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

The patients parent has requested authorization and coverage for first-omeprazole 5 ml twice a day at 2 mg/ml. Researchers reported that based on expert opinion, the working group recommends the use of proton pump inhibitors (PPIs) as first-line treatment of reflux-related erosive esophagitis in infants and children with GERD. However, PPI use is recommended in infants only when there are findings of erosive esophagitis. In this case, there was no indication the patient had an endoscopy or that the patient had been diagnosed with erosive esophagitis. She also does not have any identified abnormality of the esophageal anatomy, such as esophageal atresia. The medical evidence does not support the requested medication in this clinical setting. Therefore, first-omeprazole 5 ml twice a day at 2 mg/ml is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication 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 pediatric 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

The patient has requested reimbursement for an oral appliance. The patient has been diagnosed with mild obstructive sleep apnea (OSA). Researchers reported that they recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. They also reported that an oral appliance can be an effective treatment option for those with OSA and snoring. In this case, the patient has been diagnosed with OSA and was unable to tolerate treatment with CPAP. The patients periodontal health was noted to be grossly normal. The provider noted a panograph and revealed normal temporomandibular joints with no signs of pathology. The medical evidence supports the device at issue in this clinical setting. Therefore, an oral appliance provided on was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device at issue was 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 otolaryngology with sub-specialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for physical therapy three times per week and occupational therapy three times per week. Without optimization in functional status, this patient is at increased risk of a compromised functional status. Based on the available records, the patient partially improved with physical and occupational therapies. Specifically, the patients bed mobility improved from maximum assistance to moderate assistance, her bed rolling improved from maximum assistance to moderate assistance, and her walking improved from unable to dependent at 10-49 feet. Based on these reports, the patient demonstrated adequate progress, yet she continues to have functional goals that are reasonably expected with formal physical and occupational therapies. Ongoing efforts toward physical rehabilitation are within standard practice, and are appropriate to keep the patient on a pathway to functional recovery. All told, the requested physical therapy three times per week and occupational therapy three times per week 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 internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for gammaCore vagus nerve stimulator (VNS). The American Headache Society (AHS) position statement on integrating new migraine treatments into clinical practice states that, neuromodulation may be useful for patients who prefer nondrug therapies or who respond poorly, cannot tolerate, or have contraindications to pharmacotherapy. Researchers reviewed the evidence of noninvasive VNS for the treatment of migraine. The authors concluded that patients with migraine who experience two or more headache days per month and remain dissatisfied with their current treatment are the best candidates to try gammaCore. In addition, the FDA has approved gammaCore VNS for the acute treatment of migraine and cluster headache. In this case, the patient has migraines that have not responded to multiple oral medications. She has tried gammaCore in the past, which resulted in improvement in migraine frequency and severity. The AHS position statement and medical studies support treatment with gammaCore for this patients migraines. Therefore, the requested GammaCore VNS 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology 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: Upheld Decision of Health Plan

The parent of an enrollee has requested reimbursement for Applied Behavioral Analysis (ABA) therapy services, including social skills group therapy. While an autism diagnosis is a necessary component to access Applied Behavioral Analysis (ABA), it is only one component, and another necessary component is documentation outlining patient assessment results and course of treatment. Guidelines established by the Council of Autism Service Providers (CASP) highlight essential elements of ABA including direct observational data, a carefully constructed individualized and detailed behavior-analytic treatment plan, and treatment protocols. CASP guidelines also detail critical features of a treatment plan for service authorization. In this case, the patient has been diagnosed with autism, and the treatment in issue, ABA, is the most evidence based treatment for individuals on the autism spectrum. However, there is no documentation of the specific needs of the patient during the period under consideration, as the submitted records do not include a treatment plan for this period. Furthermore, the submitted records do not set forth direct observational information or include medical record documentation of ABA services that were provided to the patient during the period under consideration. Under these circumstances, Applied Behavioral Analysis (ABA) therapy services, including social skills group therapy, provided during the period under consideration were not medically necessary to treat the patients condition.Final Result: The reviewer determined that services at issue were not medically necessary to treat the patients condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed B.C.B.A., board certified in psychology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Lyrica (pregabalin) 100 mg capsules. The patient presents with a history of neuritis and neuralgia, for which standard treatment options include gabapentin, Lyrica, and Cymbalta. The patient was unable to tolerate treatment with gabapentin due to side effects. The provider switched the patient from gabapentin to Lyrica and the patient had good benefit and no adverse effects. Given the limited medical therapies that are safe and effective for this patients neuritis and neuralgia, his positive response and ability to tolerate Lyrica support its continued use. All told, the requested Lyrica (pregabalin) 100 mg capsules are medically necessary for 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 anesthesiology with subspecialty certification in pain management 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 intramuscular (IM) amino acids methionine, proline, and cystine; placement in a treatment program for chronic Epstein-Barr virus (EBV) using lysine, anti-virals, and rest; and paracervical prolotherapy with neck tracking and physical therapy. Per the current evidence-based peer-reviewed medical literature, treatment with intramuscular (IM) amino acids and prolotherapy are not recommended for patients with fibromyalgia, spine pain, Ehlers-Danlos syndrome, or any of the patients listed diagnoses in the medical records. Tzadok and Ablin noted that fibromyalgia is involved with neural oversensitization and decreased conditioned pain modulation (CPM), combined with cognitive dysfunction, memory impairment, and altered information processing. The authors reported that, only three drugs, pregabalin, duloxetine, and milnacipran are currently FDA-approved for fibromyalgia treatment. This patients records do not demonstrate that she has failed standard therapies including pregabalin, duloxetine and milnacipran. Therefore, the requested IM amino acids methionine, proline, and cystine; placement in a treatment program for chronic EBV using lysine, anti-virals, and rest; and paracervical prolotherapy with neck tracking and physical therapy are not 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 IM amino acids methionine, proline, and cystine; placement in a treatment program for chronic EBV using lysine, anti-virals, and rest; and paracervical prolotherapy with neck tracking and physical therapy are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in rheumatology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in allergy and  immunology and rheumatology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in rheumatology and is 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: Upheld Decision of Health Plan

The patient has requested reimbursement for psychiatric residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers 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. Applying the LOCUS framework, the patient did not meet the criteria for psychiatric RTC services. The patients composite score is consistent with high intensity community based services. Given the lack of pharmacologic interventions and medical stability as well as lack of suicidality or safety concerns, the patient did not meet the requirements for medically monitored residence based services. Given these findings, the psychiatric RTC services 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 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 H.P. Acthar Gel corticotropin injection 80 units subcutaneously, three times a week.The submitted documentation fails to demonstrate the medical necessity of the requested medication. Based on the available information, symptomatic sarcoidosis is a presumptive diagnosis in this patient at the current time. Sarcoidosis is a diagnosis of exclusion, with a broad differential diagnosis, including mycobacterial/fungal infection, hypersensitivity pneumonitis, drug-induced hypersensitivity, pulmonary histiocytic disorders, foreign body granulomatosis, vascular inflammatory disease, and primary immunodeficiencies. Thus, the diagnosis of sarcoidosis necessitates a broader infectious, pulmonary, occupational/environmental and inflammatory work-up. In this case, there is insufficient data to support the diagnosis of sarcoidosis at the current time, particularly without a negative infectious work-up or tissue biopsy showing non-caseating granulomas.Moreover, in the setting of biopsy-proven sarcoidosis, current treatment guidelines do not recommend initial therapy with H.P. Acthar Gel. Glucocorticoids are generally recommended as first-line treatment for sarcoidosis. In those intolerant or unresponsive to glucocorticoids, intensification of therapy typically involves immunosuppressive agents, such as methotrexate, azathioprine, leflunomide, or tumor necrosis factor-alpha inhibitors. It remains unclear why this patient is unable to take immunosuppressive agents, in keeping with current guidelines, as poorly controlled diabetes is not a contraindication to such therapies. Therefore, H.P. Acthar Gel corticotropin injection 80 units subcutaneously, three times a week, is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat 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 pulmonary disease and critical care medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for BRCA genetic panel testing.According to the National Comprehensive Cancer Network (NCCN) criteria for genetic testing for hereditary breast and ovarian cancer, at least one of the following should be met: personal history of breast cancer diagnosed at or before 45 years of age; personal history of breast cancer between age 46 and 50 with unknown or limited family history, or second breast cancer diagnosed at any age, or one or more relatives with breast, ovarian, pancreatic or prostate cancer; personal history of triple negative breast cancer diagnosed before 60 years of age; personal history of breast cancer at any age and one close relative with ovarian cancer, metastatic prostate cancer, pancreatic cancer or breast cancer diagnosed at 50 years of age or younger; personal history of ovarian cancer at any age; personal history of exocrine pancreatic cancer at any age.In this patients case, the NCCN criteria were not met. She was diagnosed with breast cancer at age 63. The records noted a family history of colon cancer. Based on the submitted clinical documentation, the patient does not meet criteria to qualify for the BRCA gene panel testing. Given the patients age of diagnosis and absence of family history of relevant cancers (ovarian, pancreatic and prostate), the probability of hereditary predisposition is low. Therefore, the requested BRCA genetic panel testing is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in clinical genetics and genomics 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 excimer laser therapy. Ultraviolet light therapy is an established treatment modality for vitiligo. Excimer therapy is a targeted form of ultraviolet B (UVB) therapy, which has some advantages over traditional narrowband UVB including lower cumulative UV dose exposure and shorter course of therapy, as well as better-directed treatment at sites of skin pathology rather than compromising normal adjacent skin. Currently, excimer laser therapy is considered part of the standard of care for patients with vitiligo. In addition, there is ample data supporting the safety and efficacy of excimer laser therapy on the face when compared to tacrolimus. This patient also has a history of hypothyroidism, which has a known association with vitiligo. Moreover, clinical and wood lamp examination revealed findings consistent with vitiligo. Her providers have recommended treatment with excimer laser therapy. Given the support in the medical literature, the requested excimer laser therapy 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested reimbursement for mobile cardiac telemetry monitoring. Current expert consensus guidelines endorsed by several national organizations consider patient activated event recorders and other offline monitoring devices appropriate initial tests for evaluation of supraventricular dysrhythmias. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services has not been shown to improve health outcomes compared to standard monitoring techniques. In this patients clinical circumstance, cardiac monitoring during recurrent symptoms with non-real-time monitoring devices, such as 48-hour Holter monitoring or event monitoring, would have been sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Similarly, self-activated non-continuous monitoring devices that are not real-time are effective at recording symptomatic dysrhythmias during less frequent symptoms. In cases of infrequent asymptomatic dysrhythmias that require identification, monitoring devices with auto-triggering capability without real-time monitoring are appropriate. In this case, the patients diagnoses include essential thrombocythemia as well as intermittent chest discomfort, and presyncope. There is no documentation to indicate that the patient was unable to manage standard monitoring devices or that these options were attempted to evaluate the patients condition. For these reasons, the mobile cardiac telemetry monitoring was not medically necessary for this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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 cardiovascular 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.