Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for intravenous immunoglobulin (IVIG). There is insufficient documentation in the medical records provided to support a diagnosis of a hypogammaglobulinemia, or PANDAS, based on the documentation provided for review. PANDAS has been described as the acute onset of obsessive compulsive disorder and/or motor tics in children following recent streptococcal infection. Symptoms frequently relapse and remit, and may respond poorly to psychotropic medications. A study demonstrated the efficacy of plasmapheresis and IVIG in patients with refractory symptoms. The proposed disease mechanism suggests that PANDAS should respond to immunomodulatory therapies, such as oral steroids, IVIG, and therapeutic plasmapheresis. A randomized controlled trial that compared IVIG against plasmapheresis and placebo found that at one month, neuropsychiatric symptom severity was reduced by 45% in the IVIG group, by 58% in the plasmapheresis group, and by 0% in the placebo group. Another randomized placebo controlled trial of IVIG in children with PANDAS failed to demonstrate a benefit of treatment with IVIG. This patients records do not support an underlying immunodeficiency. The patients immunoglobulin titers are normal. The patient has immunogenic responses to diphtheria, tetanus and pertussis. Although the patients titers to several pneumococcal serotypes were low, it is unclear when the pneumococcal vaccine was administered in relation to the titers being drawn. Based on these findings, the IVIG provided was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the IVIG provided was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the medication at issue was not and is 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:  One reviewer is board certified in pediatrics and neurology with special qualification in pediatric neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care and is actively practicing.  One reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care 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: A male enrollee has requested authorization and coverage for a foam roller. Physical therapy can be important in the initial stages of a rehabilitation program for rotator cuff issues and other shoulder conditions. However, based on the current medical literature, there is a lack of data supporting a role of foam rollers for these types of conditions. Although this patient may have persistent symptoms, there is no indication for the requested equipment for treatment of his medical condition. All told, the requested foam roller is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for one hour one-on-one talk therapy sessions (psychotherapy), once monthly. In the medical literature, Nutt noted that psychotherapy is an integral part of patients treatment. The author reported that psychotherapy has been shown to be effective for acute depression and can help in preventing depressive relapse and recurrence. There is evidence that patients with chronic, complex mental illness improve with long-term psychodynamic psychotherapy, and a greater number of sessions is associated with better outcome. Similarly, the American Psychiatric Association (APA) states that to prevent a relapse of depression in the continuation phase, depression-focused psychotherapy is recommended. This patient has complex chronic depression and anxiety, for which regular psychotherapy is considered the standard of care. Given these findings, the requested one hour one-on-one talk therapy sessions (psychotherapy), once monthly, is medically necessary for treatment of this patients 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Humira for treatment of the patients plaque psoriasis. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication. The patient has a history of psoriasis and psoriatic arthritis and has requested coverage for Humira. However, the patient is currently being treated with Otezla. There is a lack of support to prove that the efficacy of the combination of Otezla and Humira is greater than the effect of either alone. Additionally, the current evidence has not demonstrated the safety of this combination of agents. There are other U.S. Food and Drug Administration (FDA) approved single agents that may have better efficacy than the specifically excluded combination of Humira and Otezla. Therefore, Humira is not medically necessary 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for weekly allergy shots for treatment of the enrollee who has sensitivity to numerous allergens. Findings:  The physician reviewer found that Subcutaneous allergen immunotherapy (AIT) is a treatment for allergic rhinitis, allergic conjunctivitis, allergic asthma, and stinging insect hypersensitivity that induces immune modulation by administration of gradually escalating doses of allergen. Conventional allergen immunotherapy schedules involve a build up phase and a maintenance phase, at which time the maintenance dose is reached.  The maintenance dose, or effective dose, is that which is believed to provide therapeutic efficacy without significant adverse local or systemic reactions.  If clinical improvement is not apparent after one year of maintenance therapy, possible reasons for lack of efficacy should be evaluated. If none are found, discontinuation of immunotherapy should be considered.Weekly maintenance dosing is a nonconventional schedule for allergen immunotherapy.  There is unclear evaluation for other potential factors for nonresponse in this patients case noted above. It is unclear from the documentation exactly how long the patient continued on monthly dosing prior to discontinuation. Data is lacking regarding the need and effectiveness for more frequent maintenance dosing. There is not a clear rationale provided for the nonconventional and more frequent dosing in this patients case. Therefore, weekly allergy shots has not been demonstrated as medically necessary for the treatment of this patients medical condition. Final Result: The reviewer has determined that the requested medication frequency 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 pediatrics and allergy and immunology 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 bilateral mastectomy revision treatment plan as proposed by out of network surgeon, including one surgery, removal of extra skin, nipple re-grafting, and single incision from behind each armpit connected to the center of the enrollees chest. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who had undergone a chest reconstruction. Findings:  Based on the documentation provided, the patients original gender-conforming surgery produced a significantly abnormal result. The records indicate the patient continues to have significant excess skin, contour deformity and abnormal nipple positions. His condition should be considered a complication of the original male chest reconstruction that was performed.  As such, reasonable measures to correct this are medically necessary. The photographs show evidence of an abnormal male appearance of the chest consistent with previous examinations. There is significant soft tissue redundancy bilaterally and significant contour deformity of the left lateral chest. The nipple positions are asymmetric and not in a normal position for a male. The medical documentation and review of the photographs support a significantly abnormal result that would not be expected from chest surgery.  The two plastic surgeons offered different surgical plans for treatment of this patients abnormal chest presentation.  However, the in-Plan surgeon did not address the asymmetric and abnormal nipple positions, which significantly contributes to this patients chest deformity.  The surgical plan proposed by an out of network surgeon is consistent with the treatment of the deformity present in this patient according to the examination and photographs. Therefore, the documentation provided supports the medical necessity for bilateral mastectomy revision treatment plan as proposed by an out of network surgeon, including one surgery, removal of extra skin, nipple re-grafting, and single incision from behind each armpit connected to the center of the patients chest.Final Result: The reviewer has determined that the requested services are medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  The reviewer is board certified in plastic 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 reimbursement and prospective authorization and coverage for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Findings:  The American Society of Addiction Medication (ASAM) criteria is a set of objective guidelines used by clinicians to assist with treatment planning and advocates for service intensity provided in the least intensive but safe treatment setting. In this patients case, the provided documentation for continued admission at the residential facility does not support the medical necessity for the services at issue. Recent documentation does not note the patient had suicidal or homicidal ideation, aggression, self injurious behavior, non-response or adverse response to medications, frequent medication changes, or difficulty with attending to activities of daily living. The records also do not contain reports of the patient having active withdrawal symptoms, unstable vital signs, lack of motivation to change, continued substance use, a dangerous or non-supportive recovery environment, or lack of access to effective care, all of which would support treatment at the residential level of care. Based on the clinical documentation provided and current medical literature, the residential treatment services were not and are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer has determined the services at issue were not and 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 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: An enrollee has requested authorization and coverage for Supartz hyaluronan injections. Hyaluronic acid injections for osteoarthritic knee pain is an established part of osteoarthritic knee pain treatment algorithms and generally considered a second-line treatment after independent exercise, weight loss and medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and/or acetaminophen. Multiple studies have documented efficacy, although the magnitude of benefit varies between studies and individual patients. With long-term and widespread use, the injections have been confirmed to be safe with no severe or systemic side effects. The requested hyaluronic acid injection is a standard treatment option which is likely to be beneficial for this patients painful knee osteoarthrosis. Thus, the requested Supartz hyaluronan injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested Supartz hyaluronan injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the 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 orthopedic surgery and is actively practicing. One reviewer is board certified in orthopedic surgery and is actively practicing.  One reviewer is board certified in orthopedic surgery 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hip resurfacing. The submitted documentation supports the medical necessity of the requested services. This patient presents with persistent and worsening right hip pain with functional limitations in weight-bearing activities and activities of daily living. The records indicated he had normal bone quality and shape. He had failed conservative treatment, including activity modification, physical therapy, and medications. A hip resurfacing procedure has been recommended over total hip arthroplasty based on the patients age and activities. The current peer-reviewed literature supports hip resurfacing in this clinical setting. Therefore, the requested hip resurfacing is medically necessary for the treatment of this patient.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cold therapy (cryoablation)  for treatment of the enrollees Mortons neuroma.  Findings:  The physician reviewer found that After the use of other treatments, sclerosing injections or cryotherapy is noted as a treatment option. However, there are fewer data demonstrating improved health outcomes with cryotherapy in this clinical setting. Given these findings, the cold therapy (cryoablation) was 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 cold therapy (cryoablation) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in podiatry 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

An enrollee has requested authorization and coverage of Mavyret 100 mg - 40 mg tablets for eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus, genotype 2b.According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 2 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. The SURVEYOR-2 trial showed a 99% cure rate with eight weeks of treatment AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100 - 40 mg tablets for eight weeks for treatment of hepatitis C is supported as medically necessary. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Coflex interlaminar stabilization device. Findings:  Two of the three physician reviewers found that the current evidence-based literature and long-term studies support the use of Coflex interlaminar stabilization with decompression as a safe and efficacious alternative to decompression and/or lumbar fusion for the treatment of lumbar spinal stenosis. This patient presents with persistent and worsening low back pain radiating into the left lower extremity with numbness and tingling. She had significant functional limitations in activities of daily living. Her symptoms are consistent with imaging evidence of disc extrusion with moderate to severe subarticular and foraminal stenosis with nerve root compromise. She had failed physical therapy, medications, and activity modification. Therefore, the requested Coflex interlaminar stabilization device is likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested device is 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 orthopedic surgery 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.