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 reimbursement and prospective authorization and coverage for 40 hours per week of one-on-one applied behavioral analysis (ABA) therapy, two hours per week of caregiver training, 16 hours per week of program supervision by Board Certified Behavior Analyst (BCBA) and eight hours per month to conduct clinical team meetings for treatment of the autism.  Findings:  The physician reviewer found that Linstead and colleagues studied the intensity and learning outcomes in the treatment of children with autism spectrum disorder. The study showed a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. The Behavior Analyst Certification Board indicates that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, given the patients behaviors that include elopement, self-injury, aggression, noncompliance and tantrums, stereotypy, protests, and verbal and physical self-stimulatory behaviors, the request for 40 hours per week of one-on-one ABA therapy, two hours per week of caregiver training, 16 hours per week of program supervision by BCBA and eight hours per month to conduct clinical team meetings was and is medically necessary for treatment of the patients autism spectrum disorder. Final Result: The reviewer determined that the services at issue were and 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 sub-specialty certification in developmental-behavioral pediatrics 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 female enrollee has requested authorization and coverage for removal of bilateral breast implants with bilateral mastopexy (breast lift) for treatment of the enrollee who has had a history of left breast pain. Findings:  The physician reviewer found that based on the medical documentation for this review, the patient appears to have a possible complication from a cosmetic procedure, in which her volume of augmentation was excessive. She has undergone physical therapy, but appears to continue to complain of pain. However, the plastic surgery documentation does not support that her enlarged breast size is the source of the pain, but is more likely due to her history of the motor vehicle accident. Moreover, the plan by the plastic surgeon is more consistent with cosmetic intervention, as the plan was to remove the implants and then perform a mastopexy. Thus, a well-defined functional impairment that would likely be resolved with implant removal and mastopexy has not been adequately supported in this patients case. There are times when a mastopexy or implant removal may be considered reconstructive surgery, namely following postmastectomy reconstruction and congenital breast deformities. However, there is no documentation to support this or that the patient had an original congenital breast deformity. There is insufficient documentation that her preoperative condition was significantly abnormal given her previous cosmetic intervention. Although the patient has pain, the medical documentation from the provider does not support that this is likely due from the enlarged breasts. As such, the medical records do not support that the mastopexy and implant removal are being performed for treatment regarding functional concerns. Instead, this request is more consistent with aesthetic treatment following complicated cosmetic surgery. In addition, the plan for mastopexy appears supportive or aesthetic intervention. For these reasons, removal of bilateral breast implants with bilateral mastopexy (breast lift) is not medically necessary and not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty for treatment of the enrollees severe persistent asthma. Findings:  Two physician reviewers found that bronchial thermoplasty is indicated for the treatment of bronchial asthma such as in this case. The procedure is approved by the U.S. Food and Drug Administration (FDA), and medical studies have shown that many patients experience fewer symptoms, have better quality of life and require less intensive medical treatment than comparable patient who did not have the procedure and follow up studies thus far indicate the procedure is safe.  In addition, this patient has severe persistent bronchial asthma. The patient continues to have daily symptoms despite maximal medical therapy and requires courses of prednisone several times a year. This is the type of patient in whom bronchial thermoplasty can be of help. Due to the effectiveness of bronchial thermoplasty in this population of patients, the procedure has been supported by the Global Initiative for Asthma guidelines. For the reasons provided, the bronchial thermoplasty is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested procedure 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in pulmonary disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees psoriasis. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. According to guidelines by the American academy of Dermatology, the Health Plans formulary alternatives that include Humira, Enbrel and methotrexate are recommended for patients with chronic plaque psoriasis who are candidates for systemic treatment. In this case, the Health Plans formulary alternatives are medically reasonable and appropriate for this patient. Given the lack of failure or contraindication to formulary alternatives, the request for Otezla has not been established as medically necessary for treatment of the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that 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. For these reasons, treatment is needed at this time.  All told, Epclusa 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for residential treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that On an initial evaluation, the patient reported chronic suicidal ideation. The patient reported other behavioral issues as well as problems with impulse control and substance use. The patient reported relational issues with his family. During the disputed period, he reported some suicidal thoughts.  It does not appear that he was acting on these thoughts during that time. It appears that the residential treatment was effective for the patient in terms of reducing suicidal ideation as well as reducing substance cravings. The current medical evidence supports residential treatment in this clinical setting. All told, residential treatment was 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued inpatient antifungal intravenous treatment (Diflucan intravenous) for treatment of the enrollees medical condition.Findings:  The physician reviewer found that There is a lack of support in the medical literature for the requested services in this clinical setting. The patient had reported that she needed to remain in the hospital for this therapy and that she was allergic to oral antifungals but not to intravenous ones. However, the standard recommendation for catheter associated fungal bacteremia in most hosts is an oral antifungal and catheter removal.  In this clinical setting, the standard of care would be removal of catheter and treatment with an oral antifungal.  The blood culture that grew candida also grew a coagulase negative staphylococcus which suggests the culture represents contamination with skin flora and not true catheter associated infection. The intravenous administration of an antifungal in this patients case is not supported by standard practice. In addition, treatment in the acute care setting is not clinically indicated for this patient. All told, inpatient antifungal intravenous treatment (Diflucan intravenous) at Providence Little Company of Mary Medical Center 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 internal medicine with sub-specialty certification in infectious 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 knee surgery for treatment of the enrollees bilateral knee degenerative joint disease. Findings:  The physician reviewer found that the medical literature, reviewed 13 randomized clinical trials and 12 observational studies and found no long-term difference between patients who underwent arthroscopy with debridement versus patients treated conservatively with regard to pain or function. Another study evaluated the benefits of arthroscopic knee surgery involving partial meniscectomy, debridement, or both for middle aged or older patients with knee pain and degenerative knee disease. The studies concluded that the benefit with intervention was small and inconsequential for degenerative tears and chondromalacia. Taken together, these findings do not support the arthroscopic surgery for older patients with knee pain with or without signs of osteoarthritis. Thus, this patient may be a candidate for a total knee arthroplasty based upon the degree of pain, difficulty with ambulation, lack of response to multiple corticosteroid injections, and magnetic resonance imaging (MRI) findings of tricompartmental osteoarthritis. However, the clinical information does not indicate that arthroscopy will be of benefit in the presence of tricompartmental osteoarthritis as noted on the MRI report. Final Result: The reviewer determined that the requested surgery 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for lumbar spinal fusion of L5 and S1 discs for treatment of the enrollees back and radicular pain. Findings:  The physician reviewer found that the patients records do not support the medical necessity of the requested surgical intervention. The patient has no dermatomal/myotomal symptoms or findings compatible with a lumbar radiculopathy.  In addition, there is no documentation of neurogenic claudication. Except for two recent epidural steroid injections, there is no documentation of failed conservative management such as physical therapy, home exercise program, chiropractic care, pain management, or cognitive behavioral therapy. Moreover, there is no documentation of pain affecting his activities of daily living. According to current guidelines from the National Imaging Associates (NIA), for lumbar fusion require spondylolisthesis, spinal stenosis that is moderate-to-severe with functional impairment despite three months of conservative management; spondylolisthesis or instability or anticipated instability, fracture, or recurrent herniated nucleus pulposus with radiculopathy and instability; documentation and evaluation and management of addiction issues. Thus, the requested lumbar spinal fusion of L5 and S1 discs is not medically necessary for treatment of this patients back pain. Final Result: The reviewer determined that the requested surgery 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve block for treatment of the enrollees chronic migraine.  Findings:  Two reviewers found that the records indicate the presence of occipital neuralgia as documented by physical examination findings. However, occipital nerve blocks are not supported for the treatment of migraine or other type headaches. Occipital nerve blocks are supported for diagnostic purposes, and not supported for therapeutic treatment as there is a lack of long term benefit supported by peer reviewed literature. Cuadrado and colleagues noted there was no long term improvement of headache of chronic migraine type with use of occipital nerve block. A study noted that greater occipital nerve block does not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. In addition, another study noted there was no long term improvement of headache of chronic migraine type with use of occipital nerve block. Final Result: Two reviewers determined that the requested service is 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 neurology 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 has requested reimbursement for the inpatient hospital admission for evaluation of the enrollees left-sided neck pain.Findings:  The physician reviewer found that although the documentation indicates the patient should have been placed on observation status to allow time for neurosurgical consultation and repeat examination, there is no documentation of intravenous heparin, surgical treatment, or interventional neurological treatment to support an indication for inpatient admission. Observation status would have been adequate to safely monitor the patient due to the unstable nature of the artery dissection. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg/mL Sureclick for treatment of the enrollees pure hypercholesterolemia. Findings:  The physician reviewer found that this patient has an abnormal coronary calcium score indicating the presence of coronary atherosclerosis. In addition, her LDL cholesterol is greater than 190 even while on maximally tolerated therapy, which is evidence for genetic heterozygous familial hypercholesterolemia. Therefore, the patient meets the criteria for use of PCSK9 inhibitors. Accordingly, the requested Repatha 140 mg/mL Sureclick is supported as medically necessary for treatment of this patients medical condition. 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 reimbursement for neuropsychological testing for evaluation of the enrollees difficulties with attention regulation, managing her emotions and academic concerns. Findings: the physician reviewer found a study showing that there is a lack of evidence supporting neuropsychological testing as improving outcomes in diagnosing and treating patients with ADHD. Moreover, neuropsychological testing is not the standard of care in this clinical setting. The diagnosis of ADHD is typically made utilizing a standard psychiatric evaluation, parent surveys, teacher surveys, and other rating scales and screening tools. Final Result: The reviewer determined that the testing at issue was 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 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.