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

The enrollee is requesting authorization and coverage for Euflexxa injections to both knees. An x-ray showed degenerative/arthritic changes in both knees, markedly severe in the left knee and moderate in the right knee. The enrollee has been treated with cortisone injections, non-steroidal anti-inflammatory drugs, knee braces, viscosupplementation injections every six months, and arthroscopy of the left knee. Office notes indicate the enrollees symptoms have been well controlled with steroid and viscosupplementation injections and non-steroidal anti-inflammatory drugs. The enrollee was due for viscosupplementation injections. The treatment plan includes Euflexxa injections in both knees, as well as rest, ice, and non-steroidal anti-inflammatory drugs. The enrollee indicates injections provide significant relief from the chronic pain in her knees. The treatment helps cushion and protect her knees from the hard exercise in which she engages. She believes the Euflexxa treatment is relatively mild and less risky for her than a total knee replacement. Review of the record indicates viscosupplementation has been successful in controlling this patient's bilateral knee pain and temporarily increasing function. Repeat injection therapy is indicated. The enrollee has failed bracing, oral NSAID therapy, ice, and steroid injections. The medical literature describes osteoarthritis as a common condition that can cause pain, reduced mobility, and decreased function. Those with more severe radiographic change often had a better response with the second course of IA-HA, specifically Euflexxa, in this study.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) mutation testing.Findings:  Three of three physician reviewers found that American College of Medical Genetics (ACMG) guidelines do not support the use of MTHFR mutation testing for the evaluation of symptoms. Studies of MTHFR mutation testing have been plentiful and have focused on a wide varieties of conditions that include vascular disease, neural tube defects, mental illness, autism, and cancer. While some studies have found associations, other studies have found no association. While there is an association between MTHFR polymorphisms and lower folate levels and higher homocysteine levels, measuring folate and homocysteine directly, rather than performing MTHFR gene testing, is the recommended strategy. Several meta-analyses of MTHFR and various health conditions have been performed, and none of these analyses have concluded that MTHFR testing has clinical utility in any setting. ACMG guidelines indicate that MTHFR polymorphism testing has minimal clinical utility. Therefore, the methylenetetrahydrofolate reductase (MTHFR) mutation testing at issue was not likely to have been more beneficial than any other available standard treatments for the patients medical condition.Final Result: Three of three reviewers determined that the services at issue were not likely to have been more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in medical genetics and genomics, with primary specialty certification in clinical genetics and genomics, and are actively practicing. Physician reviewer 3 is board certified in medical genetics and genomics, with primary specialty certification in clinical biochemical 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patients parent has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Applying CALOCUS, the patient did not meet the criteria for RTC services. A study found that the best place for children and adolescents is at home with their families. It is also noted that an adolescent with mental illness should be treated in the safest and least restrictive environment and needed services should be wrapped-around to provide more intensive home or community-based services. The records indicate the patient was stable to be stepped down to a lower level of care. All told, the RTC services were not medically necessary for 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 subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for a wearable cardiac defibrillator LifeVest.  In this circumstance, there was potential for recovery of left ventricular function over time with medical therapy and there was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed with continued left ventricular dysfunction demonstrated by an ejection fraction less than 35% despite appropriate treatment. A prophylactic defibrillator before this time has not been demonstrated to improve outcome. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. For these reasons, the wearable cardiac defibrillator LifeVest was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the wearable cardiac defibrillator LifeVest was 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 services at issue were 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 internal medicine with subspecialty 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: The patient has requested reimbursement for residential treatment center (RTC) and partial hospitalization program (PHP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient met the criterion for dimension 1, given her prior withdrawal symptoms included tremors, body aches, and increasing suicidal ideation. For dimension 2, the patient was noted to have spinal compression and obesity. Dimension 3 was satisfied due to the presence of comorbid depression, anxiety and PTSD. The patient demonstrated self-harming behavior and suicidal ideation. For dimension 4, the patient appeared motivated, but lacked insight into the amount of effort required to maintain sobriety. For dimension 5, the patient was at high risk of relapse, considering her poor judgment, lack of impulse control, and lack of sober support. The records report the patient had low frustration tolerance and was unable to avoid or prevent relapse. She continued to use despite consequences of withdrawals and blackouts as well as impaired functioning. For dimension 6, the patients living environment did not include any sober supports. The patient was not stable enough to maintain sobriety without a highly structured 24-hour therapeutic environment. The patient presented with severely limited coping skills, including a pattern of self-medication and required 24-hour supervision in a sober setting to treat presenting problems and improve coping skills. The patient required a safe and stable living environment in order to develop her recovery skills. The patient qualified for ASAM Level III treatment, which is similar to what the patient received at the RTC and PHP. Given the severity of the patients illness, RTC and PHP were in accordance with generally accepted standards of medical practice. All told, the RTC services and PHP services were medically necessary for 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 psychiatry with expertise 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

The patient has requested authorization and coverage for two 1.5-hour sessions of social skills therapy weekly. To determine the medical necessity of services, medical literature provides the 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. Based on this definition the patient does not meet criteria (c). Specifically, if a patient is engaging in maladaptive behavior, this area should be addressed prior to working on adaptive, social, or functional skills. While the patient should continue to receive 1.5 hours of social skills therapy per week and continued 1:1 applied behavioral analysis (ABA) therapy to address maladaptive behaviors and additional adaptive deficits, the presenting information does not support an additional 1.5 hours of social skills training per week will address the patients presenting concerns. Further, the provider has recommended a reduced level of intensity at this time. Therefore, the requested two 1.5-hour sessions of social skills therapy weekly is not medically necessary for 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 a licensed BCBA, board certified in psychology 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

The patient has requested reimbursement and prospective authorization and coverage for inpatient psychiatric treatment program services including electroconvulsive therapy (ECT). The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Based on this patients disorganized behavior and ongoing psychotic symptoms as well as symptoms suggestive of an emerging catatonia, she meets the criteria for inpatient level of care with ECT. The patient is at serious risk of harm. Although she denies suicidal ideation, she has compromised ability to care adequately for herself and to be aware of her environment given her level of disorganized and psychomotor instability. The patients functional status is severely impaired due to her psychosis and catatonic features. The records document that she has shown significant social withdrawal and often does not interact with staff or peers. She required prompts for her activities of daily living (ADLs). The patients recovery environment is mildly stressful. She recently lost her sister and her children are no longer at home. The patients recovery environment is supportive. The patient has a therapist and psychiatrist, as well as a supportive husband. The records document poor response to prior treatment. She has required multiple inpatient hospitalizations and failed multiple medication trials. The patient has been minimally engaged in treatment and only attended a few group sessions. She has also been intermittently nonverbal with her provider. She has not been interactive and displays limited understanding of her treatment. The patients composite score is consistent with medically managed residence based services. She would likely be unsafe and unable to function in any lower level of care such as PHP where she would be at home at night and unmonitored. Moreover, treatment with ECT is appropriate. The records document that the patient has experienced episodes of tachycardia. ECT is the gold standard of treatment for severe depression as well as catatonia. All told, the inpatient psychiatric treatment program services including ECT provided were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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 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

The patients parent has requested authorization and coverage for Zolgensma. In this patients case, Spinraza therapy has not prevented worsening of his scoliosis. This is indicative that Spinraza has been ineffective. As his disease progresses, it further compromises his respiratory function. U.S. Food and Drug Administration (FDA) approved Zolgensma as the first gene therapy to treat patients younger than two years of age with SMA. Children with SMA Type 1 typically have motor neuron death that manifests clinically between birth and six months of age. Since Zolgensma therapy can lead to a disease-modifying outcome by creating the production of normal SMN protein, it is possible to rescue motor neurons before they die at any point in an affected patients clinical course. Zolgensma can provide a disease-modifying outcome for this patient because there are still motor neurons that can be rescued that may have been preserved with Spinraza therapy, but not completely restored to a functional state, given the progression of scoliosis.Spinraza works by acting as an antisense oligonucleotide that targets SMN2, so that it creates more functional SMN protein. In contrast, Zolgensma delivers sustained expression of normal SMN protein, bypassing production of either mutated or absent SMN. Since Spinraza needs to be administered repeatedly via an intrathecal route, there is an additional risk of general anesthesia in infants/toddlers that may have respiratory compromise, while Zolgensma only needs to be given once. In this patients case, Spinraza has not halted the progression of scoliosis, and repeated intrathecal administrations may be associated with additional respiratory compromise from general anesthesia. Thus, the medical evidence supports Zolgensma therapy in this patients case. Therefore, the requested Zolgensma 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 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

An enrollee has requested authorization and coverage for a continuous glucose meter. A continuous glucose monitoring system is one of several FDA-approved devices that record blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed and can thereby help maintain tight glycemic control and prevent hyper and hypoglycemia. It can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, and evaluate how diet and exercise affect blood sugars. A continuous glucose monitoring system can be used as a precautionary device in order to prevent potentially dangerous consequences of uncontrolled diabetes. Continuous glucose monitoring systems have been shown to improve HbA1C levels of diabetic patients. They have been confirmed to be a very safe method, with high accuracy in glycemic values and a low complication rate. In this case, the patient has had erratic glycemic control and has been experiencing intermittent episodes of hypoglycemia. By using a continuous glucose monitoring system, she can mitigate this problem and improve her overall health. Therefore, a continuous glucose meter is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in endocrinology, diabetes & metabolism, 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

The patient has requested authorization and coverage for a consultation with a dermatologist. A dermatologist is the appropriate provider to diagnose and treat hair loss. As noted in this patients records, the primary care provider referred the patient to a dermatologist to perform a work-up to determine the etiology of the patients hair loss. Some skin diseases that present as hair loss can be diagnosed by evaluation of the hair and scalp. Once the etiology of the patients hair loss has been determined, the provider can help formulate a plan for treatment. All told, the requested consultation with a dermatologist is medically necessary for this patient.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 dermatology 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.