Persius/hicric huggingface dataset:
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 peripherally inserted central catheter (PICC). In this case, the patient was being treated appropriately with intravenous Invanz for a complicated urinary tract infection with extended-spectrum beta lactamase producing Escherichia coli. Per the records, seven additional days of intravenous antibiotics were recommended after the inpatient hospitalization from late October 2017.  Subsequently, she had another urine culture that was positive for extended-spectrum beta lactamase producing Escherichia coli and required treatment with intravenous antibiotics as recommended. The bacteria were sensitive to Invanz, which can be administered intramuscularly or in a peripherally placed line.  There is no documentation to support that she requires a PICC line to be placed for administration of this medication.  Furthermore, there is no clear documentation to support that she has been evaluated by a medical provider who has ordered a PICC line to be placed. Therefore, the requested PICC line is not medically necessary for the treatment of this patient. 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 internal 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 a polysomnogram supervised sleep study. In this case, the patient presented with a clinical presentation that is suggestive of a sleep related breathing disorder. The patient was noted to snore, have excessive daytime sleepiness, frequent arousals from sleep, and disturbed/restless sleep and weight gain. Given the symptoms present that are consistent with obstructive sleep apnea (OSA), testing for OSA is reasonable. However, there has been a shift from testing in the attended environment to the unattended setting. Current literature including randomized controlled trials have demonstrated equivalence in diagnosis and outcomes with provision of services in attended versus unattended settings. Overall, the attended sleep study would exceed this patients clinical and diagnostic needs. For these reasons, the requested polysomnogram supervised sleep study is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are 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 neurology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for radiofrequency ablation of the right knee. Findings:  Two of the three physician reviewers Per the medical evidence, radiofrequency ablation of the genicular nerves of the knee is not recommended until higher quality studies with longer follow-up periods are available, to demonstrate the efficacy and track any long-term adverse effects. Choi and colleagues reported that radiofrequency neurotomy of genicular nerves resulted in significant pain reduction and functional improvement in a subset of elderly chronic knee osteoarthritis pain, and thus may be an effective treatment in such cases. However, the authors concluded that further trials with larger sample size and longer follow-up are warranted.  Bhatia and colleagues concluded that radiofrequency treatments on the knee joint (major or periarticular nerve supply or intra-articular branches) have the potential to reduce pain from osteoarthritis or persistent post-arthroplasty pain. However, the authors noted randomized controlled trials of high methodological quality are required to further elaborate role of these interventions in this population. This patient presents with chronic bilateral knee pain. The records indicated that she has been diagnosed with osteoarthritis of the knees, severe in the medial compartment. She reported significant functional limitations in activities of daily living. The treating provider has recommended genicular nerve radiofrequency ablation for the right knee to reduce knee pain, following positive genicular nerve blocks. She has been advised to lose weight prior to total knee replacement and delay surgery due to her young age. However, the requested services are not currently supported as safe and effective by evidence-based guidelines and peer-reviewed literature. There is a lack of large volume, long-term peer-reviewed outcome studies to support the requested services in this clinical setting. Therefore, the requested radiofrequency ablation of the right knee is not likely to be superior over other available treatment options. 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 reviewers 1, 2 and 3 are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a computed tomography (CT) scan of the heart. Based on the records provided for review, the patient presented with increased coronary risk with hyperlipidemia and a family history of heart disease but no known coronary disease. In this circumstance of increase coronary risk, current guidelines endorsed by several national organizations do not recommend the routine use of coronary CT scanning to help guide the use of statin therapy. Specifically there is a lack of evidence that treatment change based on coronary CT scanning results yields an improved cardiovascular outcome incremental to that achievable with treatment guided by standard clinical risk profiling and basic lipid analysis. Based on the patients high LDL level and family history of coronary disease, a statin medication is indicated, regardless of results on coronary CT scanning. Thus, the CT scan of the heart performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the CT scan of the heart performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the CT scan of the heart performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 reimbursement for air ambulance transport services. Review of the submitted documentation demonstrates the air ambulance transport services the patient received were not medically necessary. At the times of transport, the patient's medical condition did not require immediate and rapid transportation that could not have been provided by ground transportation. Review of the progress notes prior to both transfers reveals the patient's medical condition was stable for transport. The patients medical conditions were chronic and the patients needs during transport could have been adequately met with ground transportation. The submitted documentation does not reveal any unstable medical issues at the time of either transport which would have posed a threat to the patient's health. As such, the medical necessity of the disputed air ambulance transportation services has not been established.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tysabri. Tysabri (natalizumab) is one of several disease-modifying agents that effectively reduces the relapse rate for patients with relapsing-remitting multiple sclerosis. The main concern with natalizumab therapy is the risk of developing progressive multifocal leukoencephalopathy. Early American Academy of Neurology guidelines recommended that natalizumab be reserved for patients with relapsing-remitting multiple sclerosis who failed other therapies because of continued disease activity or medication intolerance, or who had a very aggressive initial disease course. In this case, the patient had two relapses treated with steroids. However, there is a lack of evidence that the patient has aggressive disease that failed other therapies. The records do not document that the patient had negative serology for John Cunningham virus. The medical evidence does not support the requested medication in this clinical setting. Therefore, Tysabri 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 neurology 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: A 54-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the wrist. Lynch syndrome is a well-recognized inherited disorder which predisposes the patient to cancer in multiple organs including colon, uterus, stomach, small bowel, pancreas and the urinary tract. A variant known as Muir-Torre syndrome is associated with cutaneous lesions including cancer of superficial soft tissues but not bone. This patient has a palpable cystic lesion along the radial aspect of the left wrist, which is a common location for ganglion cyst. This patients records do not include findings of a solid mass on ultrasound. For these reasons, MRI of the wrist is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for partial hospitalization program services. The submitted documentation fails to demonstrate the medical necessity of the requested services. The American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining necessary level of care for adults. In terms of risk of harm, the records support a score of 1-2 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to some problems with role performance. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability. In terms of level of stress of the recovery environment, the records support a score of 3 due to a stable living situation. With regards to level of support for the recovery environment, the records support a score of 2 due to family support and availability of treatment resources but also some difficulty in relationships with her family members. With regards to treatment and recovery history, the records support a score of 3 due to recent success at the residential treatment center level of care. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Thus, the patient has a composite score of 15-16. This correlates with treatment in a community-based outpatient clinic setting. The literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for the treatment of eating disorders. All told, the requested partial hospitalization program services are not medically necessary for the treatment of this patient. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Spinraza. Spinraza is an antisense oligonucleotide that is designed to increase the expression of the survival motor neuron protein. Spinraza has been approved by the U.S. Food and Drug Administration (FDA) as a disease modifier for patients with SMA. This patients medical records document the presence of residual motor function allowing the patient to engage in some of the activities of daily living. However, the patients muscle weakness has continued to progress. Given the current medical literature, this patient is likely to benefit from Spinraza to reduce disease progression and prolong the patients ability to function.  Given the lack of alternative treatments in this setting, Spinraza is a medically appropriate next step for treatment of the patients condition. All told, the requested Spinraza is medically necessary for treatment of this patients SMA. 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 neurology with sub-specialty certification in neuromuscular 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for endoluminal ablation of varicose veins. Findings:  Three physician reviewers found there is sufficient support for the services at issue in this case. This patient has a long history of varicose veins, and the symptom severity has been adequately documented. On physical examination, large varicose veins were adequately documented in the territories of the treatment in question. There is adequate documentation of satisfactory arterial perfusion to the lower extremities bilaterally.  There is documented reflux in the veins that were treated, including documentation of saphenofemoral reflux. The treatment performed was medically appropriate. In sum, endoluminal ablation of varicose veins was likely to have been of greater benefit than other treatment options.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in vascular surgery and are actively practicing. Physician reviewer 2 is board certified in surgery 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly allergy shots. The Health Plan has denied this request indicating that the requested medication frequency is not medically necessary for treatment of the enrollee who has sensitivity to numerous allergens.Findings:  Weekly maintenance dosing is a nonconventional schedule for allergen immunotherapy.  There is unclear evaluation for other potential factors for nonresponse in this patients case noted above. It is unclear from the documentation exactly how long the patient continued on monthly dosing prior to discontinuation. On 8/17/17, a case note reported that nasal congestion has increased on monthly shots, but this same documentation noted symptom control had improved. It is unclear if more minor adjustments in dosing/frequency were tried. Data is lacking regarding the need and effectiveness for more frequent maintenance dosing (i.e., every week). There is not a clear rationale provided for the nonconventional and more frequent dosing in this case. As such, the medical necessity for weekly allergy shots has not been demonstrated for the treatment of this patients medical condition. Final Result: The reviewer has determined that the requested medication frequency 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 pediatrics and allergy and immunology 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 parent of an enrollee has requested authorization and coverage for speech therapy, including augmented alternative communication (AAC) therapy and feeding therapy. As noted in the medical literature, 1p36 deletion syndrome is characterized by intellectual disability, seizures, feeding difficulties, congenital heart disease, ophthalmologic abnormalities, and skeletal abnormalities as well as hearing loss. In addition, speech and language delays in 1p36 deletion syndrome are common, with up to 40% of patients reported to have complex speech difficulties. One study reported that patients with 1p36 deletion syndrome greatly benefit from enrollment in a personalized rehabilitation program with attention to motor development, cognition, communication, and social skills. Given that the age of verbal speech onset is significantly delayed, progress is often slow and long-term speech therapy is recommended (study). Since starting speech therapy in 2014, this patient has improved from non-verbal to vocal, and is using her voice to gain attention and demonstrate desires as well as reject objects and activities. Overall, the patients speech therapy records indicate slow, steady progress, which is typical in this condition. Given the presence of feeding difficulties in 1p36 deletion syndrome, feeding therapy with attention to oral motor skills is also appropriate. Special feeding techniques or devices can be used for feeding a hypotonic patient without a cleft palate or those with an unrepaired cleft palate (study). Moreover, the use of AAC technology is appropriate in this case. According to Luke, speech-generating devices (SGD), as one method of AAC, can effectively enhance the communicative and linguistic development of children with severe childhood apraxia of speech. All told, the requested individual speech therapy services, including AAC therapy, and feeding therapy services are medically necessary for treatment of this patients medical condition. 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 pediatrics with sub-specialty certifications in neurodevelopmental behavioral pediatrics and genetics 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.