Persius/hicric huggingface dataset:
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 (RTC) services. Findings:  The physician reviewer found that he 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.Regarding the six CALOCUS dimensions, the patient had no risk of harm; the patient was not actively suicidal or passively suicidal (score = 2). Regarding functional status, the patient had some issues with level of functioning due to mental illness and relational issues, but overall, showed appropriate daily functioning while in treatment and indicated that prior school functioning was good (score = 2). There were no comorbidities noted (score = 1). The patient had a mild level of stress. He was noted to have interpersonal conflict with his father and a good relationship with his mother, peers and siblings (score = 2), and the patients parents were involved in treatment on a regular basis (score = 2). The patient had a good response to a short period in the RTC, with minimal continued signs or symptoms of anxiety and depression (score = 3). He participated in therapy actively for a majority of the time but was also uncooperative on occasion (score = 2-3) and his parents worked actively and constructively with clinicians on a regular basis (score = 2). This gives the patients presentation a composite score is 16-17, which corresponds with an Intensive Outpatient Services level of care. This score is judged by the acuity of the patients symptoms and environment during the period at issue. Accordingly, the Residential Treatment Center (RTC) services at issue were not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with a 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive outpatient program (IOP) services. The submitted documentation supports that the services at issue were medically necessary. The American Psychiatric Association treatment guidelines for substance use disorders notes that for many patients with a cocaine use disorder, clinical and research experience suggests the effectiveness of intensive outpatient treatment in which a variety of treatment modalities that focus on the maintenance of abstinence are simultaneously used. The IOP level of care is classified by the American Society of Addiction Medicine (ASAM) as Level 2.1 treatment, which encompasses services that are capable of meeting the complex needs of people with addiction and co-occurring conditions.In this case, the patient had the addiction and co-occurring condition of cocaine use disorder and bipolar disorder. Near the start of the services at issue, the patient was noted to be ambivalent about long term abstinence, to have impaired insight into his triggers, and to be at high risk of relapse outside of an IOP level of care. He was noted to have cravings during the period in question and he had ongoing mood issues through the end of the services at issue. Under these circumstances, the IOP services provided to the patient were medically necessary for treatment of the patients medical condition.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 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 33-year-old female enrollee has requested authorization and coverage for Caris Profile genetic testing. Findings:  Two out of three physician reviewers found that the current standard of care approaches for endometrial adenocarcinoma include surgery, radiation, cytotoxic chemotherapy and hormonal therapy. Biologic therapies have also shown some response rates. There are 2 phase II trials demonstrating the safety and efficacy of bevacizumab in endometrial cancer. Further, the National Cancer Institute (NIH) recommends clinical trials for such patients and considers such referrals standard care. The NCI is also enrolling into the MATCH trial where targeted therapies are given to those patients with amenable mutations. One study of 86 patients reported the progression free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. Given these findings, the Caris Profile genetic testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   One reviewer found that the Caris Profile genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology 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

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with chronic low back pain and lumbar post-laminectomy syndrome who requested authorization and coverage for Percocet and Soma. The Health Plan has denied the request as not medically necessary. Findings:  The physician reviewer found that the CDC (Centers for Disease Control and Prevention) clinical practice guidelines do not recommend the prescription of opiates for non-malignant pain. Further, the patient had a positive toxicology screen. Prescribing opiates after a positive toxicology screen is not acceptable practice as defined by the Federation of State Medical Boards (FSMB). Chronic use of Soma would be off-label.  It was approved for short-term use only by the FDA (Food and Drug Administration). The requested medications are not medically necessary, and the Health Plans denial should be upheld.Final Result: The reviewer determined that the requested medications 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 a subspecialty 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 patient has requested authorization and coverage for stereotactic body radiation therapy (SBRT). Based on the current medical literature and the American Society for Radiation Oncology (ASTRO) policy, the requested SBRT is medically necessary and appropriate for treatment of this patients oligometastatic rectal cancer. The records document that the only evidence of progression is along the right lung suture line. With the treatment focus limited to this area, treatment with SBRT is appropriate. In addition, the patient can continue with the same systemic therapeutic regimen, which has been predominantly effective. Overall, SBRT is supported as safe and effective for management of oligometastatic colon cancer to the lung by numerous high quality reports in the peer-reviewed medical literature. 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 reviewer is board certified in radiation oncology 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: A patient has requested authorization and coverage for a right total hip arthroplasty. The Health Plan has denied the request as not medically necessary. Total hip arthroplasty is a very successful and effective orthopedic operation with very good immediate as well as long-term results to alleviate pain and improve the quality of life of the patient. It is indicated in end-stage hip osteoarthritis in patients with a clear indication, as in this case. The decision for total hip arthroplasty includes evaluation of the medical history, clinical examination, and radiographic findings, and the degree of suffering; in addition to, having clear outcome expectations. The timing of the total hip arthroplasty is based on the patient's level of discomfort, the main goal being, to improve the quality of life.In this case, the records document subjective, objective, and radiographic findings consistent with end stage osteoarthritis. The literature supports that after four years of symptoms and with this degree of disease, it is unlikely for conservative treatment to provide long term relief. As such, the right total hip arthroplasty is medically necessary for the treatment of the 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 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 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 Botox injections every 12 weeks.Findings:  Two of the three physician reviewers found that the current medical evidence supports the requested services in this patients case. The records documented a history of at least 15 headache days per month. Botox injections are indicated in this clinical setting. Botox injections have been approved by the U.S. Food and Drug Administration for the treatment of chronic migraine. Based on the submitted clinical documentation, this patient is likely to benefit from Botox injections. Thus, Botox injections every 12 weeks are likely to be superior over other available treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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

The patient has requested authorization and coverage for inpatient psychiatric care. The patients twice weekly outpatient psychotherapy abruptly stopped then she reported increased symptoms of depression, anxiety with vegetative signs of depression. This rapid decline occurred within days after reporting that she was doing ok and the provider noted the patient was stable. In treatment, the patient consistently reports passive, with occasionally active, suicidal ideation. There have been no reports of active suicidal plan or intent. This has become the patients baseline on review of all of the psychotherapy notes provided. Throughout treatment, the patients provider has noted that partial hospitalization program (PHP) level of care was available if necessary, and the patient has consistently declined it. The patient would be able to continue psychotherapy, which is a service that is provided in a PHP. There is no evidence that the patient poses an immediate danger to herself or to others. She has not demonstrated any self-harming behaviors, she was not gravely disabled, and she is cognitively intact. She has not been manic, psychotic, agitated or impulsive. She has not been abusing substances, and she has been compliant with all forms of treatment and medications. Overall, she does not require the structured setting of 24-hour nursing care and medical monitoring. PHP level of care, as recommended by the provider and approved by the Health Plan, is the appropriate setting. Thus, the requested inpatient psychiatric care is 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 psychiatry with subspecialty certification in geriatric 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 laboratory testing.Findings:  Three physician reviewers found that in the evaluation of rupture of membranes, available standard diagnostic evaluation can be performed with pelvic examination for pooling of amniotic fluid, testing the pH of the vaginal fluid, and microscopic visualization of the fluid for the presence of arborization. An obstetric ultrasound may be done to assess for amniotic fluid index. AmniSure is a rapid slide test that uses immunochromatography methods to detect trace amounts of placental alpha microglobulin-1 protein in vaginal fluid. Per the medical evidence, AmniSure testing may be appropriate if the diagnosis remains uncertain after physical examination, nitrazine and fern tests, and ultrasound assessment. Based on the available clinical documentation, this patients diagnosis was not uncertain. She had no evidence of rupture of membranes on physical examination or ultrasound assessment. Furthermore, it does not appear that traditional evaluation with nitrazine and fern tests were performed. Therefore, laboratory testing was not likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 obstetrics and gynecology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  Two of the three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Noninvasive prenatal screening by cell-free DNA is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is more sensitive than sequential screening, but does not require the invasive procedure of chorionic villus sampling or amniocentesis. Therefore, genetic testing was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewers 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for laboratory testing (CPT 81551). Findings:  The physician reviewer found that there is a lack of support for the services at issue in this patients case. The ConfirmMDx test is a multiplex polymerase chain reaction assay which measures DNA methylation of three biomarkers associated with prostate cancer: GSTP1, APC and RASSF1. The National Comprehensive Cancer Network (NCCN) guidelines do not consider the ConfirmMDx test standard of care in this setting. American Urological Association guidelines do not comment on the utility of the ConfirmMDx test in patients undergoing a prostate biopsy. At this time, there is limited data on clinical outcomes to support routine use of the ConfirmMDx test. Therefore, laboratory testing (CPT 81551) was not likely to have been superior over other methods of evaluating this patient. Final Result: Three physician reviewers found that the services at issue were 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 urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy. The submitted documentation supports that the requested services are medically necessary. Delays or disruptions due to isolated expressive language delay, articulation errors, multiple sound production errors with motor planning deficits, or mixed expressive and receptive language delay, often bring widespread consequences. In this case, the patient has a severe articulation disorder, as documented by two speech pathologists and as evidenced by two speech evaluation tools. The research on articulation disorder confirms that individual speech therapy may be critical in preventing the patient from being placed at risk for life-long disability. The present request for speech therapy, one time per week for 60 minutes, is reasonable and appropriate. Accordingly, the requested speech therapy, one time per week for 60 minutes, is medically necessary for the treatment of the patient's 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 reviewer is board certified in both pediatrics and 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a sleep study. The submitted documentation supports that the services at issue were medically necessary. There has been a shift in the provision of sleep study services from the in-laboratory attended setting over to the home-based environment. In this case, the patient had symptoms and complaints that were suggestive of the presence of OSA. Specifically, he complained of snoring, non-restorative sleep, and excessive daytime sleepiness. All of these symptoms are suggestive of OSA. Given that the patient had symptoms suggestive of sleep-disordered breathing and other complaints that were suggestive of OSA, it was clinically appropriate for the patient to undergo diagnostic sleep testing. The patient did not have any contraindications to the provision of services in the home setting. Accordingly, the sleep study performed for the patient was medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the service 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 neurology, with subspecialty certification in sleep 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.