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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 22.5 hours per week of direct one-to-one applied behavioral analysis (ABA) therapy for six months. The requested services of 22.5 hours per week of direct ABA therapy are not medically necessary for treatment of the patients medical condition. The patient has been receiving ABA services for at least the past 12 years. Details regarding the number of hours received during that time were not provided. The patient has been documented as having had a significant decline in the frequency of his problematic behaviors, several of which have been extinguished. A medical literature reviewed the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder and found no correlation between the number of hours provided per week and outcomes. The authors reported that the age at which ABA therapy was started and duration of treatment was correlated with outcome. Another study reached similar conclusions. The Health Plans approved for 65 hours per month (16.25 hours per week) of direct one-to-one ABA services is reasonable given this patients current behavioral issues. Given these findings, the requested 22.5 hours per week of direct ABA therapy 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Hyalgan injections for both knees. Knee hyaluronic acid injection for osteoarthritic pain is not a first-line treatment and is typically recommended only after lower risk treatments such as independent exercise, weight loss and over-the-counter medications have failed. In this patients case, there is no documentation of knee osteoarthritis by imaging studies. Moreover, the patient is taking high-dose opioids and benzodiazepines. There is no reasonable expectation viscosupplementation with hyaluronic acid would bring about substantial pain relief in this patient in this clinical setting. Thus, the requested Hyalgan injections for both knees are not supported as 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for a consultation with a clinical geneticist. Findings:  The physician reviewer found that the records indicate that this patient has a mitochondrial disorder due to a mutation in mitochondrial DNA (m.3242A>G). This particular mutation and the spectrum of disease associated with it is reasonably well characterized. This mutation is associated with mitochondrial encephalopathy, lactic acidemia and stroke-like episodes (MELAS). Some patients present with a MELAS phenotype and others present with diabetes and hearing loss, and there is a spectrum of disease, depending in part on the mutation burden and tissue distribution of the mutation. Thus, referral to a clinical geneticist with expertise in mitochondrial diseases is indicated for diagnostic purposes. All told, the requested consultation with a clinical geneticist is medically necessary for evaluation of this patients medical condition. 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 clinical genetics 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 a doctor visit and echocardiogram services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. In this patients case, the records documented a prior small ventricular septal defect that was only questionably present on the most recent echocardiogram in 2013 and was not associated with any documented recent cardiac symptoms, cardiac abnormalities on recent physical examination or recent electrocardiogram. In addition, no murmur was identified suggesting that the ventricular septal defect has spontaneously closed, which is a common occurrence.  Moreover, the scheduled breast augmentation surgery is a low-risk non-cardiac surgical procedure that does not warrant a preoperative echocardiogram in the absence of cardiac symptoms or objective cardiac abnormalities on physical examination or electrocardiogram. In aggregate, in a stable patient without documented cardiac symptoms or findings scheduled for a low risk non-cardiac procedure, a repeat echocardiogram is not medically necessary and not recommended by current guidelines. Thus, the doctor visit and echocardiogram services were not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a enrollee has requested reimbursement for the magnetic resonance spectroscopy . Based upon a review of the information provided and the medical literature reviewed, the magnetic resonance spectroscopy was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient presented with seizures and was found to have ischemic stroke and a subdural hematoma on CT scan of the brain. The MRI/MRA/MRV of the brain revealed that the patient had an embolic stroke. The providers noted that the patients did not likely have a metabolic disorder. MRS has been shown to be useful in children with seizures when the MRS yielded information that prompted evaluation for metabolic disorders, brain tumor, or cortical dysplasia, or when the MRI was normal. When an MRI/MRA/MRV provide a diagnosis of embolic stroke, there is a lack of data to support the use of MRS as an additional diagnostic modality. Thus, the magnetic resonance spectroscopy  was not likely to have been more beneficial than standard imaging including MRI, MRA and MRV. One reviewer found that the magnetic resonance spectroscopy was likely to have been more beneficial than standard imaging including MRI, MRA and MRV.Final Result: Two of the three reviewers determined that the diagnostic procedure at issue was 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:  One reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care and is actively practicing. One Reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care and is actively practicing.  One Reviewer is board certified in pediatrics and neurology with special qualification in pediatric neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) coronary angiogram. This patient presented with increased coronary risk and a screening stress test that reported no chest pain and mild non-diagnostic electrocardiographic changes. In this circumstance, if further evaluation for coronary ischemia were thought to be medically necessary, some form of imaging stress test would be most appropriate. Coronary CT angiography defines anatomy only and does not assess the functional significance of any potential stenosis that may be identified, and thus cannot assess for coronary ischemia.  Moreover, current guidelines on the evaluation and management of dyslipidemia do not recommend routine performance of coronary CT angiography to help guide lipid therapy since treatment change based on CT results has not been shown to incrementally improve outcome compared to treatment based on clinical risk and standard lipid analysis alone.  All told, the requested coronary CT angiogram is not medically necessary for the evaluation of this patient.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 10 hours per week of applied behavioral analysis (ABA) therapy to be provided in four sessions per week at 2.5 hours per session, eight hours per week of parent training, and 10 hours per month of supervision. There is an extensive literature on the stress experienced by families with children with autism. A study describes that family-centered support decreases parental levels of stress, and problems with co-parenting a child with autism increases stress. The patient is noted to have decreased contact with his mother and he has demonstrated a significant deterioration in his behavior. It is not in the patients best medical interest to have ABA services faded out at this time, as further decline in his behavior is likely to occur. The patient has comorbid ADHD. Z study concluded that parent training may have a positive effect on the behaviour of children with ADHD. It may also reduce parental stress and enhance parental confidence. All told, the medical literature supports the 10 hours per week of direct ABA therapy to be provided in four sessions per week at 2.5 hours per session, eight hours per week of parent training, and 10 hours per month of supervision as medically necessary 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for carotid ultrasound Doppler. There is a lack of support for the services at issue in this patients case. Nonspecific symptoms such as dizziness and lightheadedness are not indicative of carotid stenosis. Therefore, patients with these symptoms are considered asymptomatic. Guidelines from U.S. Preventive Services Task force do not recommend screening for carotid artery stenosis for patients who are asymptomatic.  Furthermore, there is a lack of evidence that the auscultation of the neck to detect carotid bruits is accurate or provides benefit. In this case, the documentation does not support that the patient had symptoms that were concerning for carotid artery stenosis. Per the records, she was considered asymptomatic, as she did not have symptoms that would indicate ischemia in the ipsilateral carotid artery territory of the brain. There is a lack of support for the services at issue in this clinical setting. Thus, carotid ultrasound Doppler was not medically necessary for the evaluation of this patient. 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 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 Vemlidy tablets for treatment of the enrollee's chronic hepatitis B virus (HBV).  The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients chronic hepatitis B virus (HBV). Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. The submitted documentation supports the medical necessity of the requested medication. Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects, such as osteopenia and renal disease. As such, the request to switch the enrollee to Vemlidy to reduce the risk of tenofovir-related nephrotoxicity and loss of bone density is medically reasonable and appropriate. For these reasons, Vemlidy tablets are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the enrollees 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for fentanyl patch 100 mcg and oxymorphone HCL 40 mcg. The Health Plan has denied this request indicating that the requested medications are not medically necessary for treatment of the patients fibromyalgia. The submitted documentation does not support the medical necessity of the requested medications. The patient may have opioid-induced hyperalgesia. The patient has been treated with medications, physical therapy, transcutaneous electrical nerve stimulation, and acupuncture and still has considerable pain. This patient should be slowly detoxified as the patient is receiving opioids in the amount of 600 mg of morphine equivalents per day. In addition, the records do not indicate that there is a history of malignancy, recent urine toxicology results, or an opiate maintenance agreement in place. Therefore, fentanyl patch 100 mcg and oxymorphone HCL 40 mcg are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medications 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 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 enrollee has requested authorization and coverage for speech therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria.Findings: A review of the literature suggests that speech and language therapy is successful at creating an acceptable fundamental frequency in transgender patients, as well as influencing other communication behaviors. The medical literature indicates that individuals who are in the process of transitioning from male to female may often benefit from speech/language pathology services. Speaking fundamental frequency (pitch) and resonance are part of gender transitioning treatment because the combination of these two voice characteristics can account for the majority of how listeners perceive a speakers gender.  However, while speech therapy can be effective in feminizing the voice, in this patients case, there was no information in the records provided about this patients voice to substantiate that the patient is likely to benefit from speech therapy. There was no documentation from speech pathology regarding an evaluation of this patients voice. Therefore, speech therapy is not supported as medically necessary for treatment of this patients medical condition at this time.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for once a week allergy injections for 52 weeks (two sets), CPT code 95117 x 16 within a 120-day period and CPT code 95144 x 32 within a 120-day period.  The submitted documentation fails to demonstrate the medical necessity of the requested services. The records do not establish the need for more frequent immunotherapy dosing, According to records, the patients allergy and asthma symptoms were decreased, medications needed were decreased, and quality of life was improved. The records do not document a clinical basis for more frequent dosing. The current medical evidence does not support the requested services in this patients case. Therefore, once a week allergy injections for 52 weeks (two sets), CPT code 95117 x 16 within a 120-day period and CPT code 95144 x 32 within a 120-day period are not medically necessary for the treatment of this patient. 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 pediatrics and allergy and immunology 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 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.   According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, should be treated with Mavyret,  for eight weeks. these guidelines  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. Findings:  The physician reviewer found that