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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for partial hospitalization program mental health treatment services. The enrollee has a history of attention deficit hyperactivity disorder and depression. His family noticed he was more depressed with a decrease in his self-esteem.  He exhibited agitation and frustration. Per the psychiatric admission note, the enrollee denied manic symptoms, psychotic symptoms, suicidal/homicidal ideation and self-injurious behavior. He denied difficulty with sleep and change in appetite. The enrollee denied substance abuse or drinking alcohol. Medications were started for depression and anxiety. He received psychoeducation and psychotropic medications. He was cooperative and participated in all groups. According to the medical literature, treatment should be provided in the least restrictive setting that is safe and effective for an enrollee. The enrollee had temporary impairment in school functioning due to identifiable stressors with consistent and normal physical functioning. There was no report of medical illnesses that would pose a threat to the enrollees present mental health and no history of mental health hospitalizations. The enrollee lives in a stable household, was cooperative and participating in his treatment. Applying CALOCUS scoring, the enrollees composite score is 12, which correlates with recovery maintenance and health management. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an automatic external defibrillator.Findings:  The physician reviewer found that a study in Circulation in 2016 looked at Sudden Death in the Young and found that home AEDs are important for these patients. There have been numerous articles published in journals describing the safety and efficacy of the devices in children. Most pediatric cardiologists recommend that families obtain AEDs for their children with long QT and carry them, as AEDs are not always readily available in public. AEDs have been proven to save lives. Survival is greatest when the AED is placed within three minutes of a witnessed collapse. The goal is to let children have as normal a life as possible without excessive risk. The medical literature stated that prescribing an automated external defibrillator should be considered for children at increased risk of sudden arrhythmic death, especially when the risk/benefit ratio of an implantable defibrillator is unclear or delay to defibrillator implantation is deemed necessary.In this case, the submitted documentation supports that the requested AED is medically necessary. The patient with long QT syndrome and with multiple episodes of syncope associated with exercise. Although undocumented by EKG, these episodes of syncope may have been due to a potentially life threatening arrhythmia. The patient has a markedly abnormal and prolonged QTc on EKG, which puts her in a higher risk category for sudden death due to an arrhythmia. The patient also has a strong family history of sudden death and possible long QT. An implanted ICD has been discussed with the patient but she is currently not a candidate at this time, as she has not had an aborted episode of sudden death or documented ventricular arrhythmia. An ICD in active patients at this age also carries increased risks of inappropriate shocks and lead fractures. An AED is necessary to be immediately available in the event that the patient does have a life-threatening arrhythmia. Under these circumstances, the requested automatic external defibrillator is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested device 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 subspecialty certification in pediatric cardiology, 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: The parent of an enrollee has requested authorization and coverage for behavior analysis services and applied behavioral analysis services.In this case, the patient has diagnoses of anxiety, attention deficit hyperactivity disorder (ADHD), and sensory processing disorder, but does not have a diagnosis of autism. The number of hours in the patient's treatment request is also very low, which is better suited to an outpatient program. As established above, outpatient therapies such as family based CBT therapy, utilize an outpatient model that is more conducive to the severity of problem behavior identified. Given the rates of behavior on the functional behavior assessment were low (.17/hr meltdown and 1.7/hr protests) and the family is only requesting parent training, the case can also be made that this is not a significant problem that warrants ABA intervention. Under these circumstances, the behavior analysis services in issue, and the requested applied behavioral analysis services, were not, and are not, medically necessary for the patients medical condition. Final Result: The reviewer determined that the services in issue and requested services were not, and are not, medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed psychologist, and board certified behavior analyst, 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:  The enrollee is requesting authorization and coverage for MRI of the right knee. The patient has chronic pain due to bilateral osteoarthritis of the knees; right more painful than the left. During an office visit the provider noted a probable sprain. Progress notes from the visit indicate the patient believes she has a meniscal tear. She consulted with a sports medicine physician, on who diagnosed left knee degenerative joint disease. Previous treatments, including medications, cold therapy, and stem cell injections were ineffective. Her physician  explained a magnetic resonance imaging (MRI) scan was not needed at the time to help with diagnosis or to make treatment recommendations. She then presented to anotherorthopedic physician, who diagnosed her with a meniscal tear and ordered an MRI. The medical literature indicates the use of MRI to diagnose a possible meniscus tear is not supported without a trial of six to ten weeks of physical therapy as a majority of patients with osteoarthritis and meniscus tears do get better without surgery. Furthermore, an analysis of randomized trials of surgery for patients with osteoarthritis and a meniscal tear found the benefit was limited to three to six months duration and not present beyond that time period. There is insufficient evidence in the record of the patients trial of physical therapy. In sum, there was no indication for the use of MRI to guide therapy. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery and sports 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 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 acupuncture services. There is a lack of support for the requested services in this clinical setting. Researchers performed a systematic review assessing evidence from randomized controlled trials on the effectiveness and safety of acupuncture and elecroacupuncture in patients with chronic neck pain. The authors noted that acupuncture and conventional medicine for chronic neck pain have similar effectiveness on pain and disability...When acupuncture was added onto conventional treatment it relieved pain better, and electroacupuncture relieved pain even more. In this case, this patient has received acupuncture services. Although she has reported that prior acupuncture services were beneficial, the provider failed to document that measurable and sustained objective functional improvement was obtained with previous acupuncture. Based on the records, the patient is not presenting with a flare-up of the condition or a re-injury. The documentation does not specify what further improvements would be achieved with acupuncture that could not be accomplished with a home exercise program. Therefore, acupuncture 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 oriental 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 consultation for laparoscopic peritoneal pull-through vaginoplasty.The penile inversion method for vaginoplasty for transgender women is the gold standard method. The penile inversion method is the most commonly described technique for primary male-to-female transgender vaginoplasty. The technique has been widely researched and described.). The Medical literatures Standards of Care lists penile inversion, pedicled colosigmoid transplant, and free skin graft as means of vaginoplasty, but does not mention peritoneal vaginoplasty. While peritoneal vaginoplasty has been done for vaginal agenesis in cisgender woman, and recently has been tried for transgender women, there is no published evidence comparing outcomes to traditional methods for vaginoplasty in transgender women. As this outcome data is currently lacking, medical literature does not reflect whether peritoneal vaginoplasty is superior or inferior to penile inversion. Under these circumstances, the requested consultation for laparoscopic peritoneal pull-through vaginoplasty is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested service 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 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:  The enrollee is requesting reimbursement for 25-Hydroxy Vitamin D Laboratory Testing. The enrollee has a history of hypothyroidism. On an annual exam her chief complaints were fatigue, weight gain, shortness of breath and sleep problems. The physician documented normal physical exam elements, wrote a refill of medications, discussed routine screenings. She had 25-hydroxy Vitamin D laboratory testing as part of her lab work-up. Results showed a normal total Vitamin D level. Her physician indicates her Vitamin D levels were low on a previous test and she was treated with supplemental Vitamin D.  Routine testing for Vitamin D deficiency is not recommended by major professional societies. There is not enough evidence to clearly support or oppose this practice in low risk enrollees, recommending the testing be reserved for those considered high risk, such as enrollees with darker skin, obesity, or poor Vitamin D absorption. There was no evidence in the record of the enrollee having any of these risk factors. The medical literature indicates Vitamin D deficiency testing for enrollees with high-risk conditions, such as renal failure, hepatic failure, and osteoporosis. Studies conclude little benefit is realized from testing those enrollees who do not have risk factors for deficiency. Some literature supports the relationship between Vitamin D levels and enrollees with Hashimotos thyroiditis and Graves disease; however, no professional societies include hypothyroidism as a risk factor for Vitamin D deficiency screening. Additionally, there is no documentation the enrollee had Hashimotos thyroiditis or Graves disease, or that the physician screened her for Vitamin D deficiency as part of the treatment plan for hypothyroidism. Although the enrollee has hypothyroidism, there is no support for Vitamin D testing.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested reimbursement for intensive outpatient program (IOP) services. The enrollee has a diagnosis of anorexia nervosa with laxative abuse, and a history of anxiety/depression who was admitted to the intensive outpatient program (IOP) level of care. The discharge note indicates her weight was consistent with her goal weight. Findings:  The physician reviewer found that according to LOCUS guidelines, for risk of harm, the enrollees composite score is 14, which correlates with low-intensity community based services. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Pifeltro 100 mg.Doravirine is a non-nucleoside reverse transcriptase inhibitor. Other members of that class include Sustiva (efavirenz), Intelence (etravirene), and Viramune (nevirapine).Findings:  The physician reviewer found that doravirine has been shown to have a better safety profile than Sustiva and a low potential for drug to drug interactions. It has also been shown to have a higher barrier to the development of resistance than rilpivirine (RPV) and efavirenz (EFV) at the concentrations achieved in the clinic setting (Feng, et al.). In addition, it has been demonstrated that food had no clinically meaningful effect on doravirine (Behm, et al.). Doravirine is also non-inferior to Sustiva.In this case, the patient is reported to have had issues with tolerating antiretroviral therapy (ART) and a concern for clinically demonstrated side effects. In this setting, it is the standard of care to adjust the regimen to the safest regimen with the least potential for interactions. Under these circumstances, the requested medication Pifeltro 100 mg is medically necessary for treatment of the patients medical condition.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 subspecialty certification in infectious 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lower back injection (lumbar/sacral facet joint block). Findings:  The physician reviewer found that there is sufficient support for the requested services in this patients case. The records document a history of chronic low back pain with some radiation down the left lower extremity. She is status post lumbar laminectomy. The documentation noted excellent results from prior facet blocks. The medical literature noted that lumbar facet joints are a common source of low back pain. The authors evaluated the diagnostic validity and therapeutic value of lumbar facet joint interventions for patients with chronic low back pain. The authors indicated that there was significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain. In this patients case, the requested services are medically appropriate. Therefore, lower back injection (lumbar/sacral facet joint block) is 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for substance abuse residential treatment center (RTC) services.Findings:  The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, 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 CALOCUS criteria, the substance use RTC services were not and are not medically necessary for treatment. The patient presents a composite score of 18, which correlates with intensive outpatient services. Given these findings, the substance use RTC services were not and are not medically necessary for treatment of this patient behavioral health issues. Final Result: The reviewer determined that the services at issue were not and 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 with subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Prometheus Anser ADA serum assay. Findings:  Three physician reviewers found the Prometheus Anser ADA serum assay was not and is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. For these reasons, the Health Plans denial should be upheld. The Anser ADA test assesses serum adalimumab (ADA) and anti-ADA antibodies. Some evidence exists that low serum levels of adalimumab and/or the presence of antibodies to adalimumab may play a role in response failures. However, there are few well-controlled clinical trials to confirm the utility of the Anser testing in this clinical leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. This patient presents with recent symptoms intermittent pain and diarrhea. However, there is a lack of elevation in his inflammatory markers known to correlate with a Crohns flare. For these reasons, the Prometheus Anser ADA serum assay was not and is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The three reviewers determined that the services at issue were 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 subspecialty certification in gastroenterology 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.