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

Nature of Statutory Criteria/Case Summary: The patient was admitted for inpatient level of care. The patient reported that he had been engaging in self-harm via cutting. He was initially admitted after a physical altercation with his parents. The patient reported that he had an argument with his mother. The patients father reported that the patient had been out of control and physically aggressive. The records documented no prior inpatient psychiatric hospitalizations.  He was observed interacting appropriately and was calm and polite on evaluation. He reported feeling safe living at home and wanted to return home after his hospitalization. He denied thoughts of self-harm or psychotic symptoms. He reported feeling safe and comfortable in the psychiatric unit. Psychiatric progress notes noted a family meeting where the parents expressed feeling unsafe taking the patient home. The plan was to discharge the patient to a partial hospitalization program (PHP). The patients diagnoses included oppositional defiant disorder, attention deficit/hyperactivity disorder with a history of early childhood trauma, and maternal abandonment. The patients parent has requested reimbursement for the inpatient level of care. The Health Plan has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. 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. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patient had a composite score of 17. This correlates with intensive outpatient services. Therefore, inpatient level of care was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 sub-specialty 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: The parent of an enrollee has requested authorization and coverage for GeneDx Autism/ID Xpanded Panel.Findings:  Two of the three physician reviewers found that there is sufficient support for the requested services in this clinical setting. In this patients case, several prior genetic studies have been conducted, all of which failed to reveal a unifying molecular diagnosis to guide both treatment and surveillance strategies. The records indicate a logical and stepwise genetic evaluation has occurred. Neurodevelopmental disorders are often complex clinical scenarios from a genetic perspective. In a recent studies, 100 families with 119 children affected by neurodevelopmental disorders received diagnostic whole-genome sequencing and/or whole-exome sequencing, of which, forty-five percent received molecular diagnoses. Studies show, 78 patients with various neurodevelopmental disabilities and unrevealing work-up were selected to undergo multigene sequencing, with results yielding a presumptive diagnostic rate of 41%. Both studies demonstrated multigene sequencing to be a powerful diagnostic tool with results that directly impact patient care. Thus, GeneDx Autism/ID Xpanded Panel is likely to be more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in clinical genetics and genomics 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

Findings:  The physician reviewer found that the patient has requested authorization and coverage for Nucynta ER 200 mg. In this case, the patient has a neurological history that includes Chiari malformation and headaches. In addition to surgery to correct the Chiari malformation, the patient has undergone several ventriculoperitoneal shunt surgeries and suffered an infectious complication from one of his procedures. The patient reports a daily pressure like headache. While the submitted documentation reflects that the patient has tried CGRP inhibitors, valproic acid, topiramate, and other opioid analgesic medications, there is no indication that the patient has tried other therapies such as nortriptyline or verapamil. Under these circumstances, Nucynta ER 200 mg is not medically necessary to treat 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 reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continuous glucose monitoring system (CGMS) that can turn on and off the basal supply of insulin in response to hypoglycemia (or predicted hypoglycemia), including a transmitting device, receiver device, and continually renewing supply of sensors. CGMS devices have been approved by the U.S. Food and Drug Administration (FDA) for use in this clinical setting. Moreover, the utility of CGMS has been demonstrated in clinical trials. Overall, the peer-reviewed literature supports the long-term use of CGMS in adult patients with type 1 diabetes with hypoglycemia unawareness and episodes of hypoglycemia. Specifically, the American Diabetes Association (ADA) noted that CGMS may be a valuable supplemental tool to standard blood glucose monitoring in patients with hypoglycemia unawareness and/or frequent hypoglycemic episodes. CGMS device has multiple benefits for this patient who has type 1 diabetes, on insulin pump with frequent hypoglycemia. Based on readings from the Dexcom G6 CGMS, the Control-IQ algorithm automatically adjusts basal insulin to prevent high and low blood sugars. Given this support, the requested CGMS that can turn on and off the basal supply of insulin in response to hypoglycemia (or predicted hypoglycemia), including a transmitting device, receiver device, and continually renewing supply of sensors, are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 endocrinology, diabetes and 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mekinist. Findings:  The physician reviewer found that noted in the medical literature, treatment for Erdheim-Chester disease (ECD) is reserved for patients who are symptomatic. This patient reports symptoms including bilateral thigh pain, back pain and abdominal discomfort. Further, the patient is reported to be wild type for BRAF, meaning he does not harbor a mutation limiting treatment options. Treatment with a MEK inhibitor such as Mekinist is considered the standard of care in patients who have a wild-type BRAF. Thus, the requested treatment with Mekinist is supported as medically necessary for treatment of this patients ECD. 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 certifications in medical oncology and hematology 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

Use of Xolair to treat this patients moderate persistent asthma and recurrent infection is not medically necessary since there is inadequate medical chart documentation that the patient was treated with oral steroids more than once in the past year or that he required a visit to the emergency room, or hospitalization, for the management of asthma. The patient demonstrated a positive blood test allergen sensitivity to aeroallergen, and presented with asthma symptoms that appeared to persist despite daily inhaled corticosteroid with Advair, which is a long-acting beta-agonist. He also has demonstrated symptoms that required the use of almost daily Xopenex rescue inhaler. The patient demonstrated a total IgE of. However, spirometry report from medical chart note demonstrated normal function without evidence of airway obstruction and fractional exhaled nitric oxide (FeNO) level was in the normal range. Given lack of documentation of emergency department visits, hospitalizations, use of oral steroids more than once in the past year, in the setting of normal spirometry and normal FeNO levels, there is no indication that patient is in need of add-on therapy with Xolair. 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 allergy and immunology with subspecialty certification in pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has experienced weight regain after a Roux-en-Y gastric bypass. She has been in a supervised diet and weight loss program for one year.  The upper gastrointestinal series revealed significant findings. The patient has multiple obesity-related comorbidities, including hypertension, diabetes mellitus type 2, which is complicated by retinopathy, acid reflux, and obstructive sleep apnea. The patient has requested authorization and coverage for gastric bypass revision surgery.  The Health Plan has denied the request as not medically necessary for the treatment of the patients weight regain.In this case, the patient has a sufficient BMI to support a bariatric surgery such as Roux-en-Y gastric bypass, based on guidelines from the American Heart Association (AHA), American College of Cardiology (ACC), the Obesity Society and from the National Institutes of Health (Jensen, et al).  Additionally, this patient has anatomic defects confirmed with imaging, a dilated gastrojejunostomy and pouch, which can result in loss of restriction followed by weight regain.  A systematic review reports that indications for corrective procedures after gastric bypass include inadequate weight loss, weight regain, or recurrence of weight-related co-morbid conditions.This patient meets these criteria. The patient has a BMI over 40 kg/m2, for which primary surgery would be indicated to prevent obesity-related complications. She also has a recurrence of weight-related comorbidities and is at risk for multiple additional complications of weight regain in the future if weight regain is not reversed. Diet and lifestyle modifications have been attempted but has not resulted in sufficient weight loss to prevent obesity-related complications.  For these reasons, the request for revision of gastric bypass is supported as medically necessary for the 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 internal medicine with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with mild bronchiectasis, which was confirmed by computed tomography (CT) scan of the chest. The records document chronic obstructive pulmonary disease. He has had two episodes of acute exacerbation of his bronchiectasis with an increase in productive cough. His symptoms reportedly improved with antibiotics. The patients provider recommended utilizing airway clearance techniques to manage his sputum production.  The patient was determined by his provider not to be a candidate for manual chest physiotherapy and postural drainage due to the lack of a care provider who could assist him with this type of therapy. The patient has requested authorization and coverage for a high-frequency chest wall oscillation system. The Health Plan has denied this request and reported that the requested device is not medically necessary for the treatment of this patient. The submitted documentation fails to demonstrate the medical necessity of the requested device.  Studies noted that although airway clearance techniques and high-frequency chest wall oscillation, in particular, could increase sputum expectoration, selected measures of lung function, symptoms, and health-related quality of life, the role of these techniques in acute exacerbation of bronchiectasis is unknown. Studies noted that the impact of airway clearance techniques on individuals experiencing chest infection is unknown. Studies concluded that performing airway clearance techniques on patients with stable chronic obstructive pulmonary disease did not appear to affect flare-ups or hospitalizations. The medical evidence does not support the requested device in this setting. Therefore, the requested high-frequency chest wall oscillation system is not medically necessary for the treatment of this patient. 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 internal medicine with sub-specialty certification in pulmonary disease 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 patient has requested authorization and coverage for acupuncture. He had previously complained of ongoing and increasing numbness and tingling in the lower extremity. Radiographic imaging revealed lumbar degenerative disc disease. He requested acupuncture treatments via email. The Health Plan has denied this request, indicating that the requested treatment is not medically necessary for the treatment of the patients medical condition.The available literature indicates that acupuncture can be beneficial in treating pain related sciatica and in relieving discomfort and pain when applied correctly. According to Zhao and Wang, acupuncture has a rapid therapeutic effect and analgesia for sciatica. Despite literature supporting the use of acupuncture for sciatica and for resolving pain and discomfort, in this case, the patient is not a candidate for acupuncture. The submitted documents do not support the presence of characteristics that support a diagnosis of sciatica. The medical records report subjective intermittent numbness and tingling and the objective findings of tightness along the hip flexors and iliotibial (IT) band. Moreover, the patient noted that stretching resolves the numbness and tingling. Thus, the requested acupuncture is not medically necessary for the treatment of the patients medical condition.Final Result: The medical reviewer determined that the requested acupuncture is not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  The medical reviewer is board certified in chiropractor with subspecialty practice in oriental 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 patient has requested authorization and coverage for palliative care. In this case, the patient has a past medical history significant for chronic lumbar radiculopathy, left rib pain, PTSD, depression and multiple concussions with loss of consciousness. However, the medical literature does not support the use of palliative care for any of this patients medical conditions. In addition, the documentation does not indicate that the patient has a terminal condition which would benefit from palliative care. Moreover, the records do not provide a specific rationale to support the request for palliative care. All told, the requested palliative care is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 patients parent has requested authorization and coverage for direct one-on-one applied behavioral analysis (ABA) therapy services, to be provided from a therapist while in school. This patients provider listed 13 goals and of these goals, three of them require peer interaction. However, since only a few of the patients ABA treatment goals require peer interaction, these goals can be completed in the home or community settings. Based on the current medical literature, there are sufficient goals to justify ABA services to be provided in the home setting for this patient. Moreover, this patients provider did not provide specific rationale to support services to be provided in the school setting in lieu of the home setting. As progress is made, future services may include the educational setting as an opportunity to practice generalization of skills. Medical literature highlights that in order to ensure continuity of care, sufficient ABA treatment and consultation should be delivered in subsequent educational and therapeutic settings. At this juncture, ABA services within the home are appropriate, and have been approved by the Health Plan. All told, direct one-on-one ABA therapy services, to be provided from a therapist while in school, are not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.