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

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for a group three power wheelchair with power tilt and power center mount. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees back pain and degenerative joint disease.At issue in this case is whether the requested group three power wheelchair with power tilt and power center mount is medically necessary for treatment of the patients medical condition.The records indicate that the patient has multiple chronic medical conditions but her primary mobility-related issue is bilateral knee arthritis. She has demonstrated normal upper limb strength on examinations by multiple different providers. Per the most recent physical therapy evaluations, the patient is independent with weight shifts and requiring minimal assistance for transfers and getting to the stand position, the latter of which was assessed while she was still an inpatient in the hospital in 9/18. The patient, moreover, has health conditions that would be better addressed through higher levels of physical activity, rather than the lower levels of physical activity that a power mobility device with power tilt and power leg elevation would encourage. Power tilt and power center mount leg elevation are not medically necessary for this patient. The group three power wheelchair base has been requested to accommodate the power tilt and power center mount leg elevation functionality. Therefore, the requested underlying group three power wheelchair base is also not medically necessary. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for visual communication analysis (VCA). As noted in the medical literature, visual communication analysis has not been systematically evaluated and demonstrated to provide improved patient outcomes as compared to standard available therapies. In the medical literature, Borowiak and colleagues found that this patient population did not respond to visual-movement or gestures during speech. Overall, the findings suggest that visual communication strategies are not substantially helpful. Applied behavioral analysis (ABA) has a large research base showing efficacy to treat the core symptoms of autism including communication, aggression and other behaviors. Visual communication analysis is not the standard of care treatment for autism. Accordingly, the requested visual communication analysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested visual communication analysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested visual communication analysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics and neurology with special qualification in child neurology and is actively practicing. Physician reviewer 2 is board certified in pediatrics and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cryosurgical ablation. Per the current high quality peer-reviewed medical literature, cryotherapy is an acceptable standard of care therapeutic modality for management of small renal cell carcinomas. Multiple studies with follow-up data exceeding five years strongly support the long-term oncologic efficacy of cryotherapy for renal cell carcinomas measuring under 3 cm. Moreover, the National Comprehensive Cancer Network (NCCN) guidelines for management of renal cell carcinoma supports the use of ablative therapies, such as cryotherapy, for management of clinical stage T1 kidney cancers. All told, the requested cryosurgical ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested cryosurgical ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested cryosurgical ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in surgery with subspecialty certification in vascular interventional radiology 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: 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 Optune Plus Transducers for treatment of the patients medical condition. Findings:  The physician reviewer found that the medical literature, one large multi-institutional prospective randomized controlled trial, treated recurrent glioblastoma patients with providers choice chemotherapy or the Optune device. The authors concluded that no improvement in overall survival was demonstrated, however efficacy and activity with this chemotherapy-free treatment device appears comparable to chemotherapy regimens that are commonly used for recurrent glioblastoma`. In the most recent National Comprehensive Cancer Network (NCCN) guidelines, Optune for newly diagnosed glioblastoma carries a category 1 recommendation. However, Optune is not mentioned for use in patients with grade 3 gliomas. In the absence of data demonstrating improved patient outcomes with use of the Optune device, the Optune Plus Transducers provided were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the Optune Plus Transducers provided were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the Optune Plus Transducers provided were not and are not 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 radiation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) scan of the heart.Findings:  Two of the three physician reviewers found that guidelines for the evaluation and 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 coronary calcium scoring and coronary CT scanning.  Treatment change or addition based on the results of screening with specialized tests, including screening coronary CT scanning, has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. In this patients case, aggressive risk factor modification is indicated regardless of results of coronary CT scanning. Moreover, coronary CT scanning provides only an anatomic evaluation, is less accurate compared to conventional angiography and does not assess the functional significance of any potential stenosis identified. In sum, computed tomography (CT) scan of the heart is not likely to be superior over other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for C-naltrexone 4.5 mg capsules.Findings:  Three physician reviewers found that the submitted documentation does not establish that the requested medication is likely to be more beneficial than standard therapy. Of note, there is no documentation of percent relief, duration of relief or improvement in function with the use of the requested medication. Further, there is a lack of controlled studies documenting the efficacy of compounded naltrexone capsules in the management of complex regional pain syndrome. The limited studies that are available regarding naltrexone therapy are not relevant to this clinical setting. Thus, C-naltrexone 4.5 mg capsules are not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested medication is 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 reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for IVIG (intravenous immune globulin) therapy with Gammunex-c/Gammaked. Findings: Two of the three physician reviewers found that the requested therapy is not indicated under these circumstances. In this case, there is no clear evidence that the patient has a post-infectious encephalopathy. The patient is not reported to be encephalopathic, and has had no altered consciousness, seizures or other neurological symptoms. There is also no documentation that the patient has had a lumbar puncture or neuroimaging in the form of an MRI of the brain to investigate whether the patient has any acute neurological process. The patients autoantibodies were noted to be negative. The patient does not appear to have had standard psychiatric treatments for obsessive compulsive disorder, anxiety and depression such as cognitive behavioral therapy or a consistent trial of psychotropic medication. Therefore, IVIG therapy with Gammunex-c/Gammaked is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: The reviewers determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics and in allergy and immunology, and is actively practicing. Physician reviewer 2 is board certified in pediatrics, with subspecialty certification in pediatric infectious diseases, and is actively practicing. Physician reviewer 3 is board certified in pediatrics and in neurology with special qualification in child neurology, and is actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy. There is increasing evidence that IVIG is safe and effective in a subset of patients with autonomic disorders and evidence for autoimmunity. A four month IVIG trial should be considered in severely affected patients who are refractory to lifestyle and pharmacological therapies. Antiphospholipid antibodies and novel Sjogren antibodies are often present in these patients and correlate with a high response rate to IVIG. The clinical improvement with immunotherapy in these patients correlated with markedly improved findings on autonomic testing in all. There is increasing evidence that immunomodulation with IVIG is helpful in treating patients with autonomic dysfunction and Sjogren syndrome. These studies are small and there are no national guidelines to recommend this therapy. In this case, the medical records provided fail to demonstrate a diagnosis of Sjogren syndrome and confirm the diagnosis of peripheral neuropathy. The medical records demonstrate normal thyroid studies, normal complete blood count, normal renal panel and normal/negative rheumatoid factor. There is a presumed diagnosis of Sjogren syndrome, mast cell activation and POTS. The records provided fail to demonstrate a diagnosis of Sjogren syndrome. As such, the request for intravenous immunoglobulin (IVIG) therapy is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested treatment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plan denial should be upheld.Credentials/Qualifications: The reviewer is board certified in allergy and immunology and internal medicine with subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for intensive outpatient program (IOP) services. The Health Plan has denied this request indicating that the services were not and are not medically necessary for treatment of the enrollees behavioral health condition.At issue in this case is whether the intensive outpatient program services were and are medically necessary for treatment of the patients behavioral health condition.In cases such as this, an evidence based instrument such as the CALOCUS (Child and Adolescent Level of Care Utilization System) is indispensable for determining the necessary level of care for adolescents; to ensure their level of care meets their individual needs at the least restrictive setting possible. This gives the patients presentation a composite score of 19. A score of 19 correlates with a treatment intensity level of three which correlates with intensive outpatient services. This score is judged by the acuity of the patients symptoms and environment during the period in review.The progress notes indicate the patient has made some improvements behaviorally and is not aggressive or expressing active suicidal ideation. The patient continues to have a stressful relationship with family. The progress notes indicate that the patient appears to be only minimally invested in treatment and often does treatment activities to appease others. The continued group and individual therapy will be beneficial for the patient. Therefore based on the CALOCUS scoring and clinical presentation, the intensive outpatient program services were and are medically necessary. Final Result: The reviewer determined that the services were and 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 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: 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 center services (RTC). The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees major depressive disorder, generalized anxiety disorder and social anxiety disorder.The patient was admitted to the residential treatment center due to problems with anxiety. The patient was noted to show cooperative behaviors. The patient expressed how their relationship with family had improved. The patients main issue that continued was unhappiness with how peers were acting in the residential treatment center. The patient did not have active suicidal or homicidal ideation or psychosis during this timeframe.The patient denied a history of substance use. The patient was noted to have migraine headaches as well as celiac disease and these were not mentioned as problems during this timeframe.  The patient was noted to scratch herself during times of stress. The patient did not display aggression towards peers or staff during this timeframe. The patients family was involved with treatment. The records did not document any severe mood or anxiety symptoms or any serious behavioral issues.   The patients presentation resulted in a composite score of 17.  This score correlates with a treatment intensity level of three which correlates with a level of Intensive Outpatient Services.  Therefore, the requested residential treatment center services at issue were not 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for the Optune tumor treatment fields therapy. As noted in the medical literature, the Optune device is a wearable, noninvasive medical device designed for continuous use throughout the day by the patient. The device has been shown in both in-vitro and in-vivo studies to slow and reverse tumor growth by inhibiting mitosis, the process by which cells divide and replicate. There are studies reporting positive results with use of the Optune device in patients with glioblastoma multiforme. In addition, there is no evidence of cumulative damage to healthy tissue when exposed to tumor treatment fields therapy. For these reasons, the Optune tumor treatment fields therapy was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the Optune tumor treatment fields therapy was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in neurosurgery and is actively practicing. One Reviewer is board certified in neurosurgery and is actively practicing.  One Reviewer is board certified in neurosurgery and is 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.