluation and treatment plan indicated the enrollee had several problems with her health plan and is afraid of certain plan therapists. This has been corrected, but now she has panic attacks. Her medications include Prozac, Trazodone, and Ativan, as needed. Past therapists have told her she has post-traumatic stress disorder (PTSD) but nothing really life threatening has happened to her, other than her problems with the health plan. The enrollee was seen more recently for a medication review, as well as laboratory results.  It was noted she was utilizing Ativan two times a day as needed for anxiety.  On physical exam, there was no significant abnormality.  The enrollee was advised to return if not improving. According to the medical literature, lorazepam (Ativan) is appropriate for the management of anxiety disorders or for the short-term relief of symptoms of anxiety or anxiety associated with depressive symptoms.  Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic and the effectiveness of this medication has not been assessed by systematic clinical studies.  The enrollee has previously used lorazepam and a note indicates the enrollee complained of increased stress and the need for occasional use.  She requested a refill. However, evidence is insufficient in the record to support why the continued use of this medication is appropriate.  There is a lack of updated clinical documentation in the record indicating the prior objective benefit with use.  Furthermore, the literature does not detail effectiveness of the requested medication when utilized beyond four months. Ongoing use is not supported.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The EE has requested authorization and coverage for weekly individual therapy sessions, weekly dialectical behavior therapy (DBT) skills group, and DBT coaching for one (1) year. DBT is typically used for patients with the diagnosis of borderline personality disorder. However, as the therapy techniques in DBT are related to emotion regulation, interpersonal skills, affect of instability, and distress tolerance, it appears that these skills could be clinically useful for this patient (Neacsiu, et al.). The evidence base indicates that patients experiencing suicide ideation as well as self-harm and emotional regulation can benefit from DBT. Specifically, DBT has been shown to be an effective treatment for reducing suicidal ideation and para-suicidal behavior while improving emotion regulation and symptoms of anxiety in patients without borderline personality disorder (Gunderson, et al.). DBT focuses on implementing coping skills in patients with emotion regulation issues. The progress notes provided for review indicate that this patient has experienced steadily worsening symptoms over the past two to three months. The progress notes reflect interpersonal and family problems as well as suicidal ideation. The patient has been treated in an intensive outpatient program (IOP) and partial hospitalization program (PHP) but he continues to have symptoms. The current standard of care for DBT includes individual and group therapy for approximately one year. Therefore, the requested weekly individual therapy sessions, weekly DBT skills group, and DBT coaching for one (1) year are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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.