Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested authorization and coverage for esophagogastroduodenoscopy endoscopy with capsule (wireless capsule endoscopy). Findings:  Two of the three physician reviewers found there is sufficient support for the requested services in this clinical setting. Based on the history of abdominal pain and weight loss, she may have an undiagnosed Crohns disease. Further, around 10 to 15% of patients with inflammatory bowel disease may have normal inflammatory markers. Per the medical records, the previous esophagogastroduodenoscopy/colonoscopy with biopsies was normal except Helicobacter pylori. Wireless capsule endoscopy is the appropriate next step in this setting. Therefore, the requested esophagogastroduodenoscopy endoscopy with capsule (wireless capsule endoscopy) is likely to be of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in pediatric gastroenterology and are actively practicing. Physician reviewer 3 is board certified in pediatrics 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: The parent of an enrollee has requested authorization and coverage for a baby scale.  Failure to thrive generally refers to growth below the percentile, or crossing of two major percentiles over a short period of time. The etiology may be organic or psychosocial, or a combination of both. The list of organic causes of failure to thrive is quite long, and includes gastroesophageal reflux disease, metabolic disorders, and chromosomal disorders, all of which were under consideration in this case.  Hospitalization is indicated in cases of severe malnutrition. Goals of hospitalization include identification, if possible, of etiology, formulation of an appropriate feeding strategy with demonstrated pattern of weight gain, and correction of any metabolic derangements. Family education is also essential. Early identification and treatment of failure to thrive are essential to prevent the substantial complications that would otherwise arise.In this patients case, she had evolving evidence of gastrointestinal issues, and was ultimately diagnosed with food protein induced enterocolitis syndrome. With the exception of the letter from the provider, there was no mention of failure to thrive in the clinic notes. The patient was described as healthy and thriving. While weighing the patient before and after meals may have initially been appropriate to determine how much breastmilk she was actually receiving, at her current age, such close monitoring is not indicated. It would be reasonable to monitor the patients weight gain progress with weekly clinic visits or possibly a nutrition consultation. All told, the requested baby scale is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested equipment 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 pediatrics 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 reimbursement for residential treatment. The submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient was engaged and participated in treatment. Although the patient initially reported thoughts of self-harm, the records do not document thoughts of suicide or self-harm during the dates of service in dispute. The patient was cooperative and did not have aggressive behaviors toward staff or peers. The documentation indicated that the patient was making progress with his understanding of his anxiety. There was no documentation that the patient was not attending to his activities of daily living. The patients family is supportive of the patient. Based on the records, he did not have medical problems which required 24-hour supervision. There was no documentation that the patient was using illicit substances. The patient continued to have anxiety, but this treatment could have taken place in a less restrictive environment. It is standard of care to treat the patient in the least restrictive environment possible. Per the medical records, the patient had improved enough to be discharged to a less restrictive environment. Thus, residential treatment provided was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise 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: An enrollee has requested reimbursement for an acute hospital stay. The submitted documentation supports the medical necessity of the services at issue. The postoperative instructions for toe-touch weight bearing were appropriate and medically necessary for management of the tibial plateau fracture status post open reduction and internal fixation. This patient had difficulty with ambulation, and transfer to a skilled nursing facility was medically indicated. As such, she could not have been discharged home. Complications after tibial plateau fractures can result in poor outcomes. Postoperative protocol and rehabilitation was important in this patients case. She was unable to ambulate independently. Therefore, the acute hospital stay 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 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: An enrollee has requested reimbursement for Botox injection (J0585). The Health Plan has denied this request indicating that the medication at issue was medically necessary for treatment of the enrollees medical condition.Findings: There is support in the medical literature for the medication at issue in this clinical setting. Botox is a neurotoxin that causes local muscle weakness through interference acetylcholine release and it has been shown to be effective for treating patients with cervical dystonia.  Botox has been compared to oral drugs like trihexyphenidyl and has been shown to be effective. Botox is considered to be the first line therapy for patients with focal dystonia including cervical dystonia and has been shown to improve pain and morbidity. This patient reported that his Botox treatment provided pain relief. For these reasons, Botox injection (J0585) provided was medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the medication at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for lumbar spine magnetic resonance imaging (MRI). The Health Plan has denied this request indicating that the requested services were not medically necessary for evaluation of the patients spinal stenosis of lumbar region and neurogenic claudication. The submitted documentation supports the medical necessity of the requested services. Given the patients reported history of low back pain, difficulty walking, and the presence of neurologic symptoms and signs, the requested services are medically indicated. Plain x-rays are often of limited value in making the decision concerning surgery. In this patients case, the presence of diminished reflexes and urinary incontinence are signs that should not be ignored. Given the plan for surgery, an MRI is the best means to provide anatomic information. According to the medical records submitted, the patient has had conservative therapy. Therefore, lumbar spine magnetic resonance imaging (MRI) is medically necessary for evaluation of the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Euflexxa injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested bilateral Euflexxa injections are supported as medically necessary for treatment of this patients knee osteoarthritis. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Rituxan 720 mg weekly for four doses for treatment of the enrollees anti-muscle specific kinase (MuSK) myasthenia gravis. Findings:  The physician reviewer found that Myasthenia gravis with anti-muscle specific kinase (MuSK) antibodies is known to be more resistant to treatment than myasthenia gravis with acetylcholine receptor binding antibody disease, and is often more symptomatic. Rituxan is recognized to be effective in the treatment of myasthenia gravis, and one recent paper indicated the most effective therapies are corticosteroids, plasma exchange, and Rituximab. This patient currently remains symptomatic on corticosteroids and azathioprine, and previously with IVIG. Rituxan is a reasonable therapy with the plan of tapering down or off of corticosteroids and possibly off azathioprine as well. For these reasons, the requested Rituxan 720 mg weekly for four doses is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the requested Rituxan 720 mg weekly for four doses is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program consisting of four days per week treatment with individual counseling once a week, parent support group, alcohol and drug education, addiction education, coping and recovery skills, stress management, random drug testing, and teen group sessions. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral condition.Findings:  The submitted documentation fails to demonstrate the medical necessity for the services at issue in this clinical setting. The patient reported using cannabis at the age of 12. The patients motivation has been decreasing and the patients academic performance had been declining. However, the documentation does not report that the patient was engaging in regular outpatient treatment. The documentation did not report that the patient had failed routine outpatient treatment or failed an outpatient community 12-step program. The records did not demonstrate that the patient had any suicidal or homicidal ideation. The patient had a supportive mother. The records did not indicate that the patient had any medical problems. The patient was attending to his activities of daily living.  Based on the provided record, the patient could have been treated in a routine outpatient setting. The standard of care, in this clinical setting is to treat the patient in the least restrictive environment possible. Accordingly, the documentation indicates that this patient can be treated with routine outpatient services. Therefore, intensive outpatient program consisting of four days per week treatment with individual counseling once a week, parent support group, alcohol and drug education, addiction education, coping and recovery skills, stress management, random drug testing, and teen group sessions were not and are not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer has 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 expertise 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total disc replacement surgery at L4-L5. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient presents with persistent low back pain radiating into the anterior, lateral and posterior left thigh with some associated left leg and foot weakness. Functional limitations are documented in walking tolerance and activities of daily living. There was reported concordant pain at the L4-L5 level in a discogram in November 2015. She has been diagnosed with lumbar radiculopathy. She has reportedly failed long-term conservative treatment, including physical therapy and epidural injections. She is requesting surgical intervention to include an artificial disc replacement over lumbar fusion as she reportedly desires future pregnancy. Current evidence-based medical guidelines do not recommend artificial disc replacement based on insufficient evidence of its effectiveness on improving patient outcomes. The U.S. Food and Drug Administration (FDA) exclusion criteria include radicular compression syndromes and anticipation of pregnancy within three years. In this case, the actual imaging reports were not provided to confirm single level disease and no nerve root compromise. Given the presence of reported radiculopathy and desire for pregnancy, the medical necessity of the lumbar artificial disc replacement has not been established. There is no compelling rationale presented to support the medical necessity of the requested lumbar artificial disc replacement as an exception to evidence-based medical guidelines and FDA exclusion criteria. Therefore, the requested total disc replacement surgery at L4-L5 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 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: An enrollee has requested reimbursement for FoundationOne genomic analysis. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of breast cancer.Findings There is a lack of support for the services at issue in this clinical setting.  FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician or yields a result that is reliably clinically beneficial. There are various nonrandomized studies exploring the value of molecular profiling but these studies are not conclusive.  A randomized study by colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. Some recent studies have expressed serious reservations about this approach in general. In sum, FoundationOne testing was not likely to have been of greater clinical benefit over the standard options available for the evaluation of this patients medical condition.Final Result: Two of 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. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for wireless capsule endoscopy for gastrointestinal imaging procedure. Findings:  Two of the three physician reviewers found per the medical evidence, accepted indications for capsule endoscopy include obscure gastrointestinal bleeding, small bowel Crohns disease, assessment of celiac disease, screening and surveillance for polyps in familial polyposis syndromes, and evaluating the small bowel for tumors such as lymphoma, carcinomas or carcinoids. In this patients case, the records do not support these accepted indications. Although capsules have been designed specifically to assess colon and esophagus, conventional wireless capsule endoscopy is not ideal for histologic follow-up of gastroesophageal reflux disease and is not the standard of care for this indication. As such, the superior effectiveness of wireless capsule endoscopy for gastrointestinal imaging procedure has not been established. Final Result: The 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. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty 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.