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

Nature of Statutory Criteria/Case Summary: The parent male enrollee has requested reimbursement for residential treatment center (RTC) services. 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. The CASII utilizes dimensions that are relevant to the patients 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, patient involvement in services, and parent involvement in services. Based on the patients clinical history provided and documentation as outlined above, the patient met CASII criteria for non-secure 24-hour psychiatric monitoring. The patient remained symptomatic throughout his admission. He was noted to be depressed, anxious, and irritable. He had documented incidents of yelling, cursing and physical aggression towards staff and inappropriate behaviors toward his peers. Due to the patients persistence of symptoms, he had changes in his medication regimen to target these symptoms including trials of buspirone, duloxetine, and aripiprazole. The patients clinical status, in addition to current medical literature, support that the treatment at the residential level of care was appropriate for this patient. For these reasons, the RTC services provided were medically necessary for treatment of this patients behavioral health issues. 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 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: A 27-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) services.  Findings:  The physician reviewer found that the medical literature, Lusicic and colleagues reported that evidence for repetitive TMS in patients with OCD is accumulating and informing further developments in the field of neurostimulation. Further, Jaafari and colleagues noted that two random controlled studies demonstrated benefit with TMS for patients with OCD in patients resistant to first-line conservative treatment. The records provided for review indicate that this patient has OCD and has failed first-line conservative care. Given these findings, the TMS services provided were medically necessary for treatment of this patients OCD. 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 neurology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus, genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent 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 limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Mavyret daily for eight weeks. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret for eight weeks is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret. According to the most recent 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The ENDURANCE-1 trial showed that only eight weeks of treatment is needed. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that the parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients short stature. The submitted documentation supports the medical necessity of the requested medication. Based on the specific medical needs of the patient, current literature and published guidelines, this patient would benefit from growth hormone treatment for the diagnosis of idiopathic short stature for the following four reasons. First, this patient has clearly abnormal growth velocity as indicated by the growth chart, which was always growing below the third percentile. Second, the patient had a bone age, which gave an estimated adult height of 147 cm. This is an extremely low adult height. This patient will not be able to function properly as an adult without treatment with a growth hormone and it is expected that the patient might have problems driving, finding adult womens clothing, and shoes, etc. Therefore, it is highly recommended that the patient receive treatment with a growth hormone that will enable a more physiologic adult life. Third, the Food and Drug Administration has approved growth hormone for children with a height that is less than 2.25 standard deviations below the mean, and this recommendation has been endorsed by the Pediatric Endocrine Society and other professional organizations. In this case, the patient has a height that is less than 2.5 standard deviations below the mean, and depriving treatment is likely to have adverse effects on the patients adult life. Fourth, while familial short stature is not an indication for growth hormone treatment, when the familial target height is below the normal adult height that could indicate that one of the parents had an undiagnosed genetic disorder that caused severe short stature. Therefore, a patient can still qualify for growth hormone treatment even in the context of familial short stature, when of course certain criteria are met. Therefore, Nutropin AQ Nuspin is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 vaginal hysterectomy and one day hospital stay. In this case, there is no documentation that any treatment option was discussed outside of a hysterectomy. Given that the patients uterine fibroid is small, and intramural, it may not be related to her heavy cycles. The patients grand multiparous uterus with reduced efficiency may be the cause of her symptoms. Moreover, the patient can be treated with low dose over the counter contraceptive pills to control her cycle. There is no documentation of any absolute or relative contraindication to hormonal control of her cycles. All told, hysterectomy is not considered a first-line treatment option in this clinical setting. Thus, the requested vaginal hysterectomy and one day hospital stay is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services 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 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: A patient has requested reimbursement for the intensive outpatient program (IOP) services received at the Recovery Road Medical Center. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation of the patients medical needs and generally accepted standards of medical practice support the medical necessity of the services at issue. The patient was not able to commit adequately to meaningful relapse-prevention therapy, placing him at high-risk of relapse, deepening depression, and decompensation. Continued intensive therapy was medically necessary to prevent high-risk of continued self-harm through dependence on cannabis, tobacco, and benzodiazepines. Accordingly, the intensive outpatient program (IOP) services received at the Recovery Road Medical Center was medically necessary for the treatment of this patient.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 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: A female enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. The records provided for review document that this patient has a long history of eating disorder since she first purged by vomiting at age eight, and currently engages in purging five to six times per week. The treatment plan includes meeting with a primary therapist twice per week and registered dietician once per week, as well as therapeutic and psychoeducational group meetings daily on program days. Per the report, the patient reported experiencing suicidal ideations with no definite plan. Per the American Psychiatric Association (APA) guidelines, services available for the treatment of eating disorders range from intensive inpatient settings in which subspecialty general medical consultation is readily available, to residential and PHP levels of care, to varying levels of outpatient care in which the patient can receive general medical treatment, nutritional counseling, and/or individual, group, and family psychotherapy. Pretreatment evaluation of the patient is essential for determining the appropriate treatment setting. The patients weight, rate of weight loss, cardiac function, and metabolic status are the most important physical parameters for making this determination. This patient has experienced an eating disorder since age 8 and her symptoms have worsened with reported suicidal ideation. Conservative strategies and inpatient level of care services have been tried, but have not been successful. Thus, the PHP services provided were and are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 reimbursement for the Guardant360 test. Findings:  Two of the three physician reviewers found that molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care for stage III and IV disease. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) guidelines strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Thus, Guardant360 test was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cordran tape. The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has been diagnosed with psoriasis. She has failed therapy with clobetasol and Vectical ointment. The Health Plan requires failure of the preferred formulary agents prior to approving coverage for Cordran tape, and this requirement is medically appropriate. As there is no medical documentation of failure of therapy with topical steroids outside of clobetasol, the medical necessity of the non-formulary medication, Cordran tape, has not been established. Therefore, Cordran tape 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Orthovisc/hyaluronic injections of both knees and prospective authorization and coverage for Orthovisc/hyaluronic injections of both knees every six months. Evidence-based peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and has been shown to be more effective than corticosteroid injections. In this case, the patient has been diagnosed with osteoarthritis of both knees. She presented with progressive bilateral knee pain with associated crepitus, grinding, and limited motion. Activities of daily living had been limited. Clinical examination findings were consistent with reported bilateral knee osteoarthritis. Conservative treatment failure has been documented to include corticosteroid injections, nonsteroidal anti-inflammatory drugs, ice, and exercise. The Orthovisc injections performed were medically necessary for the treatment of her medical condition. However, the medical necessity of future Orthovisc injections cannot be established at the time. Current evidence-based literature would support future Orthovisc injections for both knees if there is documented significant improvement in symptoms for six months or more, and symptoms recur. In sum, prior Orthovisc/hyaluronic injections of both knees were medically necessary for the treatment of this patient. However, the medical necessity of future Orthovisc/hyaluronic injections of both knees every six months has not been demonstrated.Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the platelet rich plasma and stem cell injections. Platelet rich plasma and stem cell injections are not supported by sufficient clinical evidence for use in this clinical setting. Long-term benefits of platelet rich plasma have not been demonstrated in the knee. Short-term benefits, lasting from six months to over one year, include functional improvement and pain relief. However, these results have been demonstrated primarily in patients under age 50 with mild to moderate osteoarthritis or recalcitrant patella tendinopathy. One study in patients with early arthritis compared the effectiveness of platelet rich plasma with hyaluronic acid injections and reported that platelet rich plasma is promising for less severe early arthritis in patients under 50 years of age, but not for more severe osteoarthritis, especially in older patients. Based on the available evidence, the platelet rich plasma and stem cell injections were not likely to be more beneficial for treatment of the patients left knee osteoarthritis than any available standard therapy.One reviewer found that the platelet rich plasma injections were likely to be more beneficial for treatment of the patients left knee osteoarthritis than any available standard therapy, and the stem cell injections were not likely to be more beneficial for treatment of the patients left knee osteoarthritis than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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.