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 speech therapy. The requested speech therapy is medically necessary for treatment of the patients speech and language delay. The patient has significant scatter in his evaluation scores, but on the Comprehensive Assessment of Spoken Language performed his lexical/semantic language was at the fifth percentile, and syntactical language at the fourth percentile. Moreover, evaluation using the Goldman-Fristoe Test of Articulation Third Edition revealed a standard score of 94 and percentile rank of 34. The Goldman Fristoe Test of Articulation 2 (GFTA-2) demonstrated skills at the five year, four month age equivalent. Given these scores, the requested speech therapy is supported as medically necessary for treatment of this patients speech and language delays. 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 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 the graft procedure, Kerecis Omega3. Findings:  Three physician reviewers found that Kerecis Omega3 is a tissue-based, skin-substitute wound care product that has been used in perioperative and chronic wound care. In this case, the patient had a full thickness, venous stasis ulcer which was located over the ankle. To date, large scale prospective clinical trials have not been performed to compare the efficacy of Kerecis Omega3 to other biologic skin substitutes versus existing wound therapies. As such, Kerecis Omega3 was not likely to have been superior over other available treatment options. Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 are board certified in surgery 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the dual energy x-ray absorptiometry (DEXA) bone density study. According to the National Osteoporosis Foundation (NOF), the decision to perform bone density assessment should be based on an individuals fracture risk profile and skeletal health assessment. The International Society for Clinical Densitometry (ISCD) states that bone density is indicated for post-menopausal women younger than age 65 a bone density test is indicated if they have a risk factor for low bone mass such as: low body weight, prior fracture, high risk medication use, disease or condition associated with bone loss. In this case, the patient is postmenopausal and has a history breast cancer and chemotherapy, all of which are high risk for bone loss. This patient meets several indications for bone density testing. Accordingly, the DEXA bone density study was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the DEXA bone density study was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Botox injections Findings:  Two of the three physician reviewers found that the use of Botox is indicated for the treatment of chronic headaches in individuals who have at least 14 headache days per month. Furthermore, Botox has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of migraines. It is widely used by neurologists for this purpose. Therefore, Botox injections were likely to have been of greater benefit than other treatment options. Final Result: 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 reviewers 1, 2 and 3 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for oxycodone-acetaminophen tablets. The Health Plan has denied this request indicating that the medication at issue was not medically necessary for treatment of the patients chronic, open wound of the left ankle. The medical needs of the patient and medical literature supports the medical necessity of the medication at issue. In this patients case, the prescriptions were medically reasonable and necessary. Researchers clearly state that the use of Percocet (oxycodone-acetaminophen) is appropriate in the peri-operative period for pain relief. Similarly, other researchers mention that narcotics are frequently used for pain post-operatively. This patients case has nothing to do with chronic low back pain and citations of chronic pain guidelines are not applicable. Accordingly, the provided oxycodone-acetaminophen tablets were medically necessary for treatment of this patient.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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent a patient has requested authorization and coverage for Nutropin AQ Nuspin 20 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients idiopathic short stature. The submitted documentation does not support the medical necessity of the requested medication. Based on the medical needs of the patient and current practice guidelines, this patient does not meet criteria for growth hormone treatment for the diagnosis of idiopathic short stature for the following four reasons. First, there is no documentation of severe growth deceleration. Second, the patients estimated predicted height based on the bone age prior to growth hormone treatment (61 inches) falls within the range of the mid-parental target of (65 inches), although at the lower end of normal. Third, the patients estimated predicted adult height falls within the normal range for adult females and is at the 10th percentile. Fourth, the criteria for ISS is not met because this patient's height is not below standard deviations for the chronological age and sex. There is also no documentation to support other diagnoses for which growth hormone would be indicated. Therefore, Nutropin AQ Nuspin 20 mg 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: A patient has requested reimbursement for the substance abuse residential treatment center services provided. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. The medical guidelines for substance use disorders recommends that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, lack sufficient social and vocational skills, and drug-free social supports to maintain abstinence in an outpatient setting. In this case, the patient required a safe and stable living environment in order to develop recovery skills. The patient required residential or inpatient treatment consistent with ASAM level III treatment at least i.e., residential or inpatient treatment similar to what patient received. Patients conditions can wax and wane. Relatively positive documentation by one person on one day does not indicate a miraculous cure or that a patient is in the clear; it simply denotes progress and that treatment is working, which is an indication to continue, not cease treatment. Following detoxification treatment, the standard rehabilitation program is a residential treatment, which was in accordance with generally accepted standards of medical practice, clinically appropriate for the patient's illness, not more costly than an alternative service for treatment of the patients condition, and was therefore medically necessary. Therefore, the substance abuse residential treatment center services provided 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 55-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy. Based on the available documentation, the intraoperative radiation therapy provided to this patient on 5/10/18 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Accelerated partial breast irradiation (APBI) is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria. These criteria include an age of 45 years or older and a tumor less than 3 cm. Negative surgical margins and negative lymph nodes are also criteria and are confirmed at the time of surgery. For these reasons, the intraoperative radiation therapy was likely to provide this patient with an improved health outcome when compared to standard available treatment options. One reviewer found that the intraoperative radiation therapy was not likely to provide this patient with an improved health outcome when compared to standard available treatment options.Final Result: Two of the three 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:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Hyalgan injections to both knees and prospective authorization and coverage for Hyalgan injections to both knees. There is sufficient support for the services at issue in this clinical setting. A study performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors noted that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. The study noted that viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Therefore, previous Hyalgan injections to both knees and future Hyalgan injections to both knees were and are medically necessary for the treatment of this patient. 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 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: An enrollee has requested authorization and coverage for computed tomography angiography (CTA). The records provided for review document that this patient has undergone standard evaluation with lipid profile and exercise stress test. According to medical guidelines, either stress testing or coronary CTA may be indicated. However, the guidelines notes that coronary CTA may be appropriate in certain clinical situations such as coronary anomaly or left bundle branch block. When a patients exercise stress test has been normal, there is a lack of data supporting an indication for a coronary CTA. As this patients exercise stress test was normal, the requested CTA is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira Pen 40 mg every seven days. The submitted documentation fails to demonstrate the medical necessity of the requested medication regimen in this clinical setting. Currently, there is a lack of guidelines or large phase III randomized controlled studies which demonstrate efficacy and safety or recommend accelerated dosing of a tumor necrosis factor inhibitor for the treatment of psoriatic arthritis. A study involved patients with ankylosing spondylitis and demonstrated improved results in disease control with no increased adverse events. However, this study included patients with ankylosing spondylitis, not psoriatic arthritis. In this case, the patient has failed Humira every two weeks. The current medical evidence supports switching agents in this setting. There is a lack of support for increased dosing of the requested tumor necrosis factor inhibitor in this patients case. Therefore, Humira Pen 40 mg every seven days is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 rheumatology 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 Xiidra. This patients records do not document an adequate trial and failure or a contraindication to another drug that was authorized by the Health Plan. Further, Xiidra has not been demonstrated in the medical literature to be a superior topical treatment option as compared to the drug authorized by the Health Plan. Thus, an adequate trial of the drug authorized by the Health Plan is reasonable as the next treatment step for this patients dry eye syndrome. Accordingly, the requested Xiidra is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in ophthalmology 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: A female enrollee has requested reimbursement for the Cartiva synthetic cartilage implant. Based on the current peer-reviewed medical literature, the Cartiva implant was not likely to be more beneficial for the treatment of the patients condition than any available standard therapy. Conventional therapies include joint fusion or standard implant. Due to the limited published data on the Cartiva device, including the short- and long-term benefits and potential side effects, the Cartiva synthetic cartilage implant was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the Cartiva synthetic cartilage implant was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in podiatry and is actively practicing. One Reviewer is board certified in podiatry and is actively practicing.  One Reviewer is board certified in podiatry and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus, genotype 4. The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive; genotype 4 patients should be treated with Mavyret three tables daily for eight weeks. The ENDURANCE-4 trial showed a 99% cure rate with eight weeks of treatment. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret for eight weeks is medically necessary for 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.