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

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested an adaptive feeding chair (Rifton activity chair) for treatment of the enrollees medical condition.  The physician reviewer found that the current medical evidence supports the requested equipment in this clinical setting.  This patient requires specialized equipment in order to participate in activities of daily living while minimizing risk of complications.  Since she is unable to sit independently, she must have a seating device that provides necessary trunk, head, and foot support.  The harness must be adequate to prevent injury should she experience a seizure.  The use of a tray allows for hand positioning as well as additional trunk support should she fall forward.  Finally, the support provided by the chair improves her feeding positioning by supporting her head, neck, and torso.  Functional mobility is medically necessary to maximize her developmental potential.  All told, the requested adaptive feeding chair (Rifton activity chair) is medically indicated for the treatment of this patient.   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 pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested residential behavioral health services for treatment of the enrollees Aspergers disorder and anxiety disorder.   The physician reviewer found that this patient has a long history of behavior problems and his history reveals that a death in his family has caused him to decline significantly from his previous level of functioning. His problems are not amenable to a short-term solution, such as an acute hospitalization. This is reflected in his diagnoses of Aspergers disorder which indicates longstanding problems, combined with a new diagnosis of major depressive disorder precipitated by his fathers death. As noted in the medical literature, residential treatment is appropriate when a patient demonstrates chronic maladaptive behaviors that need more structure than can be provided in a less restrictive setting such as partial hospitalization program (PHP) or intensive outpatient program (IOP) levels of care. This patient has chronic maladaptive behaviors that prevent him from functioning in society. Specifically, he is refusing to attend school, and is unlikely to comply with attendance in PHP or IOP treatment. The only treatment setting that provides staff who can regulate this patients sleep patterns, wake schedule and monitor his socialization is a residential treatment setting. Consistent with these findings, the residential behavioral health services are supported as medically necessary for treatment of this patients medical condition. 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Synvisc One injections for treatment of her osteoarthritis.   The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  In their meta-analysis of 137 studies with 33,243 participants, Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids.  Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee.  The peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  In this case, the patient has undergone prior Synvisc One injections with significant benefit documented in terms of both pain reduction and maintenance of function in activities of daily living. Therefore, Synvisc One injections were medically indicated 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  An accurate assessment of fibrosis is vital in assessing the urgency for treatment.  The degree of hepatic fibrosis is one of the most robust prognostic factors used to predict disease progression and clinical outcomes.  In this patients case, a fibrosis score was not provided.  Fibrosis stage should be obtained before the medical necessity of the requested treatment can be established.  Therefore, Harvoni for 12 weeks is not medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Cialis for treatment of his erectile dysfunction secondary to finasteride.  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. In this case, the patient presents with ED secondary to finasteride. The treating provider recommends continuing finasteride and adding Cialis for treatment of ED.  Finasteride has been shown to cause ED. Given that the providers treatment plan includes continuing using finasteride, Cialis is medically necessary to treat ED.  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 urology 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 tumor necrosis factor (TNF) antagonist testing for treatment of the enrollees Crohns disease.  Two physician reviewers found that the TNF antagonist testing was appropriate to determine whether the patients use of infliximab monotherapy had led to the known potential outcomes of formation of neutralizing antibodies and/or premature clearance of drug from his circulation. The medical literature indicates that measurement of infliximab levels and anti-infliximab (anti-chimeric) antibodies produces actionable data. Change of dose or drug based on these results improves response to treatment, as measured by clinical response. The study by Hoekman and colleagues demonstrates that lower infliximab troughs are associated with elevated markers of mucosal inflammation in children. Antibody measurements can also be useful in determining whether an additional immunomodulator should be started. In addition, the use of such an adjunctive medication can suppress antibody levels, and is associated with a longer response to infliximab. Moreover, in clinical practice, infliximab levels and antibodies allow the provider practitioner to adjust or change biologic therapy with some objective determinants. Therefore, the TNF antagonist testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result:  Two reviewers determined that the testing at issue was 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 gastroenterology with sub-specialty certification in pediatric gastroenterology and is actively practicing. Two reviewers are board certified in pediatric gastroenterology and are 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Prometheus Anser IFX testing (serum infliximab and antibodies to infliximab) for evaluation of his medical condition.   Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  The records do not indicate that Anser IFX testing was needed in the management of this patient.  Although there may have been concern that he was developing a lupus-like syndrome from his anti-tumor necrosis factor drug, the appropriate testing in this setting would have been a serum anti-nuclear antibody and anti-histone antibody.  All told, the services at issue were not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Three 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intravenous antibiotic treatment for treatment of her medical condition.  Three physician reviewers found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard. The patient does not demonstrate by history or physical exam findings of late stage Lyme disease. There was no present tick bite or rash, and no sequelae that are consistent with Lyme disease. The patients symptoms are non-specific and are generally not consistent with the diagnosis of Lyme disease. In addition, the patients history is inconsistent as multiple antibiotic courses have made little difference in her clinical course. A positive plasmid DNA does not make the diagnosis of active Lyme disease. It may be positive from previous infection but does not correlate with disease activity. In sum, there is a lack of documentation supporting a diagnosis of late stage Lyme disease. Therefore, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three 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: Three reviewers are board certified in internal medicine and are 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested percutaneous sacroiliac joint fusion using the SImmetry Sacroiliac Joint Fusion System for treatment of her medical condition. Three physician reviewers found that the current medical literature has not demonstrated the superior efficacy of the requested services.  Shaffrey and Smith concluded that there was insufficient high-quality evidence regarding surgical management of sacroiliac joint pathology to support the role for sacroiliac joint fusion in the management of chronic lower back pain.  This patient presents with persistent bilateral sacroiliac joint pain following lumbar fusion.  Clinical examination documented positive provocative sacroiliac joint testing and injections have provided good relief of pain.  However, there is a lack of CT scan evidence to corroborate significant arthrosis or sacroiliitis. There is no radiographic evidence of sacroiliac joint disruption.  Given the absence of evidence-based, peer-reviewed support for sacroiliac joint fusion and lack of clear diagnostic findings isolated to the sacroiliac joint, the requested percutaneous sacroiliac joint fusion using the SImmetry Sacroiliac Joint Fusion System is not likely to be more efficacious than other treatment options.   Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in orthopedic surgery and are 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested BRCA gene testing for evaluation of her medical condition.  Three physician reviewers found that screening for BRCA mutations is indicated in individuals whose personal or family history predicts a high likelihood of finding one of these mutations.  Identifying individuals who carry these mutations has clinical importance in that it mandates the adoption of special measures aimed at risk reduction.  Well-established guidelines identify those individuals in whom genetic screening is warranted.  Per National Comprehensive Cancer Network guidelines, an individual with a first-degree relative with breast cancer diagnosed younger than age 50 is eligible for BRCA testing.  This patients relative was diagnosed with breast cancer at age 38.  All told, BRCA gene testing was likely to be of greater benefit than other modalities for evaluating this patient.  Final Result: Three 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: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are 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:   An enrollee has requested a positron emission tomography (PET) scan and aquatic therapy for evaluation and treatment of her condition.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient was admitted for surgical removal of back hardware and she reportedly tolerated the procedure without complications.  Subsequently, the patient was admitted for an acute flare of back pain.  Diagnostic studies at the time included x-rays of the spine that did not demonstrate any acute disease or concern for metastatic disease.  An abdominal ultrasound was unremarkable.  Later still, the records noted abdominal pain and chronic back pain, and physical therapy was declined by the patient for low back pain.  The records note that she has been started on omeprazole.  Lastly, the patients oncologist documented that the patient was stable.  In this case, the documentation does not support that the patient requires aquatic therapy instead of traditional physical therapy.  Therefore, the requested aquatic therapy is not medically necessary.  The diagnosis of gastric cancer is typically made with endoscopy.  A PET scan is not routinely used for the diagnosis or staging of gastric cancer.  In this case, the documentation submitted does not show that the patient has an active diagnosis of cancer or a concern for a recurrence of breast cancer.  Therefore, the requested PET scan is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee requested speech therapy three times per week for treatment of the enrollees language impairment and autism spectrum disorder.  Findings:  The physician reviewer found that the medical literature states that most children with autism spectrum disorder receive speech services in the preschool and elementary school years but typically by middle school speech services have been replaced by resource room supports. In addition, the medical literature indicated that speech and language therapy did provide improvements in communication skills and social skills, but no improvements on standardized testing.  In this case, the patient presents with autism spectrum disorder and additional speech language impairments. Some of his speech deficits are related to autism spectrum disorder such as abnormal prosody and asking questions rather than stating what he wants. In addition, some of his speech deficits are receptive and expressive language delays. Thus, speech therapy is clinically indicated for this patient. However, per the progress notes the patient missed several of his visits, which may impact his rate of progress. Given that the patient has missed several of his visits, increasing his speech therapy to two times per week is medically necessary and appropriate in this clinical setting.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Percocet or Norco for treatment of her medical conditions.  Findings:  The physician reviewer found that in the medical literature, Felicilda-Reynaldo discussed opioid risk mitigation tools that are part of standard practice. The author noted that when patient safety issues are identified such as lack of compliance, lack of adherence to prescription, or aberrant use, opioids should not be continued. Cheung and colleagues indicated that opioids are generally not recommended as first-line therapy. In addition, the authors reported that opioids should be tapered when patient safety risks are identified. Overall, the peer-reviewed guidelines support use of opioids with ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects. The medical records in this case report chronic pain. All told, the documentation provided for review does not support the medical necessity of the requested Percocet or Norco for treatment of this patients chronic pain.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 neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.