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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient behavioral health treatment has requested reimbursement for inpatient behavioral health treatment. Findings:  The physician reviewer found that based on the clinical documentation provided, the inpatient behavioral health treatment provided was medically necessary for treatment of the patients medical condition. The patient remained symptomatic during the dates in question. The patient had unstable vital signs as evidenced by the documentation of elevated blood pressures and administration of as needed medication for hypertension.  In addition to the scheduled blood pressure medication, the patient received doses of as needed clonidine for hypertension. The patient was documented as having withdrawal symptoms and depressed and anxious mood. The patient received several doses of as needed lorazepam and one dose of as needed lorazepam for persistent withdrawal symptoms. The patient was documented by nursing staff as endorsing suicidal ideation with urges to self-harm.  The psychiatrist documented that the patient had depressed and anxious mood with poor grooming and endorsed urge to self-harm. The factors that support continued stay at the inpatient level of care in this patients case include documentation of active withdrawal symptoms, unstable vital signs, suicidal ideation, failure of prior treatment, and high risk of relapse as evidenced by admission in July followed by relapse upon discharge. The patients clinical status, in addition to current medical literature, support that the continued stay at the inpatient level of care was medically necessary for treatment of the patients medical condition. Final Result: The physician reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician 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: There is sufficient support for the services at issue in this clinical setting. The provided documentation indicates that, the patient remained symptomatic. The psychiatrist noted that the patient was depressed and irritable, cursing and negative towards staff and peers, not adequately attending to activities of daily living, stealing food and overeating. Due to the patients persistence of symptoms, her dose was increased to further target these symptoms. The patient was noted to be isolative and demonstrate oppositional behaviors similar to those that occurred prior to her admission.  The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP, 2014).  The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity.  These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services. Based on the patients clinical history provided and documentation as outlined above, the patient met CASII criteria for 24 hour psychiatric monitoring. The patients clinical status and current medical literature support the patients treatment at the residential level of care. Therefore, residential treatment center services were medically necessary for treatment of this patients medical condition. Fulfills requirements of (1374.33)(h)(1)(H) and (K)Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Fulfills requirement of 1374.33(h)(1)(I)
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that found the submitted documentation supports the medical necessity of the services at issue. This patient reported an early age of first use of alcohol. She self-medicated with alcohol, and her alcohol use was complicated by co-occurring depression and anxiety. The patients alcohol use and psychiatric symptoms were impairing her daily routine and contributing to significant impairment across multiple domains of functionality. She was drinking daily to the point of blackout. Finally, the patient had been treated at various levels of care over the years, but had been unable to maintain sobriety or harmonious euthymia in the outpatient setting. The treatment provided during the dates of service in dispute focused on aftercare planning and treatment consolidation with the application of complex pharmacotherapy and core elements of both cognitive and dialectical behavior therapies. In sum, the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards and facilitated transition to a less restrictive setting.  Additionally, the services at issue were reasonably expected to improve her condition and prevent a more serious episode of illness.  Therefore, partial hospitalization program services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for intensive outpatient program services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Per the records, this patient continued to need intensive outpatient program level of care in order to manage her impulsivity. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) is indispensable in determining necessary level of care for children. In terms of risk of harm, the records support a score of 2. The patient had a history of a suicidal ideation per the progress notes. With regards to functional status, the records support a score of 3. The patient had deterioration in her level of functioning in relationships as well as poor school performance. In terms of comorbidity, the records support a score of 1. The notes do not document substance use or medical problems. With regards to level of stress of the recovery environment, the records support a score of 3. The patient has severe issues with family relationships. In terms of level of support of the recovery environment, the records support a score of 2. The patients family actively participated in treatment. With regards to resiliency and treatment history, the records support a score of 3. The documentation noted recent progress in in the intensive outpatient program, but also noted repeated hospitalization directly prior to intensive outpatient program admission. With regards to acceptance and engagement of the patient, the records support a score of 2. In terms of acceptance and engagement of the parent, the records support a score of 2. Her parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 18. A score of 18 correlates with intensive outpatient program level of care. Therefore, the medical evidence supports the services at issue in this clinical setting. All told, intensive outpatient program services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne Gene Panel testing for evaluation of the enrollees B-cell lymphoma. Findings:  2/3 of the physician reviewers found that there is sufficient support for the services at issue in this clinical setting. B-cell lymphomas are a heterogeneous group, and the diagnosis can be difficult to obtain due to limited tissue samples. Molecular genetic testing of the tumor can often help identify the type of tumor and avoid a more invasive procedure as well as sometimes aid in the guidance of treatment decision-making. In this patients case, the services at issue helped identify the type of low grade B-cell lymphoma this patient had while avoiding a surgical procedure. Therefore, FoundationOne Gene Panel testing was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: 2/3 of the reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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: 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 all patients should be treated, regardless of fibrosis stage. In addition, this patient is noted to have cryoglobulinemia. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage.The ENDURANCE-1 trial showed that only eight weeks of treatment is needed .The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . these reasons, the requested treatment with Mavyret 100-40 mg, three tablets daily, for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne genomic analysis for evaluation of the enrollees synovial sarcoma. Findings:  2/3 of the physician reviewers found that the accessibility of this technology is directly affecting clinical practice because providers frequently encounter situations where cancers progress on standard therapies. At that juncture, usually the medical literature is consulted to select a therapy that has been tested in clinical protocols, or the patient is enrolled into an active protocol. This is the standard of care. Recently, it has become important to identify mutations that may be amenable to targeted therapy. A study by colleagues involved patients where the progression-free survival (PFS) on the regimen selected by molecular profiling was compared to the PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. FoundationOne has developed a panel of 400 oncogenes and tumor suppressors to be tested by next generation sequencing in hematologic malignancies and sarcomas. There is support in the medical literature for the use of genetic testing to identify mutations that may be amenable to targeted therapies. In sum, FoundationOne genomic analysis was likely to have been of greater benefit for the evaluation of this patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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 Zepatier for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 reimbursement for wearable cardioverter defibrillator for treatment of the enrollees dilated cardiomyopathy. Findings:  The 3 physician reviewers found that the physician reviewers found the documented high risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter defibrillators in this group of patients. Current data from multiple trials and registries have advocated the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction. In this patients case, the records documented an ejection fraction of 35 to 40%. Given the absence of significant coronary artery obstructive disease, this was considered a non-ischemic cardiomyopathy. The patient was also noted to have a significant amount of ventricular ectopic activity on telemetry monitoring. Current guidelines recommend against placement of implantable cardioverter defibrillators within 40 days of an acute myocardial infarction, or within 90 days of an initial diagnosis of congestive heart failure with a low ejection fraction, as in this case. Therefore, the placement of the was appropriate given the patients diagnosis of severe left ventricular dysfunction with its associated high risk for sudden cardiac death. Thus, the wearable cardioverter defibrillator was likely to have been more effective than other available treatment modalities. Final Result: The 3 reviewers determined that the device at issue was 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for buprenorphine HCL 2 mg (120 tablets in a 30-day period). The Health Plan has denied this request indicating that the medication at issue was not medically necessary. The buprenorphine HCL 2 mg (120 tablets in a 30-day period) provided was medically necessary for treatment of the patients medical condition. There is sufficient medical literature supporting the medication at issue in this clinical setting. A study concludes that buprenorphine is efficacious in detoxifying patient from opiates. In addition, another study found similar efficacy. In this case, the notes indicate the treatment plan is for detoxification using buprenorphine. The medication quantity as recommended by the patients provider will allow for a gradual weaning off opiates. Therefore, the medication at issue has been established as medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the medication at issue was 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 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.