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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lidocaine 5% patches for treatment of the enrollees back pain. Findings:  The physician reviewer found that based on the current medical literature and the presented clinical records, lidocaine 5% patches are not medically necessary for treatment of the patients medical condition. One study states that lidocaine patch 5% appears to be effective as an add-on therapy for osteoarthritis pain. The use of up to four patches, changed q24h, provides effective analgesia  without  anesthesia  and  reduces  stiffness,  disability,   and   QOL [quality of life]  impairment   in   patients   who   have responded  incompletely  to  prior  analgesic  therapy. Although there is medical literature supporting the effectiveness of lidocaine patches, there is a lack of evidence for its use in this case. The Health Plans criteria requires the patient trial gabapentin and one other oral analgesic, in addition to lidocaine cream. In this case, the patient has tried hydrocodone/acetaminophen, two different anti-inflammatories, and capsaicin cream. The Health Plans step-up criteria is medically appropriate and reasonable in this clinical setting. Therefore, in the absence of the patients trial and failure of lidocaine cream and gabapentin at a minimum dose of 1800 mg per day and one other oral analgesic, the request for lidocaine 5% patches have not been established as medically necessary for treatment of the patients medical condition. 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 physician reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Omnitrope for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that the records provided for review document that this patients height is more than two standard deviations delayed and his growth velocity is poor. In addition, the patients adult predicted height, based on the bone age and height measurement at that time is approximately, which is shorter than expected for the genetic potential and more than two standard deviations below the mean for U.S. adult males. According to  the Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or insulin like growth factor binding protein (IGFBP)-3; and/or (5) other clinical features suggestive of GH deficiency. This patient does meet most of these criteria, and he has an adult predicted height, which is short enough to warrant a trial of GH therapy based on current U.S. Food and Drug Administration (FDA) standards for treatment of idiopathic short stature. Accordingly, the requested Omnitrope subcutaneous (SQ) seven days per week is supported as medically necessary for treatment of this patients idiopathic short stature. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 advanced lipoprotein testing for the enrollees hyperlipidemia. Findings:  Three physician reviewers found that in this circumstance guidelines for the management of cardiac risk have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of LDL, HDL subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. For example, randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits. Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: Three reviewers determined that the testing at issue was 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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance transport services provided from California to Texas for treatment of the enrollees status post traumatic brain injury.  Findings:  The physician reviewer found that the air ambulance transport services provided from California to Texas were medically necessary for treatment of the patients medical condition. The patient sustained a severe brain injury with resultant profound functional impairment far from his support network and inpatient rehabilitation facility. Colleagues state that for patients with acquired brain injury different interventions and combinations of interventions are required to meet the needs of patients with different problems. For this patient, inpatient rehabilitation in Texas was approved for treatment of his functional deficits related to traumatic brain injury. Air ambulance was more appropriate than a 30 hour ground ambulance to Texas as it was contraindicated due to placing him out of reach of emergency medical services. Due to his brain injury and medical condition he was not appropriate for commercial air travel. Medical monitoring during air travel was necessary. According to colleagues medical issues related to air travel are relatively frequent. In most cases, they are related to underlying conditions and could have been easily avoided through appropriate intervention. Air travel has health risks, and medical monitoring can minimize health risks during air travel and timely rehabilitation can improve functional outcomes. In sum, to receive specialized rehabilitation with the patients support network, he required transport home by air ambulance. Thus, the air ambulance services provided were medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer number one is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee enrollee has requested authorization and coverage for private duty nursing in the home setting necessary for treatment of the enrollees mitochondrial disease. Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature demonstrate the medical necessity of the requested private duty nursing in the home setting. According to the American Academy of Pediatrics (AAP) guidelines for home care of infants, children, and adolescents with chronic disease comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens. AAP guidelines further state that the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities. In this case, the patient is extremely fragile with a complex medically history, and she has a number of skilled nursing needs as described above. It would be neither safe nor reasonable to have her parents to tend to all of her medical needs round the clock. This patient requires constant monitoring and diligent observation to maintain health and prevent unnecessary sequelae. Skilled nursing expertise is essential for rapid identification of problems with appropriate and safe intervention. Therefore, the requested private duty nursing hours in the home setting is medically necessary and appropriate for treatment 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 physician reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care 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 morphine for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that based on the medical literature and in consideration of the presented clinical records, morphine is not medically necessary for treatment of the patients medical condition. The medical records show the requested medication is not indicated in light of the patients medical condition and in addition to his medication regimen. The medical records show the patient to have chronic non-malignant pain. The current standard of care for chronic pain is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. According to one study, Conservative decisions in the treatment of degenerative disc disease are based on interventions made for patients with chronic LBP [lower back pain]. There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic LBP. There are a variety of anti-convulsants and anti-depressants considered adjunctive to pain management therapy. High dose opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. Therefore, based on current medical literature and in consideration of the presented clinical records, the request for morphine has not been established as medically necessary for this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician reviewer is board certified in anesthesiology with sub-specialty certification in pain 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 reimbursement for residential mental health and substance use treatment center services for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that there was no psychosocial assessment, treatment plan, or daily progress notes included in the documentation. In general, without such information, it is not possible to assert that a particular clinical intervention or treatment setting is medically necessary. 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 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 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 AmniSure testing for evaluation of the enrollees vaginal discharge and pelvic pain. Findings:  The 3 physician reviewers found that according to the American College of Obstetricians and Gynecologists (ACOG), AmniSure testing is not recommended as a first-line test. AmniSure testing is recommended as an adjunct to standard assessment of pooling, ferning and nitrazine testing of vaginal fluid if these tests are not conclusive. Colleagues noted that false-positive test result rates of 19-30% in patients with clinically intact membranes and symptoms of labor. In this case, the patient did not undergo standard testing with ferning or nitrazine testing before AmniSure test was performed. Therefore, the AmniSure testing performed has not been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was 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 reviewer number one is board certified in obstetrics and gynecology 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.Physician reviewer number two is board certified in obstetrics and gynecology 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.Physician reviewer number three is board certified in obstetrics and gynecology 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 authorization and coverage for biofeedback and hypnotherapy for treatment of the enrollees post-traumatic stress disorder (PTSD), severe depression, and anxiety. Findings:  2/3 of the physician reviewers found that colleagues reviewed 70 studies including 4,761 patients and reported that trauma-focused cognitive behavioral therapy was superior to other therapies including hypnotherapy and biofeedback. In addition, the American Psychiatric Association (APA) reported that there is a paucity of study on hypnosis have been conducted that would establish evidence-based evidence of their efficacy as an early or preventive intervention for acute stress disorder or PTSD. Based on these accepted guidelines, trauma-focused cognitive behavioral therapy remains superior to hypnosis or biofeedback. Trauma-focused cognitive behavioral therapy is considered standard of care and evidenced based treatment for the treatment of PTSD. Therefore, the requested biofeedback and hypnotherapy are not likely to be more beneficial for treatment of the patients medical condition than standard evidence-based therapy. Final Result: 2/3 of the reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility level of care provided for treatment of the enrollee, who sustained a hip fracture. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Hip fractures are conditions that are known to substantially affect functional performance, and negatively impact both short-term and long-term health-related quality of life.  In this case, the patient also has a history of prior intracerebral bleed with residual cognitive impairment and left hemiparesis.  She had impairments in her mobility at baseline, further complicating her convalescence.  She had been undergoing inpatient rehabilitative care but had progressed to the point that the treating facilitys staff did not anticipate a reasonable likelihood of marginally significant functional benefit with ongoing inpatient rehabilitation.  Therefore, the facility recommended discharge back to the community with caregiver assistance and home therapy services.  While further gains may have been expected going forward, there is a lack of indication in the records that the rate of this progress would have been expected to be expedient or predictable given her baseline status and new issues.  There are no indications that her rehabilitative needs could not have been addressed and met at a less intensive level of care than an inpatient skilled nursing facility, such as in the community with custodial level assistance and community based therapy services.  The records do not indicate that she required inpatient level medical or skilled nursing care.  All told, skilled nursing facility level of care provided was not and is not medically indicated for the treatment of this patient. 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 physician reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet 10 mg/325 mg, #120 necessary for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  In this patients case, non-opioid treatment options have not been exhausted.  The records do not document behavior therapy despite significant research to support its use.  Given the documentation of a history of drug abuse, continuation of such medication should be under the direct guidance of a mental health professional.  It is medically appropriate to consider alternatives to opioids and to wean the patient off opioids.  The clinical notes indicate that tolerance has taken place since the start of the narcotics.  The current medical evidence does not support the requested medication in this clinical setting.  All told, Percocet 10 mg/325 mg, #120 is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology with sub-specialty certification in pain 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.