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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services provided during a colonoscopy procedure. The Health Plan has denied this request indicating that the services at issue were not medically necessary for management of the enrollees pain during her colonoscopy. Findings: The documentation provided does not support the medical necessity of the services at issue in this clinical setting. The American Society of Anesthesiology (ASA) provides a preoperative physical status classification scoring system. In this case, the patients ASA preoperative physical status score was 2, which indicates a non-anesthesiologist or a non-certified registered nurse anesthetist could have provided intravenous sedation during the colonoscopy. Intravenous sedation performed by a non-anesthesiologist or non-certified registered nurse anesthetist is well supported in both clinical practice and in the research. Furthermore, it was noted that this patient had a successful colonoscopy performed in 2008 with intravenous sedation. The records did not indicate a failure of intravenous sedation with back pain. Given a low preoperative physical status classification score of 2 as well as a history of successful prior intravenous sedation, the anesthesia services provided during a colonoscopy procedure were not medically necessary for management of this patients medical condition.Final Result: The reviewer determined that the anesthesia services at issue were not medically necessary during the patients colonoscopy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology 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 a computed tomography (CT) of the heart. Findings:  Three physician reviewers found the current medical evidence does not support the services at issue in this clinical setting. The patient was asymptomatic with increased coronary risk and coronary calcification already being treated with high dose statin medication. In this circumstance, current guidelines do not consider screening coronary CT scanning appropriate. Specifically, therapy that already consists of high dose statin medication would not change regardless of test results. Therefore, CT of the heart 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 internal medicine with sub-specialty certification in cardiovascular disease 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 authorization and coverage for varicose vein sclerotherapy. Findings:  Two of the three physician reviewers found the documentation does not support the superior efficacy of the requested services.  This patient has undergone a fairly extensive interventional procedure that included embolization of numerous pelvic veins. However, the records do not document a follow-up evaluation. No follow-up study was provided with respect to the venous system, and there was no assessment of arterial perfusion in a patient with leg symptoms despite venous interventions. There is no documentation of ongoing activity limiting symptoms. All told, the requested varicose vein sclerotherapy is not likely to be more efficacious than other available treatment options. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in vascular 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computerized axial tomography (CAT) scan of the heart. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of serum cholesterol borderline.Findings:  Based on the records provided the patient is asymptomatic with increased coronary risk due to hyperlipidemia and a strong positive family history. In this circumstance, current guidelines for the evaluation and management of hyperlipidemia are available. These guidelines do not recommend routine screening with coronary CAT scanning.  Specifically for this patient, his 10 year risk for developing coronary disease is less than 7.5%. This patient has a risk score of 6.3% such that a statin medication would be recommended, regardless of the results from a coronary calcium scanning. For these reasons, CAT scan of the heart was not likely to have been more effective than the available standard methods of evaluating this patients medical condition. Final Result: All 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 cardiovascular disease 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program services. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 3. The patient has chronic passive suicidal ideation. She did not have any intent or plans to act on her suicidal thoughts. She has a history of self-injurious behavior. With regards to functional status, the records support a score of 2. The patient was making improvements in her functionality. She was attending her activities of daily living. In terms of comorbidity, the records support a score of 3. The patient has a comorbidity of anorexia nervosa. The patient did not have any orthostatic hypotension or other medical problems that required intensive monitoring. The patient continued to struggle with her body image. However, the patient was cooperating with treatment and had an ideal body weight ranging from 91-93% around the dates in question. With regards to environmental stress of the recovery environment, the records support a score 3. The patient continues to have interpersonal conflicts with her parents. In terms of environmental support, the records support a score of 2. The patients parents are supportive of the patient. With regards to resiliency, the records support a score of 2. The documentation reports that the patient made improvements. She was participating in treatment and was cooperative with staff. With regards to acceptance and engagement, the records support a score of 2. The patient was able to develop positive therapeutic relationships with clinicians. She was cooperative with treatment. Thus, the records support a composite score of 17. Based on these criteria, the patient meets criteria for intensive outpatient program level of care. The patient continued to need treatment for her anorexia nervosa and emotional dysregulation, but this could have been done in a less restrictive environment. Therefore, partial hospitalization program services were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that 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 expertise 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 authorization and coverage for intensive outpatient program (IOP) psychiatric level of care services. Applying the level of care utilization system (LOCUS) criteria, treatment with IOP level of care services are supported as medically necessary for treatment of this patients behavioral health issues. The records document the patient was at low risk of harm (score 2) with no prior history of suicide attempts, intermittent suicidal ideation with no plan. The patients functional status was moderately impaired (score 3) as the enrollee can only work for a limited time before becoming overwhelmed. The enrollee lives with parents and remains financially and emotionally dependent on them. The enrollee is able to maintain activities of daily living. The patient demonstrates significant co-morbidity (score 3) with major depressive disorder, generalized anxiety disorder, and an eating disorder. The enrollee does not have medical problems which require intense monitoring. The patients recovery environment is moderately stressful (score 3) as the documentation states that the patient has significant discord with family members. The patient has limited support (score 3) as providers noted that the family dynamic is not supportive of the enrollees recovery. The patient has not been responsive to prior treatment including residential treatment center (RTC), PHP and IOP in 2014 and 2015 (score 3). The patient has demonstrated positive engagement and recovery (score 2) and providers report that the enrollee has been attentive and engaged during treatment. These findings give the patient a composite score of 19, which is consistent with continued IOP treatment. The patient continues to struggle with depression, calorie restriction, family dynamic problems, and emotional dysregulation. Continued IOP will likely prevent the patient from utilizing higher levels of care. Therefore, the requested IOP services are medically necessary for treatment of this patients behavioral health issues.  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: An enrollee has requested authorization and coverage for brand name Topamax 50 mg. Topiramate is a U.S. Food and Drug Administration (FDA) approved antiepileptic drug proven to reduce the frequency of seizures, migraine headache prophylaxis, and with phentermine for weight management. Topiramate has also been utilized in patients for mood, schizophrenia, psychotropic-associated weight gain, alcoholism and eating disorders. FDA bioequivalence testing ensures that the generic product performs the same as its respective brand name product. For some patients, a particular compound associated with a specific brand name medication or generic preparation is indicated. However, this patients records do not include adequate medical records with clinic progress notes documenting the patients longitudinal illness burden, relevant psychosocial stressors, and response to medication trials. All told, the requested brand name Topamax 50 mg is not supported as medically necessary for treatment of this 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for spine surgery on the neck (insertion of artificial intervertebral disc). The Health Plan has denied this request indicating that the requested surgery is considered investigational for treatment of the enrollees neck pain. Findings:  Cervical disc replacement is an accepted alternative to a one level anterior cervical discectomy and fusion for single level cervical disease. The literature has adequate support for the use of cervical disc replacement in the cervical spine at one level. However, in this patients case, the recommended procedure involves the use of a hybrid or multilevel cervical disc procedure. Currently, a review of the peer-reviewed medical literature demonstrates the use of hybrid cervical fusion/arthroplasty remains unproven. There is insufficient evidence to permit conclusions on the net health outcomes of this procedure, in the absence of well-designed and executed randomized controlled trials with adequate follow-up. All told, the requested spine surgery on the neck (insertion of artificial intervertebral disc) is not likely to be more efficacious than the available standard modalities of treating this patients medical condition.Final Result: Two of the three reviewers determined that 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc-One injection to the left knee. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.Findings: Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. If there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to administer another series. There is no maximum amount of injections established by high quality scientific evidence. However, while medial and/or lateral compartment osteoarthritis is a recommended indication, there is insufficient evidence for other conditions including patellofemoral osteoarthritis, chondromalacia patella, patellofemoral syndrome (kneecap pain), or osteochondritis dissecans. Peer reviewed literature supports the use of hyaluronic acid injections for chronic moderate symptomatic osteoarthritis of the knee but states that application in sports related chondropathy has yet to be fully assessed. The ideal indication in the knee seems to be moderate femorotibial osteoarthritis without swelling.This patient presents with a history of left knee patellofemoral osteoarthritis. Clinical examination findings have been consistent imaging findings of patellofemoral degenerative joint disease. She reported improvement with prior Synvisc-One injection with functional improvement in work ability. However, as detailed above, evidence based medical guidelines and literature do not support the use of Synvisc-One injections for patellofemoral osteoarthritis, or for mild femorotibial osteoarthritis. Therefore, in this patients case, Synvisc-One injection in the left knee has not been established as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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 authorization and coverage for weekly allergy/immunotherapy injection. Findings: The physician reviewer found that Allergy shots are indicated for persistent symptoms on a seasonal and/or perennial basis and those with an inadequate or partial response to environmental control and medications.  Both national allergy organizations recommend skin testing and allergy shots as an effective treatment for allergic rhinitis, asthma and atopic dermatitis.  Studies have shown that allergy shots over medications for the treatment of allergic rhinitis and asthma have been effective.  However, in this case, the patients medical records fail to demonstrate signs and symptoms consistent with allergic rhinitis. Additionally, the records fail to demonstrate failure of primary therapy, which includes avoidance as well as medications.  The records appear to be requesting injections for buildup and maintenance therapy. It is unclear from the records why the patient would continue to require weekly shots once on maintenance and would not be able to space out injections as recommended in the national guidelines. According to the guidelines, weekly allergen/immunotherapy would not be recommended in this patients case. As such, the medical necessity for weekly allergy/immunotherapy injection has not been demonstrated for treatment of this patients medical condition. Final Result: The reviewer determined that requested medication quantity is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in allergy and immunology 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 gel injections. Findings: The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. The patient has clinical and radiographic evidence of osteoarthritis of both knees with failed treatment with NSAIDs and corticosteroid injections. Treatment algorithm recommends intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of NSAIDs. This recommendation is based upon accumulating evidence that intraarticular hyaluronic acid provides a significant benefit in knee osteoarthritis. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis. Additionally, the evidence also shows that the benefits from these injections are long lasting when compared with intraarticular corticosteroids. The current evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis where improvement with knee pain and function persisted for up to 26 weeks. Therefore, gel injections for treatment of this patients bilateral knee pain has been established as medically necessary. 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.