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

The patients parent has requested authorization and coverage for six months of dual diagnosis residential treatment center (RTC) in a secure facility. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework, this patient meets the criteria for six month of dual diagnosis RTC in a secure facility. These findings give the patient a composite score which is consistent with Level Five medically monitored residence based services. Per CALOCUS, due to the extreme risk of harm, the recommended level of care is a Level Six medically managed residence based services. All told, the requested six months of dual diagnosis RTC in a secure facility is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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

The patient has requested authorization and coverage for a capsule endoscopy (PillCam UGI System). A study found that capsule endoscopy (CE) was recommended for patients with suspected, known, or relapsed Crohns disease when ileocolonoscopy and imaging studies were negative if it was imperative to know whether active Crohns disease was present in the small bowel. It was not recommended in patients with chronic abdominal pain or diarrhea, in whom there was no evidence of abnormal biomarkers typically associated with Crohns disease. CE was recommended to assess patients with celiac disease who have unexplained symptoms despite appropriate treatment, but not to make the diagnosis. Colon capsule endoscopy should not be substituted routinely for colonoscopy. In this case, the patient reported GERD symptoms and a globus sensation. The patient requested a capsule endoscopy; however, his treating gastroenterologists reported it would be of low diagnostic yield. The medical evidence does not support the requested service in this clinical setting. Therefore, a capsule endoscopy (PillCam UGI System) is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service 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 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

The patient has requested authorization and coverage for topical tofacitinib. Tofacitinib has been shown to be effective in treatment of alopecia areata (AA). In a double-blind, placebo-controlled study concluded that topical Janus kinase (JAK) inhibitors could be developed as a potential new treatment for AA. In this case, the patient has tried and failed the standard treatment for focal AA. Other untried, non-standard therapeutic options are mostly systemic and may result in cumulative toxicities and other side effects. Based on the current medical literature, the requested medication is medically indicated. Therefore, topical tofacitinib is medically necessary for the treatment of this patient.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 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:  The enrollee is requesting authorization and coverage for Tramadol (Ultram). The enrollee has a history of systemic lupus erythematosus. The enrollee also has osteoarthritis in both hands. A progress note reports the enrollee is taking Tramadol, 50 milligrams daily every 8 hours, but her provider wishes for the enrollee to taper off the medication to 50 milligrams per day, due to its addictive nature.  The progress note reported the enrollee had no major complaints, no major issues, and no symptoms of active lupus. The available documentation indicates that tramadol is being used to treat pain due to osteoarthritis of the hands.  She has not experienced any apparent toxicity. Tramadol is a pain-killer, and treatment of pain is a goal of therapy. A professional society provides Tramadol with a conditional recommendation for therapy. Therefore, it is part of the spectrum of treatment for osteoarthritis of the hands. Tramadol has five morphine milligram equivalents for every 50 milligrams. Therefore, twice daily dosing has 10 morphine milligram equivalents; a very small amount. There is a low risk of addiction. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 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 NP-Thyroid and authorization and coverage for Armour Thyroid.In this case, the patient has a diagnosis of hypothyroidism that has been treated with desiccated thyroid extract (DTE) for many years with good clinical response. The patients medical history reflects that other preparations have proven ineffective or adverse to the patient in the past. Every patient is different, and it is clear that some need this combination of LT4+LT3, or DTE, to alleviate the symptoms of hypothyroidism. Studies have shown DTE to be safe and even beneficial when looking at cardiac, bone and other parameters. Under these circumstances, the NP-Thyroid purchased by the patient was medically necessary, and Armour Thyroid, the form of DTE that has provided the best response for the patient, is medically necessary going forward. Accordingly, the brand name NP-Thyroid purchased by the patient was medically necessary to treat the patients medical condition. In addition, the requested medication, brand name Armour Thyroid, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the medication at issue and requested medication were, and are, medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism, 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

The patients parent has requested authorization and coverage for occupational therapy services once a week. At issue in this case is whether occupational therapy services once a week are medically necessary for treatment of the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions. Regarding the evaluation and management of a child with autism spectrum disorder, researchers reported that treatment involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. The patient was noted to have significant delays in her ability to perform activities of daily living and sensory testing. She requires ongoing occupational therapy to address significant delays in her ability to perform activities of daily living. The record shows that the patient has made progress in therapy, as she has met several goals. The medical evidence supports the requested services in this clinical setting. Therefore, occupational therapy services once a week are medically necessary to promote physical and mental health and efficiency, and to correct or ameliorate the physical or behavioral condition of the patients impaired visual/motor coordination, poor fine motor skills, and sensory difficulties.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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Uceris (budesonide rectal foam 2 mg twice daily for two weeks, then daily). This patient has failed oral 5-aminosalicylate therapy and rectal corticosteroid suppositories. Guidelines from the American Gastroenterological Association (AGA) state, In patients with mildmoderate ulcerative proctosigmoiditis who choose rectal therapy over oral therapy, the AGA suggests using mesalamine enemas rather than rectal corticosteroids. Marshall and colleagues noted, Rectal 5-aminosalicylates (5-ASA) should be considered a first-line therapy for patients with mild to moderately active distal ulcerative colitis. In this case, there is no documented attempt of rectal 5-aminosalicylate therapy. As the patient has not attempted rectal 5-aminosalicylate therapy, the use of rectal corticosteroids is not supported by guidelines for the treatment of ulcerative colitis. Therefore, Uceris (budesonide rectal foam (2 mg) twice a day for two weeks, then daily) 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 this 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 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

The patient has requested reimbursement for monitored anesthesia care services provided during a colonoscopy. In this case, the patient underwent a colonoscopy. The patient did not have any heart, lung, kidney, or liver disease. There was no documentation of a history of alcohol or substance abuse. The patient was not morbidly obese and was unlikely to present as a difficult airway to manage. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the services at issue were not medically indicated. Therefore, monitored anesthesia care services provided during a colonoscopy were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service was 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a power wheelchair to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. The records fail to demonstrate the patients mobility limitations render him unable to perform activities of daily living in the home. The patients DME assessment indicated that he was able to ambulate in the community and at home with the help of a recently provided single point cane. The records do not reveal significant neurological deficits or physical gait abnormalities that would support the medical necessity of a power wheelchair. Therefore, the requested power wheelchair is not medically necessary to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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

An enrollees parent has requested authorization and coverage for durable medical equipment (DME) automated external defibrillator (AED). Management of patients with long QT syndrome consists of lifestyle modification, beta-blockers, left cardiac sympathetic denervation and implantable cardioverter defibrillator (ICD) implantation. Prohibition of competitive exercise and avoidance of QT interval prolonging medications are also important aspects of patient management. Indications for ICD implantation include patients who have survived cardiac arrest, have syncope despite adequate doses of beta-blockers, and patients with marked QTc prolongation of more than 550 milliseconds. This patients records do not report that she meets these recognized criteria for an ICD. In the absence of an indication for an ICD in this otherwise low risk patient, there is a lack of support for the requested AED in this clinical setting. Given these findings, the requested DME AED is not 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 equipment 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is 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: The patient has requested authorization and coverage for COVID-19 antibody testing. The Centers for Disease Control does not currently recommend antibody testing as the sole basis for diagnosis of acute infection. In certain situations, serologic assays may be used to support clinical assessment of persons who present late in their illnesses when used in conjunction with viral detection testing. In this case, the records do not establish that the patient was exposed to someone with symptoms or evidence of COVID-19. The nature of her illness in December 2019 is unknown. In this clinical setting, the testing is not medically indicated. Moreover, antibody tests for SARS-CoV-2 infections are not well-developed and are often falsely positive. Antibody testing is not standardized, and the results will vary depending on the test that is chosen. Therefore, COVID-19 antibody testing is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Hyaluronan (Synvisc) injections in the right knee, and reimbursement for a knee brace. The enrollee has a history of chronic knee pain, which has worsened over the last few years. The pain is associated with swelling, clicking or popping, instability and weakness. The note reports prior treatment included anti-inflammatory medications, physical therapy, and four injections, type not specified, four months prior. A progress note reports a magnetic resonance imaging scan showed right knee tricompartmental osteoarthritis. The physician recommended weight loss, as the enrollees body mass index was 45, and Synvisc injections. This enrollee is of a relatively young age and demonstrates significant tricompartmental arthritis that has been symptomatic. After the failure of primary measures, viscosupplementation may be considered and utilized as an evidence-based, non-operative treatment measure, particularly alongside weight loss and bariatric measures. An offloader knee brace is preferentially indicated for individuals with unicompartmental arthrosis. However, this enrollee demonstrates significant radiographic and symptomatic degenerative disease in both the patellofemoral joint and lateral compartment, thereby limiting the potential efficacy of offloading into the lateral compartment.  Similarly, custom braces are indicated where explicitly stated for abnormal thigh to calf ratio or other specific extenuating factors, which are not stated in this request.Final Result: The reviewer determined that the requested services are partially medically necessary for the treatment of the enrollees medical condition. The Hyaluronan (Synvisc) injections were found medically necessary, but the offloader knee brace was not found medically necessary. Credentials/Qualifications: The physician 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 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 transoral incisionless fundoplication (TIF) with EsophyX (CPT 43210). Appropriate patient selection is crucial before anti-reflux procedures. In prelude to surgical intervention for gastroesophageal reflux disease (GERD), authours noted that, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. This patient has undergone some of this preoperative assessment. The available records do not support that the patients GERD is advanced, or that there is good correlation of symptom benefit with acid suppression. The current medical literature supports a possible indication for TIF in patients with Hills grade I-II, no hiatal hernia or hernia up to 2 cm. However, in this patients clinical scenario, there is no documentation of formal esophageal function testing or pH studies to establish that the patients symptoms objectively correlate with acid reflux events. Furthermore, in patients who have objectively demonstrated refractory GERD, current medical literature has not demonstrated the superiority of TIF versus laparoscopic Nissen fundoplication. All told, the requested TIF with EsophyX (CPT 43210) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested TIF with EsophyX (CPT 43210) is not 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 services are 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 internal medicine with subspecialty 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.