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

Nature of Statutory Criteria/Case Summary: The parent of a 12-year-old male enrollee has requested authorization and coverage for a Nutropin AQ Nuspin for treatment of the enrollees medical condition. Findings:  The physician reviewer found that Based on the records provided for review, this patients presentation is not consistent with idiopathic short stature. A bone age reading of 14 years does not correspond to the described physical examination. The patients bone age was reported as markedly advanced versus his chronological age, despite a physical examination that documents early pubertal development. Using a reading of 14 years, the adult predicted height is 65.5 inches compared to the genetic target of 69.5 inches, which is statistically normal for the patients predicted range of +/- 4 inches. In addition, the patients IGF-1 was 238, which is -0.3 standard deviations for age and gender. Given these findings, GH therapy is not indicated and is not likely to be effective. From the available data, this patient has exogenous obesity, but not idiopathic short stature. Thus, the requested Nutropin AQ Nuspin is not 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 magnetic esophageal sphincter augmentation. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease.Findings There is a lack of randomized controlled trials with long term follow up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. One best evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. Another evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. There are 29 reports of LINX erosion through the esophagus in the publicly accessible U.S. Food and Drug Administration Adverse Events database, among other adverse events. The currently available peer reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial than standard treatment in this clinical setting. For these reasons, LINX Reflux Management System is not likely to be of greater benefit for the treatment of this patients GERD symptoms than any available standard therapy.Final Result: Two of the three reviewers determined 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 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: A patient has requested reimbursement and prospective authorization and coverage for additional theta-burst transcranial magnetic stimulation (TMS) services rendered from April 2017 forward. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the patients major depressive disorder (MDD). The submitted documentation does not support the medical necessity of the services at issue. The patient received 47 sessions of transcranial magnetic stimulation (TMS) from January 2017 through March 2017. The patient had a good response to the TMS treatment, and the patients PHQ-9 scores dropped from 20 to five. The patient received an additional 20 sessions of TMS from April 2017 through June 2017. After April 2017, the patients PHQ-9 scores were five and below with one exception on April 12, 2017 of a PHQ-9 score of a six. The patients depression after April 2017 was either in remission or he was having mild depressive symptoms. It appears that the TMS treatments from April 2017 through June 2017 were used as maintenance sessions for the patients depression. There is ongoing research into the study of maintenance TMS for depression. However, maintenance TMS treatment for depression is still being researched and further studies are needed to determine efficacy. Therefore, it is not currently standard of practice to continue to administer TMS treatment after a significant response to treatment. Thus, additional theta-burst transcranial magnetic stimulation (TMS) services rendered from April 2017 forward were not and are not medically necessary for the treatment this patient.Final Result: The reviewer determined that the services at issue were not and are not services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 onabotulinumtoxinA. There is sufficient support for the requested medication in this clinical setting. The records document a history of hyperhidrosis affecting the palms and right axilla. The patient has tried and failed treatment with aluminum chloride solution. The requested medication is likely to benefit the patients hyperhidrosis affecting the axilla. The medical evidence supports the requested medication in this patients case. Thus, onabotulinumtoxinA is medically necessary 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 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: The parent of a 10-year-old female enrollee has requested authorization and coverage for speech therapy. The requested weekly speech therapy sessions are not supported as medically necessary for the treatment of this patients speech delay as a result of her intellectual disability and microcephaly. The provider describes that her scores on standard testing have been unchanged over three evaluations at two year intervals, and that the patients rate of progress is consistent with her natural maturation. The patient has reached a plateau, thus the Health Plans recommendation for the patient to receive speech therapy for two sessions per month for the next six months, for diagnostic therapy, parent training and institution of a home program is appropriate. For these reasons, the requested speech therapy is not medically necessary for 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 pediatrics and neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for 2,000 punch hair graft. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients hair loss and are not reconstructive in nature. This patient has well-documented scar alopecia on the right side of the head, as a result of prior tissue transplant from the right temporal region of the scalp to relocate the tissue for penile reconstruction. This a complication of a medically necessary procedure. Therefore, reasonable intervention to correct this complication is medically necessary. However, the provider recommended a procedure for bilateral temple grafts (800 to 1,000 per side). A bilateral procedure is not consistent with the patients statement and previous documentation that specifically noted one-sided scarring/alopecia. Therefore, one side should be considered medically necessary, which includes 800 to 1,000 grafts. Specifically, hair graft to the right temple is medically necessary. Based on the records provided, the patients scar alopecia constitutes an abnormal presentation of the scalp. This abnormal condition is the result of the patients prior penile reconstruction for the treatment of Peyronies disease. The requested services are not likely to improve function, as there is no documentation of a functional impairment. However, the patient has an abnormal appearance of the right temporal scalp. Based on the photographs, a portion of the requested services is likely to provide more than a minimal improvement in appearance. In sum, a portion of the requested 2000 punch hair graft is reconstructive in nature. Specifically, hair graft to the right temple is reconstructive in nature. Final Result: The reviewer determined that the requested services is medically necessary and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha SureClick 140 mg/mL. Based on the records provided, the patient has hyperlipidemia with an LDL that remains above a goal of less than 70 mg/dL despite high dose atorvastatin and ezetimibe.  Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria. In this setting, there are several randomized prospective trials that demonstrate safety with adding PCSK9 inhibitors, significant additional reduction in LDL cholesterol and improved clinical outcomes. Therefore, the requested medication is medically necessary 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 internal medicine with sub-specialty certification in cardiovascular disease 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 magnetic resonance imaging (MRI) of the upper and lower extremities. The submitted documentation fails to support the medical necessity of the requested services. The only reason to obtain any imaging study is if it will change the medical management. In this case, the requested services are not likely to change medical management. There is no indication that the patient is being assessed for surgery. Even if the patient has a rotator cuff tear, the immediate management will still be rest, intensive physical therapy and nonsteroidal anti-inflammatory medications. Additionally, the submitted records do not support MRI for evaluation of the patients reported ankle pain. The medical evidence does not support the requested services in this clinical setting. Therefore, the requested MRI of the upper and lower extremities is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 reimbursement and prospective authorization and coverage for residential treatment center services provided on 6/10/18 forward. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation does not support the medical necessity of the services at issue. The patient presented to the residential treatment center with a history of substance use, which was mainly marijuana. The records noted that during treatment, the patient was cooperative, calm, and insightful into the patients psychological needs. The progress notes did not indicate that the patient had psychosis, paranoia or mania symptoms. The records did not indicate other severe psychiatric symptoms that would require intensive psychiatric care. The patient did not express suicidal ideation or severe mood lability during the disputed dates of service. The patient did not have self-harm behaviors and was medically stable. The medical record did not indicate the presence of any withdrawal symptoms. The American Society of Addition Medicine criteria for level of placement can be applied to this patients presentation to help determine the appropriate level of care. With regards to acute intoxication and/or withdrawal potential, the patient has a risk rating score of zero due to lack of withdrawal. In terms of biomedical condition and complications, the patient has a risk rating score of 0-1 due to no active serious medical problems. With regards to emotional/behavioral or cognitive conditions and complications, the patient has a risk rating score of 0-1 indicating some mild issues that were noted to be under good control with medications. In terms of readiness to change, the patient has a risk rating of 2 due to low motivation to change with some interest in continued treatment.  With regards to relapse, continued use, or continued problem potential, the patient has a risk rating of 2 due to minimal sobriety. With regards to recovery/ living environment, the patient has a risk rating of 1-2 due to no mentioned sober living environment. Overall, the patients presentation suggests risk-rating scores that range from 0 to 2. This overall risk rating is consistent with intensive outpatient services. In summary, residential treatment center services provided on 6/10/18 forward were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested   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 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 residential treatment center services. The progress notes indicate that the treatment team had recommended a partial hospital program in early June 2018. Since this recommendation, the patient had a serious overdose. The patient has a history of nonadherence to treatment and has tried other levels of care according to the records. Due to the patients apparent recent suicide attempt, outpatient or partial hospital program treatment levels of care are not likely to be safe or effective.The American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining necessary level of care for adults. In terms of risk of harm, the records support a score of 4 due to her recent suicide attempt. With regards to functional status, the records support a score of 4 due to poor overall daily function. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 1 due to overall medical stability and no substance abuse issues. With regards to level of stress of the recovery environment, the records support a score of 3 due to family discord. In terms of level of support of the recovery environment, the records support a score of 2 due to family support. In terms of treatment and recovery history, the records support a score of 5 due to minimal past treatment response. In terms of engagement and recovery status, the records support a score of 4 due to inaccurate symptom reporting in treatment and associated poor insight. Thus, the patient has a composite score of 23. This score correlates with residential treatment. Therefore, the requested residential treatment center services are 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 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 right ring finger and middle finger trigger release and right partial palmar fasciectomy. This patient presents with a history of hand pain following a hyperextension injury of the right ring and middle fingers. She reports difficulty using her hand. Her past medical history is positive for type 1 diabetes. There is intact function of all distal flexors and extensors. There were no median or ulnar nerve compression findings or sensory deficits. A recent right hand MRI documented a thin rim of peritendinous edema surrounding the flexor tendons of the index, middle, and ring fingers without tendon sheath effusion. Conservative treatment had included splinting, Tylenol, and nonsteroidal anti-inflammatory drugs, with mild improvement. She had a corticosteroid injection for possible ring and middle trigger fingers, with temporary relief followed by worsening. Hand therapy has been recommended, but not completed. She has undergone multiple consultations, with no surgical treatment recommendations. She underwent an out-of-network provider who recommended middle and ring trigger finger release surgery and partial palmar fasciectomy. There is no current evidence of active triggering or contracture in the right middle and ring fingers to support the medical necessity of trigger finger release surgery. There is no documentation of significant Dupuytrens contracture to support the medical necessity of partial palmar fasciectomy at this time. Therefore, the requested right ring finger and middle finger trigger release and right partial palmar fasciectomy are not medically necessary for treatment of the 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.