Persius/hicric huggingface dataset:
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 40 hours per week of one-on-one applied behavioral analysis (ABA) therapy for six months, nine hours per month of caregiver training for six months, 16 hours per month of supervision for six months and eight hours per month to conduct clinical team meetings for six months for treatment of the autism spectrum disorder. Findings: The physician reviewer found that based on the clinical documentation submitted for review, 40 hours per week of one-on-one ABA therapy for six months, nine hours per month of caregiver training for six months, 16 hours per month of supervision for six months and eight hours per month to conduct clinical team meetings for six months is medically necessary for treatment of the patients autism spectrum disorder. Children and adolescents with autism spectrum disorders have a high rate of irritability and aggressive symptoms (Robb). Matson and colleagues note that because of the increased physical size of older children and longer history of problems, treating these behaviors effectively is important. In addition, severe problem behaviors such as aggression, self-injury, and property destruction can result in injury, and that behavioral interventions can significantly reduce such behaviors. In this case, the patient continues to have several behaviors that pose a danger to self and others, including aggression, self-injury, property destruction and elopement. While there has overall been a documented improvement in behavior, several behaviors still warrant a comprehensive level of support. Although the patients tantrums have decreased in frequency, this behavior has increased in duration. As such, the requested services have been established as medically necessary for treatment of the 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing for evaluation of the enrollees melanoma. Findings:  The 3 physician reviewers found that the physician reviewer found there is a lack of support for the services at issue in this patients case. In this clinical setting, the standard of care is wide excision to obtain clear tumor margins. Long-term follow-up would include annual skin examinations, history and physical examination every six to twelve months for five years, then annually as clinically indicated, as well as imaging as indicated to investigate specific signs or symptoms. The National Comprehensive Cancer Network guidelines state that routine/baseline testing of primary melanomas is not recommended before or after sentinel node biopsy outside of a clinical study. The DecisionDx-Melanoma test does not have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. All told, genetic testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 3 reviewers determined that the 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prometheus Anser ADA diagnostic testing. Findings:  Three physician reviewers found that there is insufficient medical evidence to support the effectiveness of Prometheus Anser ADA diagnostic testing compared with conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. It is possible that active disease results in low adalimumab levels due to loss of adalimumab, rather than low adalimumab levels resulting in loss of disease control. Additionally, controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management.  For these reasons, the superior effectiveness of Prometheus Anser ADA diagnostic testing performed has not been established. Final Result: 3 of 3 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for the inpatient hospital stay for treatment of the enrollees chest pain. Findings:  The physician reviewer found that the evaluation of chest pain has been the subject of much study. Most centers now follow the use of the chest pain center as a method for evaluating patients in the outpatient or observation status and inpatient admission is reserved for true acute coronary syndrome or myocardial infarction in patients with positive troponin enzymes. In addition, noted that many emergency department presentations for chest pain with low risk features may be deferred for cardiac testing and safely followed up on an outpatient basis without cardiac testing. This patient presented with chest pain and negative troponin results. Thus, the patient could have been managed as an outpatient or with observation through a chest pain unit or similar procedure without inpatient admission. All told, the inpatient hospital stay services provided were not medically necessary for evaluation and treatment of this patients medical condition. Final Result: The reviewer determined that the 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 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:The patients parent has requested authorization and coverage for Norditropin FlexPro 15 mg/1.5 mL pen injector for treatment of the enrollees short stature. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patient is receiving growth hormone therapy for short stature. However, the records do not demonstrate that she is growth hormone deficient. There is no information on current height, past height and weight trajectory, or predicted adult height prior to treatment. There is no current bone age assessment to document that epiphyses remain open. The records do not document that all other causes of short stature were ruled out prior to initiation of growth hormone therapy. The current medical evidence does not support the requested medication in this clinical setting. All told, Norditropin FlexPro 15 mg/1.5 mL pen injector 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the computed tomography (CT) angiography (CPT 75574). Findings:  The physician reviewer found that as noted by the American College of Cardiology Foundation (ACCF), coronary CTA with contrast is often used to evaluate possible anomalous coronary arteries. Studies found that cardiac CTA provides excellent spatial and temporal resolution, allowing accurate anatomical assessment of these anomalies. Moreover, if the contrast coronary CTA was not done, another study such as a cardiac catheterization would have been indicated. Given this support, the CTA (CPT 75574) performed was medically necessary for further evaluation of this patients medical condition. Final Result: The reviewer determined that the diagnostic procedure at issue was 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 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 authorization and coverage for acupuncture services for treatment of the enrollees low back pain. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation supports the medical necessity of the requested services. This patient presented with chronic lower back pain, severe in intensity and not responsive to other treatment modalities such as physical therapy and medication. She underwent acupuncture in the past for the same condition, with significant pain reduction. The medical literature supports the requested services in this clinical setting. Colleagues noted the effectiveness of acupuncture, either verum or sham, was almost twice that of conventional therapy. Colleagues noted acupuncture effectively relieves chronic low back pain. All told, the requested acupuncture is medically necessary for the treatment of this patient. 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.  The reviewer is board certified in oriental 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for percutaneous tibial nerve stimulation (PTNS) treatments for treatment of the enrollees overactive bladder. Findings:  2/3 of the physician reviewers found that the PTNS treatments in dispute were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. PTNS is considered to be an appropriate salvage therapy for patient with intractable irritative lower urinary tract symptoms including urgency and incomplete emptying. According to the documentation submitted for review, the patient is symptomatic with overactive bladder symptoms including urgency. The patient has failed multimodal therapy. The patient responded well to PTNS treatments. Therefore, the PTNS treatments received have been established as likely to be more beneficial for treatment of the 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 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 urology 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 urology 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 urology 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 authorization and coverage for Acthar Gel for treatment of the enrollees scleritis.  Findings:  The physician reviewers found that scleritis is inflammation of the sclera, the wall of the eye, and is frequently associated with the rheumatologic/autoimmune spectrum of diseases. It generally presents with significant pain, and can result in severe vision-threatening problems if left untreated. The first line of treatment for uveitis is nonsteroidal anti-inflammatory drugs.  The second line of treatment is steroids. Unfortunately, treatment with steroids is not without the risk of side effects such as glaucoma and cataracts, as well as serious systemic side effects.  This patient has failed to respond to both. If the scleritis cannot be controlled adequately and safely with steroids, the third line of treatment is a disease-modifying antirheumatic drug, such as methotrexate. Disease-modifying antirheumatic drugs also carry the risk of serious side effects.  This patient has also been treated with methotrexate, and her scleritis is still not controlled. When steroids and disease-modifying antirheumatic drugs are unable to control the disease process, the fourth line of treatment is use of a tumor necrosis factor inhibitor, such as Remicade or Humira. In this patients case, her disease has not been controlled even with the addition of Remicade. She requires additional treatment in an attempt to bring her condition under control. There is sufficient support for the requested medication in this patients case. Thus, the requested Acthar Gel is likely to be of greater benefit than other options for treating this patient. Final Result: Two of three reviewers determined that the requested medication is 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 reviewers number one, two, and three are board certified in ophthalmology and 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 parent of an enrollee has requested reimbursement for acute care psychiatric hospital services. Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Per the provided documentation, the patient remained symptomatic on the day before the date of service in question. The hospital staff observed the patient attempting to strangle herself after negative interactions with her peers. The patient reported ongoing suicidal ideation and anxiety. She was documented as having extreme despondency and anhedonia. Her mood was documented as anxious, depressed and suicidal ideation was noted. The patient remained on 15 minute safety checks throughout 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. The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity.  Based on the patients history and clinical status as outlined above, the patient met CASII service intensity criteria for secure 24 hour service with psychiatric management. The patients clinical status, in addition to current medical literature, support the continued inpatient stay provided on the date of service in question. Therefore, acute care psychiatric hospital services provided on the date of service in question were medically necessary for 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: 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 custom wheelchair with rear suspension option spinergy wheels for treatment of the enrollees spina bifida. Findings: The physician reviewer found that the request for custom wheelchair with rear suspension option spinergy wheels is medically necessary for treatment of the patients medical condition. Hurd and colleagues evaluated manual wheelchair propulsion across level ground conditions encountered during everyday life. The authors concluded that The rolling resistance of level surface terrain significantly impacts wheelchair propulsion biomechanics. Boninger and colleagues suggested using the lightest wheelchair possible to decrease the risk of injury to the wheelchair user. In this case, the requested wheelchair modifications of rear suspension option and spinergy wheels are medically necessary to decrease the risk of injury to the patients extensive spinal hardware. The patient will require further extensive spinal surgery in the form of a full spinal fusion if the implanted rods are damaged. All told, the requested equipment is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 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: An enrollee has requested authorization and coverage for Epclusa 400-100 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that The physician reviewer found according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic, treatment-naive, genotype 3 patients. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, Epclusa 400-100 mg 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.