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

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for methadone. The stepwise ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. Not all non-opioid and narcotic treatment options have been utilized in this patients case. There is no documentation of the completion of behavior therapy despite much research to support its use. Furthermore, no objective treatment goals for pain and function are noted for the requested medications. When opioids are started, providers should prescribe the lowest effective dosage. For these reasons, the requested methadone is not medically necessary for treatment of 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 anesthesiology 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for general anesthesia services during dental work to be performed in a hospital or surgical setting. The Health Plan has denied this request indicating that the requested services are not medically necessary for management of the enrollees dental condition. Findings: The submitted documentation supports the medical necessity for the requested services in this clinical setting. The patient has a number of medical conditions that jeopardize her ability to tolerate outpatient management and the use of local anesthetic or conscious sedation. The standard calming techniques and communication cannot be completely successful at her age. The provider indicates that she has extensive dental caries and requires a lot of restoration, resulting in a long procedure time, increasing her risk of morbidity should her airway not be adequately protected. Per Department of Health Care Services (DHCS) criteria, if the patient requires extensive dental restoration or surgical treatment, if use of effective communicative techniques and immobilization was not successful, if the patient has acute situational anxiety due to immature cognitive functioning, or if the patient is uncooperative due to certain physical or mental compromising conditions, then general anesthetic should be considered. This patient meets these criteria. Based on the current standard of care, the requested general anesthesia services during dental work to be performed in a hospital or surgical setting is medically necessary to allow for complete dental restoration for this patient.Final Result: The reviewer determined 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 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 authorization and coverage for Humatrope 6 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who has a history of panhypopituitarism, growth hormone deficiency and adrenal insufficiency.Findings: The records support that this patient has growth hormone deficiency. While the benefits of growth hormone therapy replacement in adults with growth hormone deficiency is well documented, the medical literature and guideline recommendations do not differentiate between the different brands of medications for treatment of growth hormone deficiency. The American Association of Clinical Endocrinologists indicates in their guidelines the following:  In the United States, recombinant GH [growth hormone] is approved by the FDA [U.S. Food and Drug Administration] for adult GHD [growth hormone deficiency] and marketed by Pfizer (Genotropin), Eli Lilly (Humatrope), Genentech (Nutropin), Novo Nordisk(Norditropin), and Serono (Saizen). There is no evidence that one commercial product is more advantageous over the other, apart from differences in pen devices, dose increments and decrements, and whether or not the product requires refrigeration. In clinical efficacy, we do not advocate the use of one commercial preparation over another.  In addition, the Endocrine Society does not distinguish between brands when they refer to growth hormone therapy (Molitch, et al).  In the U.S. Food and Drug Administration approval letters for Humatrope and Nutropin, both medications have 191 amino acid residues and have a molecular weight of about 22,125 daltons. The descriptions for both brands of growth hormone medications are identical. As such, Humatrope is not medically necessary at this time because an alternative formulary medication, Nutropin, is available for this patient.  Therefore, Humatrope 6 mg has not been established as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined 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 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 parent of an enrollee has requested authorization and coverage for direct one-to-one applied behavioral analysis (ABA) therapy, at 40 hours a week. In this case, the patient presents with behavioral issues including non-compliance, inflexibility, outburst behaviors, and elopement when asked to make low preference transitions. The patient also continues to participate in socially impairing stereotypical behaviors. A treatment plan has been developed that is consistent with the patients essential health needs and consistent with the diagnosis of autism. ABA as a treatment is evidence based and scientifically proven to be effective. The purpose of ABA in this case is promote independence for the patient by addressing his current behavioral deficits. Regarding the number of hours of ABA therapy,  a study reported that a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress was demonstrated. This patients records indicate that he made progress in many areas, but continues to demonstrate significant behavioral concerns, which have increased dramatically after the decrease in ABA hours. The patient continues to require a high level of support to transition appropriately. Failure to master these skills places the patient at an increased risk for injury and makes it difficult to be successful in more generalized environments. Given these findings, the requested direct one-to-one ABA therapy, at 40 hours a week is supported as 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 pediatrics with sub-specialty certification in neurodevelopmental behavioral pediatrics and genetics 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 single-photon emission computed tomography (SPECT) scan. Findings:  Two of the three physician reviewers found there is a lack of support for the services at issue in this clinical setting. The liver/spleen scan crudely assesses whether the patient has portal hypertension, but does not clarify the cause of their medical condition. Based on this patients laboratory testing and imaging, there was no suggestion of underlying cirrhosis. Therefore, concern for portal hypertension was not a consideration. Thus, SPECT scan was not likely to be more effective than other methods of evaluating this patient. Final Result: The reviewers determined 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 internal medicine with sub-specialty certification in gastroenterology 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: An enrollee has requested authorization and coverage for omeprazole suspension. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of intractable seizures, cerebral palsy and global developmental delay.Findings: There is adequate support in the documentation provided for the requested medication in this clinical setting. Patients with neurodevelopmental disabilities frequently have gastroesophageal reflux which often fails to respond to medical management. Gastrostomy tube feeding is increasingly being used to circumvent oral motor dysfunction and prevent malnutrition. Based on the available literature the proton pump inhibitor (PPI) omeprazole is regarded as the therapy of choice in this patient population. Additionally, the studies have demonstrated the satisfactory bioavailability of omeprazole suspension in individuals with intellectual disability who are gastrostomy tube fed. During the time the patient was not receiving the medication, he was in distress, waking at night with burping. The provider noted that he has eosinophilic esophagitis and severe food allergies. The patient has failed to respond to two proton pump inhibitor medications. The patient is fed via gastrostomy tube and is unable to take medications orally. The extended release capsule form of omeprazole suspension cannot be crushed, and does not fit in the gastrostomy tube. Therefore, the omeprazole suspension is medically necessary for treating this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Humira monitoring tests. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.Findings:  There is currently insufficient medical evidence to support the superior efficacy of Anser ADA when compared with conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect (Morita, et al; Roblin, et al; Ungar, et al). These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Additionally, the ATLAS study showed that patients with loss of response may actually have high, rather than low, serum levels (Yarur, et al). It is possible that active disease results in low adalimumab levels due to loss of adalimumab, rather than low adalimumab levels resulting in loss of disease control. Moreover, controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management. All told, there insufficient evidence from controlled studies to definitively demonstrate that the Humira monitoring tests  were likely to have been more effective than the available standard therapies for managing this patients medical condition.Final Result: All three reviewers determined 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for earlobe repair. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition and are not reconstructive in nature. Findings: The submitted documentation does not support the medical necessity for the requested earlobe repair. There is evidence of a mildly elongated left earlobe piercing but there is no complete split visible. The provider noted normal external left ear and an otherwise normal appearing earlobe. Based on the documentation provided and review of the photographs, they have not demonstrated that the mildly elongated earlobe is contributing to a functional impairment. In addition, the earlobe appears relatively normal except for the mild elongation of the piercing. Accordingly, the requested earlobe repair is not supported as medically necessary for treatment of this patients medical condition.With regards to whether the requested services are reconstructive in nature, the records provided do not support that the requested earlobe repair meets the criteria under the expanded concept of medical necessity. Earlobe reconstruction may be indicated for cases of a complete cleft or a severely elongated piercing site, generally from trauma. In this patients case, the functional concerns reported by the patient are unlikely to be addressed with a partial earlobe correction and the findings are not consistent with a significant earlobe deformity. In addition, the patient has a relatively normal appearing left earlobe. The patient may have experienced a minor trauma associated with the elongated ear piercing, but based on the photographs and the records, this has not produced a significant abnormality. Moreover, there is insufficient evidence that a functional impairment is related to the earlobe elongation. As such, there would not be more than a minimal improvement that would be gained with an earlobe correction. For these reasons, the requested earlobe repair is not reconstructive in nature.Final Result: The reviewer determined requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.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

Findings:  The physician reviewer found that A 59-year-old male enrollee has requested authorization and coverage for Mavyret 100-40 mg tablets for 12 weeks. According to the most 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 non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret 100-40 mg three tablets daily for eight weeks (Kwo, et al; Zeuzem, et al). For these reasons, the requested treatment with Mavyret 100-40 mg tablets for 12 weeks is not medically necessary for the treatment of this patients hepatitis C infection. 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for tissue transfer (CPT 14021) along with the approved panniculectomy (CPT 15830). In this patients case, the records document a large overhanging abdominal pannus with associated symptoms due to skin on skin overlap. The documentation supports that a panniculectomy would be indicated as a functional procedure. This has been authorized by the Health Plan. However, the records do not support the medical necessity of the requested adjacent tissue transfer (CPT 14021). It is unclear which anatomic area will be treated with the adjacent tissue transfer, as the panniculectomy would address the significant overhang. Thus, the medical necessity of the requested services has not been established. In this patients case, the medical documentation does not support that there is an abnormal structure of the body that would be addressed with adjacent tissue transfer. Per the records, it is unclear which anatomic area will be treated with the adjacent tissue transfer. Additionally, the requested services are not likely to improve function or create a normal appearance to the extent possible. The functional component and creation of a normal appearance is associated with the panniculectomy and not with the adjacent tissue transfer. There is insufficient evidence that an adjacent tissue transfer would provide more than a minimal improvement. Therefore, the requested adjacent tissue transfer (CPT 14021) is not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld. 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 authorization and coverage for right shoulder Euflexxa injections. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient presents with a history of persistent right shoulder pain. Clinical examination findings documented limited range of motion and weakness. There is reported imaging evidence of glenohumeral osteoarthritis. Corticosteroid injections to the right shoulder have failed to provide adequate relief of symptoms. Current medical guidelines do not support the use of hyaluronan injections for the treatment of shoulder conditions. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of hyaluronan injections in the treatment of glenohumeral osteoarthritis. There is no compelling rationale presented to support the medical necessity of Euflexxa injections for this patient. Therefore, right shoulder Euflexxa injections are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is 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.