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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for septoplasty and bilateral inferior turbinate reduction. Based on the available clinical documentation, the requested septoplasty and bilateral inferior turbinate reduction are medically necessary for this patient. A published a randomized controlled trial compared surgery to non-surgical treatment in patients with a deviated nasal septum and nasal obstruction. The authors noted that 230 patients were followed across 18 hospitals. The authors found that septoplasty was more effective than non-surgical management in improving objective and subjective outcomes. This study provides high-quality evidence to support the use of septoplasty in this clinical setting. This patients records document the presence of right nasal septal deviation, caudal septum displaced into the left nasal airway, and moderately hypertrophic turbinates. Thus, the inclusion of bilateral inferior turbinate reduction is also appropriate. All told, the requested septoplasty with bilateral inferior turbinate reduction is medically necessary for 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 otolaryngology 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 patients parent has requested authorization and coverage for applied behavior analysis (ABA) services consisting of 78 hours per month of direct 1:1 therapy by a paraprofessional, eight hours per month of supervision, two hours per month of parent training, and five hours for reassessment. Based on the information reviewed, this patient meets the criteria for medical necessity for ABA services. The patients provider conducted the Vineland Adaptive Behavior Scales - 3 (Vineland-3), which measures areas related to autism spectrum symptoms, specifically, socialization, communication, daily living skills, and an adaptive composite. The patients scores reflected significant deficits in socialization and deficits in the adaptive composite score. Age equivalents in the area of socialization were also significantly discrepant from their chronological age in the areas of interpersonal relationships and play and leisure skills. The Vineland-3 is both a reliable and valid assessment measure to support ABA therapy for this patient. In addition, the patients provider included clearly defined and measurable goals for specifically targeted behaviors and skills directly related to autism. The patients treatment plan includes 12 goals, four problem behavior goals, and four parent training goals. Each of these goals is broken down into baseline, discriminative stimulus, goal, and current progress. Further, each goal identifies the specific areas that will be addressed including health and safety, adaptive functioning, social functioning, executive functioning, play and problem behavior. Moreover, ABA services are consistent with the recommendations from the Behavior Analyst Certification Board (BACB). The BACB highlights that the number, complexity, and intensity of behavioral targets and the clients own response to treatment define treatment intensity. Based on the number of goals identified, presenting behavior concerns, and progress made thus far, the request is well within the focused level of treatment requested for this patient. Therefore, the requested ABA services consisting of 78 hours per month of direct 1:1 therapy by a paraprofessional, eight hours per month of supervision, two hours per month of parent training, and five hours for reassessmenT are medically necessary for the 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 a licensed BCBA and is 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endovascular stenting.Nutcracker syndrome is a condition that is relatively rare, with few providers having significant hands-on experience. Medical literature on the subject of nutcracker syndrome is mainly based on case reports and small case series. Due to this limited experience, there are no established guidelines regarding this condition. There are, however, generally accepted indications and treatment options. Generally accepted indications for treatment include flank pain, particularly on the left side, hematuria either gross or microscopic (not absolutely required), evidence of renal vein compression by imaging studies including CT scan, and evidence of vascular engorgement. Typically, treatment is reserved as a last resort after conservative efforts, including attempts at weight gain, are not feasible or are exhausted. Symptoms typically should be severe enough that they are impacting a patients quality of life. Once intervention is determined to be necessary, both endovascular (left renal vein stenting) and open repair options are reasonable and accepted. Endovascular treatment is not without significant risks as stent migration, in-stent stenosis, and stent compression are all known complications. The incidence of stent migration, considering the small number of total patients treated, is a particular concern. For the procedure to be considered reasonable and medically necessary, there must be medical record documentation of a comprehensive evaluation by an experienced provider in which failure of conservative treatment is documented, and documentation of a plan for intervention, whether endovascular or open surgical, with rationale.In this case, the submitted documentation reflects that the patient has symptoms that could be reasonably attributed to left renal vein compression and that are impacting her quality of life. There is also documented evidence of left renal vein compression and evidence of venous engorgement. The submitted documentation does not reflect, however, that the patient has been re-evaluated by an experienced provider to assess her response to conservative treatments or that a clear plan of intervention, with rationale, has been documented in the medical record. Under these circumstances, endovascular stenting is not medically necessary for treatment of the 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 surgery, with primary specialty certification in vascular surgery, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a series of three intra-articular injections of hyaluronic acid, a third epidural steroid injection, and celecoxib. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of severe osteoarthritis of the left knee described as bone on bone, related to an old knee injury. The medical records document prior viscosupplementation for the left knee with associated benefit. The provider has therefore recommended repeat viscosupplementation with three intra-articular injections of hyaluronic acid for the left knee. The records document that the patient previously obtained lasting benefit from prior injections. Furthermore, the options are limited with the alternative being a total knee arthroplasty. As such, the requested series of three intra-articular injections of hyaluronic acid are medically necessary for this patient. Given the support for continued use of epidural steroid injections for lumbar pain, the requested third epidural steroid injection is medically necessary for the treatment of this patient.In addition, a review of the literature indicates that celecoxib is one treatment option that will reduce mucosal harm throughout the entire gastrointestinal tract, which is important for patients with a diagnosis of GERD. This patient has a diagnosis of GERD, which supports treatment with celecoxib in lieu of standard non-steroidal anti-inflammatory drugs (NSAIDs). Accordingly, the requested celecoxib is medically necessary for this patient. Final Result: The reviewer determined that the requested services and medication are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cialis. The current medical literature supports the use of Cialis for treatment of vasculogenic erectile dysfunction. This patients records document erectile dysfunction and comorbid cardiovascular atherosclerotic disease status post quadruple bypass and carotid endarterectomy. Given the evidence of systemic atherosclerotic disease in the patients medical history, Cialis is an appropriate choice of medical therapy to benefit his erectile dysfunction without placing the patient at increased cardiovascular risk. Therefore, the requested Cialis is 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for the medication, Xultophy, 100 Unit-3.6 MG/ML pen. The enrollee has a past medical history of stage three chronic kidney disease; type 2 diabetes mellitus, complicated by retinopathy, nephropathy and neuropathy; coronary artery disease with a history of ST-elevation myocardial infarction, complicated by cardiac arrest, status-post percutaneous coronary intervention; congestive heart failure, gout, hypertension, psoriasis, heparin-induced thrombocytopenia, and adrenal insufficiency. A progress note indicates the enrollees diabetes regimen included Xultophy, 35 units at bedtime. The physician recommended the enrollee continue his current regimen, as he has done extremely well on this medication, with a recent hemoglobin A1C of 6.4 percent, and his glucose control is now at goal. The provider is recommending the enrollee continue his current Xultophy regimen to decrease his risk of further cardiac complications. The enrollee has limited choices of diabetic medications due to his poor renal function state. Review of the records indicates there were questionable low blood glucose readings in the early morning hours, which indicates the enrollee's blood glucose was not well-managed with insulin and oral medications. Low blood glucose, (hypoglycemia), is an adverse effect of insulin treatment and a sign of a poorly controlled regimen. Literature notes Xultophy is a combination of insulin degludec and liraglutide.  Xultophy may provide additional blood sugar control with fewer adverse effects for individuals uncontrolled on a glucagon-like peptide-1 receptor agonist or basal insulin alone. Xultophy offers clinicians another reasonable option for these individuals. Use of the combination agent Xultophy offers the advantages of improved efficacy compared with either agent alone, a reduction in hypoglycemia, and an improved weight profile compared with basal insulin. Literature notes the use of Xultophy resulted in significant reductions in hemoglobin A1C values and a statistically insignificant weight gain over 12 months. The use of Xultophy has proven effective in improving blood sugar control in individuals who are refractory to standard treatments. The records indicate the enrollee has been using Xultophy for the past year and has shown improvement in his hemoglobin A1C; from 8.7 to 6.7 percent. He also has coronary artery disease and literature shows that use of the individual components in xultophy, liraglutide and degludec, has helped to improve outcomes. 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 endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting reimbursement for residential treatment center (RTC) services. The enrollee has diagnoses of post-traumatic stress disorder, recurrent major depressive disorder without psychotic features, severe alcohol use disorder, severe other hallucinogen use disorder, severe cannabis use disorder, severe, unspecified stimulant use disorder, and severe sedative, hypnotic, or anxiolytic use disorder. The enrollee entered the residential treatment center for further evaluation and treatment of poly-substance use, emotional trauma, and progressively worsening depression and anxiety. She endorsed an inability to perform in her normal role functioning due to the severity of her substance use and psychiatric symptoms. The enrollee participated in her treatment plan and made meaningful progress during the hospitalization. She employed grounding techniques to learn to mitigate symptoms. She experienced fairly consistent levels of anxiety, most severe upon awakening, and she would improve as the day progressed. The Level of Care Utilization System (LOCUS) is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. This tool was used in this review. The enrollees composite LOCUS score correlates with medically monitored residential level of care. Medical evidence supports the services at issue in this clinical setting.Final Result: The reviewer determined that the requested services were 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for F5 (coagulation Factor V) genetic testing.Findings:  Two of three physician reviewers found that there is sufficient support for the requested services in this clinical setting. Studies of individuals with Factor V Leiden (FVL) indicate that the annualized risk for heterozygotes to have a thrombotic event is 0.49%. It is generally not recommended to test asymptomatic adult family members of individuals known to have a Leiden variant because there are no studies addressing benefit of treatment and the practical risk of thrombosis is low. However, in certain situations, there may be coexisting risk factors that would alter the recommendations in a particular case. In asymptomatic FVL carriers, standard antithrombotic prophylaxis should be recommended during risk situations such as surgery, immobilization, or trauma. Other coexisting risk factors that may influence duration of antithrombotic prophylaxis should be considered. These coexisting risk factors would include age, family history, overweight and obesity, and prolonged immobilization. In this case, the patient has a BMI that indicates that he is overweight/obese, and therefore, with this risk factor and his compelling family history, anticoagulation might be considered if he proves to be FVL positive. Therefore, while testing is not generally recommended, it has the potential to influence patient management in this case. Under these circumstances, F5 (coagulation Factor V) genetic testing is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: Two of three reviewers determined that the requested services are likely to be more beneficial than any other available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in medical genetics and genomics, with primary specialty certification in clinical genetics and genomics. Physician reviewer 2 is board certified in medical genetics and genomics, with primary specialty certification in clinical biochemical genetics. All three physician reviewers 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: Overturned Decision of Health Plan

The enrollee requested reimbursement for Oncotype DX Prostate Cancer Assay. The enrollee has prostate cancer and the biopsy report showed prostatic adenocarcinoma. The Oncotype DX Prostate Cancer Assay determined the enrollees genomic prostate score, indicating unfavorable intermediate risk, and his prostate specific antigen level was 5.2 nanograms/milliliter. The enrollees physician ordered the test to identify the specific risk of aggressive prostate cancer. Professional society guidelines note that men with low or favorable intermediate disease may consider the use of Decipher, Oncotype DX Prostate, Prolaris, or ProMark during initial risk analysis. This testing is recommended for very low, low risk, and favorable intermediate risk prostate cancer individuals with at least 10 years life expectancy who have not received treatment for prostate cancer and who are candidates for active surveillance or definitive therapy. Medical records indicate the enrollee meets these criteria and would, therefore, be considered appropriate.  The testing has very recently become more widely used. The latest version of the professional society guidelines now recommends the use of the requested testing in this enrollee's clinical scenario.Final Result: Two of the three reviewers determined that the requested services are 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 urology 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: Overturned Decision of Health Plan

The enrollee is requesting reimbursement for intensive outpatient program (IOP) level of care services. The enrollee has diagnoses of severe generalized anxiety disorder, obsessive compulsive disorder, major depressive disorder, autism spectrum disorder, rule out eating disorder, and rule out personality disorder. The enrollee was admitted to the intensive outpatient program level of care due to obsessive compulsive disorder and eating issues that caused her to have a low body mass index. She was admitted with the stipulation that she would gain weight while in treatment or be transferred to a higher level of care. The enrollee engaged in obsessive compulsive disorder treatment faithfully and made moderate improvements over the first month. Her mood improved. She interacted with staff and she was engaged in the program. She had a significant backslide following a family session. The enrollee had difficulty with eating due to her severe anxiety. Her weight and body mass index dropped to the threshold of what the facility could allow before transferring to a higher level of care. She experienced medication side effects and acid reflux. Her weight dropped; resulting in a body mass index below 16. She was subsequently transferred to a higher level of care. This enrollee was diagnosed with superior mesenteric artery syndrome and underwent surgery. While in the intensive outpatient program, she was seen weekly by psychiatrist. She did not have suicidal ideations or self-harming behaviors. She did not report psychotic symptoms. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations and was used in this review. The enrollees composite LOCUS score correlates with an intensive outpatient program level of care. Medical evidence supports the services at issue in this clinical setting. The enrollee had lost a significant amount of weight by the final day of service, and she had dropped to 75 percent of her ideal body weight, which necessitated a transfer to a higher level of care.Final Result: The reviewer determined that the requested services were partially 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.