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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery. This patient is an adult who began evaluation for bariatric surgery with documentation of obesity with a BMI that was at least 35 kg/m2, and has ranged from 38-39 kg/m2, with serious comorbid conditions including diabetes, sleep apnea, and hypertension. The patient completed supervised weight loss efforts in the past, and completed a comprehensive multidisciplinary evaluation that did not reveal any obvious dietary or psychological barriers to surgery. The patient meets all nationally accepted criteria for bariatric surgery including the published guidelines from the American Society for Metabolic and Bariatric Surgery (ASMBS). Accordingly, the requested gastric bypass surgery is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 surgery with sub-specialty certification in bariatric 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 the services provided. This patient has a formidable formal thought disorder with co-occurring personality disorder and substance use disorder. Indeed, his longitudinal history and symptom inventory, particularly the well-entrenched delusional thought system, is consistent with severe impairment and grave disability. The patients illness burden has impacted all functional domains. His fixed false beliefs generated prominent intrapsychic distress and impulsive moves to escape perceived persecution while his errant behaviors placed both himself at others at risk. The patient demonstrated delusional beliefs and his symptoms included decreased interest, poor concentration, and insomnia. On examination, he had poverty of speech, blunted and restricted affect and poor insight. He was anxious, delusional, paranoid and perseverating. Given the patients lack of response to prior treatment attempts and his continued illness burden, discharge would have been premature. At that time, treatment in a less intensive setting would have been unsafe and inadequate, and more than likely would have resulted in prompt readmission to an acute psychiatric unit. Thereafter, the patient engaged in treatment activities and made some progress in terms of insight and behaviors. However, he remained symptomatic. Per the psychiatry notes from January to late February, the patient still felt that he was being followed. He needed pressing from the staff to participate in some areas of his treatment, such as Alcoholics Anonymous. Based on the available documentation, the services and setting were reasonably expected to improve the patients condition and prevent a more serious episode of illness and need for inpatient care. Thus, the residential services were medically necessary for treatment of the patients medical condition. Moreover, a transitional living environment represented the next reasonable step in the treatment algorithm of this case and the placement was an appropriate disposition with a duration consistent with community norms. Thus, the transitional housing services were medically necessary. Accordingly, the services provided at Spring Lake Ranch were medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) therapy in a social setting with peers for 10 weeks, then 15 hours per week at home thereafter. To determine the medical necessity of ABA, researchers provide guidelines. According to the authors, the definition entails healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. In this case, the patient has been receiving treatment at home and in school for the previous three years. The patient continues to make progress toward treatment goals and problem behavior has diminished. An area of concern continues to be the generalization of skills to natural settings. Guidelines suggest that service intensity be based on patient needs. The patients needs outlined in the progress report suggest that while needs exist, it is less intense than what was once required. Therefore, a focused level of intervention as approved by the Health Plan including 27 hours per week of direct ABA services for the 10 week period and 12 hours per week of ABA services at the onset of the school year should be sufficient for generalization and maintenance of skills. Thus, the 30 hours per week of ABA therapy in a social setting with peers for 10 weeks, then 15 hours per week at home thereafter were not and are not medically necessary for treatment of this patients medical condition. 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 psychology and is a 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for PediaSure Peptide 1.0 Cal. nutritional formula. This patient has a combination of factors which severely limit the range of his dietary intake. First, he has multiple food allergies. Milk allergy in particular places children at risk for inadequate intake of protein, calcium, and Vitamin D. Many common substitute proteins are also allergens for him, including soy, egg, and peanut. While meat is another source of protein, the patients oral phase dysphagia has prevented him from using meat as a nutritional source. Other than hypoallergenic formula, the patient is only able to eat fruits, vegetables, and some cereals. Although he has been able to maintain his weight with a combination of these foods and sample cans of hypoallergenic formula, he is at high risk for significant nutritional deficiencies without a reliable source of formula. As he progresses with occupational therapy in future, he may be able to maintain adequate nutrition without use of such supplements. However, at this point, ongoing use of PediaSure Peptide 1.0 is supported as medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested medical food is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a urology consultation. This patient presents with a history of recurrent epididymitis. The patients symptoms reportedly subsided after two courses of antibiotic therapy. The patient's diagnosis was established with physical examination and scrotal ultrasound. The patient has history of human immunodeficiency virus (HIV) which predisposes them to recurrent urinary tract infections and infections of the genitourinary tract including epididymitis. Therefore, it should be appropriate for this patient to be evaluated further for the resolution of epididymitis by an urologist. For these reasons, the requested urology consultation is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 screening. Findings:  Two of the three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Per the medical evidence, adenocarcinoma of the lung should be evaluated for specific molecular abnormalities, each of which has a specific clinical indication for treatment. This evaluation is usually done on the tissue from a surgical biopsy, although it can also be done from a plasma sample. In general, analysis is preferably done from tissue. However, biopsy is not always feasible. In this patients case, the tissue from the biopsy was not sufficient for mutational analysis. In such cases, plasma analysis is appropriate. All told, Guardant360 was likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for Mavyret 100-40 mg tablets for four weeks. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. A trial showed a 95% cure rate with eight weeks of treatment. Although 12 weeks of Mavyret is recommended in patients with compensated cirrhosis, the patient does not have any evidence of compensated cirrhosis; stage 3 liver fibrosis is distinct from cirrhosis (stage 4 fibrosis). Additionally, the patient has already completed eight weeks of therapy based on the provided information; a restart of four additional weeks after a gap without therapy is not in accordance with guidelines or FDA approval for the use of Mayvret.  For these reasons, the requested treatment with Mayvret for an additional 4 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monurol. At this time, Monurol is an appropriate treatment for this patient with disabling recurrent urinary tract infections. The records report that the patient has experienced breakthrough infections while on nitrofurantoin post coital prophylaxis therapy. Furthermore, the patient has documented allergies to various antibiotics, which limits the available agents. The patients current regimen with Monurol is medically necessary for treatment of this 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the wrist. Review of the submitted clinical documentation does not support the medical necessity of the requested MRI of the wrist. Wrist pain is a common complaint. The American College of Radiology (ACR) has established Appropriateness Criteria to better guide clinicians in efficacious imaging. For chronic wrist pain with or without trauma, the ACR recommends first obtaining plain x-rays of the wrist, and they deem MRI as usually not appropriate. Once plain x-rays are obtained and are normal, the ACR indicates that MRI is usually appropriate. However, in this enrollee, the question is whether an MRI will provide information that will guide a clinical decision. An imaging procedure is only warranted if it will change management.  In this enrollee, there is no indication that the enrollee has ever undergone conservative management. Further, there is no indication that he has ever undergone a course of anti-inflammatory medications, rest, or physical therapy. Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the enrollees 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 reimbursement for the monitored anesthesia care (MAC) services. The patient had an ASA preoperative physical status classification score of 2. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the research, given the patients low preoperative physical status classification score. Heuss and colleagues concluded that With careful monitoring, propofol sedation during [gastrointestinal] GI endoscopies is safe, even for high-risk patients. Thus, the MAC services provided were not medically necessary for evaluation of the patients medical condition.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 anesthesiology 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 UroLift procedure. Findings:  Two of the three physician reviewers found that there is support for the requested services in this clinical setting. The UroLift has been accepted by the American Urological Association as a standard treatment for benign prostatic hyperplasia. The procedure offers advantages over transurethral resection of the prostate, such as minimal anesthesia, minimal blood loss, less chance of incontinence and minimal use of a catheter in the postoperative period. Thus, the requested UroLift procedure is likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested services are 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, 2 and 3 are board certified in urology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Simponi subcutaneous solution auto-injector 50 mg/0.5 mL. There is sufficient support for the requested medication in this clinical setting. There are multiple studies demonstrating the efficacy and safety of tumor necrosis factor inhibitors in treating moderate to severe rheumatoid arthritis. There is evidence that a second tumor necrosis factor inhibitor is effective for patients who have tried and failed a previous tumor necrosis factor inhibitor or have had adverse reactions to another tumor necrosis factor inhibitor. In this patients case, she has responded well to Simponi, a tumor necrosis factor inhibitor which is the preferred agent per the 2015 American College of Rheumatology guidelines. As such, Simponi subcutaneous solution auto-injector 50 mg/0.5 mL is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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 nasal valve support. Based on the available documentation and physical examination findings, this patient does not meet the current criteria for consideration of placement of the requested device. Specifically, there is no documentation provided that shows that the patients nasal airway is obstructed or blocked. In addition, the CT scan did not demonstrate any significant deformity of the nasal septum, but rather showed open, clear sinuses. In this clinical case, there is no documentation provided that anatomical issues need to be corrected. For these reasons, the requested nasal valve support is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device 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 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.