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

Nature of Statutory Criteria/Case Summary: At issue in this case is whether all or any of the residential treatment center services that were received were medically necessary to treat the patients medical condition. The patient was admitted to RTC services admitted to the residential treatment center (RTC) approximately one-year prior for diagnoses that included anxiety, gender dysphoria, attention deficit hyperactivity disorder, and dysthymia.Applying the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS), providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System to help determine the appropriate level of care. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patients presentation a composite score of 16 correlating with a lower intensity level of care than RTC.Final Result: The reviewer determined that the requested services 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  The three physician reviewers found that The prothrombin G20210A mutation has been associated with thrombosis and adverse pregnancy outcomes. One such adverse pregnancy outcome is recurrent early pregnancy loss. While meta-analyses and a retrospective cohort study have revealed an association between inherited thrombophilia's and first-trimester pregnancy loss, prospective cohort studies have found no association between inherited thrombophilias and fetal loss. Moreover, methylenetetrahydrofolate reductase (MTHFR) mutations have not been found to convey an increased risk for venous thromboembolism or pregnancy complications. As such, genetic testing was not indicated for further evaluation of this patients medical condition. Given these findings, the genetic tests were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found genetic tests were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that genetic tests 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 reviewer 1 is board certified in obstetrics and gynecology and are actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology with subspecialty certification in maternal and fetal medicine and are actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology 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 magnetic resonance imaging (MRI) of the neck without dye. Findings:  The physician reviewer found that conventional radiographs are the first step in the evaluation of neck pain, particularly to diagnose degenerative disease, post-surgical complications, spinal stenosis or malalignment. After radiographs are obtained, a subset of patients may benefit from further imaging utilizing MRI or computed tomography (CT). According to the American College of Radiology appropriateness criteria for the evaluation of chronic cervical or neck pain with degenerative changes seen on initial radiographs, MRI is usually appropriate for further evaluation. MRI is the optimal examination for the evaluation of intervertebral discs, facet arthropathy, nerve root compression and spinal stenosis. It can also demonstrate abnormalities present within the spinal cord, which may be the cause of neck pain. These findings may not be visualized on initial radiographs and could alter the patients management. In this case, in the setting of chronic neck pain which persists despite conservative treatment, MRI is indicated for further evaluation. Therefore, MRI of the neck without dye (CPT 72141) is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.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: An enrollee has requested authorization and coverage for Norco. Norco is an opiate pain medication which is usually prescribed for postoperative pain control, chronic malignant and non-malignant pain and cancer pain. This medication is highly addictive. This patient has had multiple diagnostic studies which were negative for abdominal pathology. Opiates also cause constipation which can result in abdominal pain and discomfort. At this point, it is medically appropriate that the patient be weaned off opiates and be placed on alternative pain medications until her diagnosis is clear. The records indicate that she is awaiting a third opinion consultation with a provider who specializes in gastroenterology. The medical evidence does not support the requested medication in this clinical setting. Therefore, Norco is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: The patients parent has requested authorization and coverage for in-home nursing services up to 12 hours per day. Home health care aims to provide patients with chronic conditions comprehensive health care within a nurturing home environment. Providers are tasked with maximizing the capabilities of the patient and minimizing the effects of the disabilities. Children with special needs frequently require equipment at home to allow for safe and effective care. Such equipment may facilitate feeding and eating, toileting, bathing, safe sleeping, and mobility, as well as opportunities to achieve functional skills. This patient has a number of skilled nursing needs as a result of her congenital anomalies. She requires 24-hour care due to her inability to protect her airway and severe feeding problems. She currently receives all nutrition via the gastrostomy tube due to an inability to tolerate small amounts of formula. She requires intermittent feedings during the day with a feeding pump and continuous feedings at night. She is at risk for aspiration because of poor airway clearance, pooling of secretions, and gastroesophageal reflux. She is also at risk for skin breakdown secondary to atopic dermatitis, requiring meticulous skin care. The patients family has been trained in her care. However, requiring the patients family to provide her care 24-hours per day without skilled nursing assistance would place the patient at risk for complications. Given these findings, the requested in-home nursing services up to 12 hours per day, are medically necessary and appropriate 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 subspecialty certification in pediatric critical care 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: At issue is whether transoral incisionless fundoplication (TIF) with Esophy-X device is likely to be more beneficial for treatment of the patients condition than any available standard therapy. A review of the records indicates the patient was evaluated for a diagnosis of acid reflux. On this date, the provider documented that the patient has acid reflux and a Hill Grade 2 valve.Findings:  Three physician reviewers found that the 2013 American College of Gastroenterology guidelines for the treatment of gastroesophageal reflux disease (GERD) reported that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy. A study finds that in a meta-analysis of five randomized trials and 13 prospective studies, proton pump inhibitor use after TIF increased over time, and the satisfaction rate was only approximately 70%. There is a lack of large volume, long-term, peer-reviewed outcome studies to support the use of this procedure for this patient.Final Result: The reviewers determined that the requested procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: 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:  The patient has requested authorization and coverage for Intravenous Immunoglobulin (IVIG) Administration at an Outpatient Hospital Infusion Center. She has Stage 3 Chronic Lymphocytic Leukemia (CLL) and is enrolled in a clinical trial for the CLL using ibrutinib and venetoclax. Oncology notes indicate she is immunosuppressed.  She has also been getting IVIG infusions and has had infusion reactions with skin infections. After the first IVIG transfusion, she developed pneumonia and then olecranon bursitis with Pseudomonas infection.  She had been receiving the IVIG at an infusion center. However, the health plan denied coverage indicating that she needed to have home infusion services. Her physician indicates the patient has had several issues that were handled in the infusion center and home health infusion is not recommended for this patient. As per the medical literature, some adverse events can occur during the infusion or a few days afterwards; these represent approximately 40 percent of all adverse reactions to IVIG and include thromboembolic events or complications affecting the central nervous system, kidney, or blood cells. A home infusion and home injectable therapy would not be appropriate given the patients prior reactions to the IVIG. This patient has unique circumstances including Chronic Lymphocytic Leukemia. The patient had a prior reaction, which would increase the likelihood that she would have future reactions. Any reaction may produce dire consequences due to her complex medical history and current clinical situation. The patient needs close monitoring and observation. Thus, the outpatient hospital infusion center is appropriate. Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the patients condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in Hematology and Oncology and is actively practicing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nivolumab (Opdivo). Nivolumab (Opdivo) has been approved by the U.S. Food and Drug Administration for adjuvant treatment of melanoma with involvement of lymph nodes or metastatic disease following complete resection. The National Comprehensive Cancer Network guidelines do not mention the use of nivolumab for the treatment of multiple recurrent melanoma in situ or epidermotropic metastatic malignant melanoma. Epidermotropic metastatic malignant melanoma is a rare disorder in which cutaneous metastatic melanoma usually involves the dermis and/or subcutaneous fat, although atypical melanocytes might be observed more superficially, within the epidermis and upper part of the dermis. Although this patients lesion was an invasive melanoma, her recurrences have been in situ disease. The treatment for this is unclear given the rarity of the disorder. One may consider treating this as in-transit metastases, and per the National Comprehensive Cancer Network guidelines, the choice of therapy depends on the patients health status and tumor burden, defined by the size, location, and number of tumor deposits. Since the tempo of spread of in-transit disease is not always known at presentation, it is reasonable to start with conservative local therapies and move to regional/systemic therapy if response to local therapy is short-lived. There is a lack of data supporting the use of immunotherapy in this clinical setting. Therefore, nivolumab (Opdivo) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for anterior cervical discectomy and fusion (ACDF) from C4-7 and post-surgery bone growth stimulator therapy. Findings:  The physician reviewer found that this patient is noted to have cervical radiculopathy, but there are no dermatomal symptoms or findings consistent with cervical radiculopathy. She has no evidence of a cervical myelopathy. The records do not include documentation of failed conservative care including therapeutic doses of non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, home exercise program, and acupuncture. Moreover, other reasonable causes of pain have not been ruled out, since she has not had an examination of her shoulder, vascular, Tinels, or axillae. The patient underwent one medial branch block, but no epidural steroid injection (ESI), or other injections have been performed. The current standard requires findings of cervical radiculopathy with progressive neurological deficit, failure of six weeks of conservative management, and evidence of nerve root compression with correlating clinical examination. These criteria are not met in this patients case. Further, there is no evidence of cervical myelopathy, instability, kyphosis, pseudoarthrosis or deformity. Therefore, the requested ACDF from C4-7, and post-surgery bone growth stimulator therapy are not medically necessary for treatment of this patients neck pain. 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 neurological 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: The parent of an enrollee has requested authorization and coverage for 39 hours per week of 1:1 applied behavior analysis (ABA) for six months and eight hours per month of clinical team meetings for six months. The submitted documentation supports the medical necessity of the requested services in this patients case. ABA is the most evidence-based treatment for autism, for both children and adults. Further, the Behavior Analyst Certification Board highlights that treatment intensity and duration is dependent on the patients severity of symptoms and number of goals identified with an emphasis on closing the deficits displayed by the patient and same-aged peers. This patients Vineland scores are two or more standard deviations below the average scores of her same-aged peers. This indicates that the patient is performing significantly below her current age equivalent. The patients provider has outlined 38 goals across a variety of domains, including behavior reduction, safety, communication and daily living. Given the request for 39 hours of 1:1 ABA per week, this equates to working on each goal for approximately one hour each week. Although the patient has displayed a reduction in problem behavior, she is still engaging in a significant level of tantrum behavior. It is important that this behavior continue to be decreased to further close the gap between her performance and the performance of her same-aged peers. Therefore, 39 hours per week of 1:1 ABA for six months and eight hours per month of clinical team meetings for six months 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 a licensed B.C.B.A, board certified in psychology, 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 male who has a lifelong history of an inability to belch. Findings:  The physician reviewer found that he underwent videoendoscopy and was diagnosed with retrograde cricopharyngeus dysfunction. He was treated successfully with an injection of botulinum toxin into the cricopharyngeus muscle . Progress notes reported that the patient underwent one Botox injection, 50 units, and was able to burp for about one month.  progress notes indicated that extensive gastrointestinal (GI) work-up, including esophagogastroduodenoscopy (EGD) and manometry, were negative. The patient has requested authorization and coverage for esophagoscopy and injection of cricopharyngeus muscle with 50-75 units of botulinum toxin. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether the requested esophagoscopy and injection of cricopharyngeus muscle with 50-75 units of botulinum toxin is medically necessary for treatment of this patients medical condition.Upper esophageal sphincter (UES) and cricopharyngeus function is complex and dynamic. Treatment of UES dysfunction with botulinum toxin (Botox) injection into the cricopharyngeus muscle has been shown to be safe and effective. Botox is an exotoxin produced from Clostridium botulinum that blocks the release of acetylcholine from the cholinergic nerve end plates, resulting in inactivity of the muscles or glands innervated. The efficacy of Botox in facial aesthetics is well established. Likewise, Botox has been utilized in multiple non-cosmetic medical and surgical conditions. In this case, the patient has an inability to burp and has been treated successfully with Botox in the past. Injection of Botox into the cricopharyngeus muscle has been shown to be effective for different symptoms. Therefore, the requested esophagoscopy and injection of cricopharyngeus muscle with 50-75 units of botulinum toxin are medically necessary for the 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 otolaryngology 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 enrollee has a history of hypertension.  She has been taking generic losartan but became concerned about contamination and is therefore requesting brand-name Cozaar.Final Result: The reviewer determined that the medication at issue is medically necessary for treatment of the patients condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in Cardiovascular Disease and is actively practicing.