Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Spinraza medication therapy. The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees spinal muscular atrophy, type 2.Findings:  Currently, Spinraza (nusinersen) is the only U.S. Food and Drug Administration (FDA) approved therapy for the treatment of SMA. In addition, the medication nusinersen has been shown in clinical studies to be effective for SMA of all types. Medical literature shows Nusinersen was found to be safe and well tolerated across all age groups studied. Nusinersen has irrevocably altered the natural history of SMA and allowed for the first time children to transition between SMA types. Nusinersen should be considered as standard of care for the treatment of SMA of all types. Per the FDA approval, Spinraza is indicated for the treatment of SMA in pediatric and adult patients. In addition, there is a lack of available therapies for treatment of SMA. The natural history of the disorder is progressive weakness which progresses to respiratory failure. Spinraza, which has FDA approval, has been shown to alter the disease progression. In sum, Spinraza injection treatment has been demonstrated as likely to be more effective for treatment of the patients SMA, type 2, than any available standard treatment options.Final Result: Two of the three reviewers determined that requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in neurology and are 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 and prospective authorization and coverage for inpatient hospitalization services. Rehabilitation therapy services can be delivered in a wide variety of settings across the care continuum. Post-acute settings differ in the types of available rehabilitation therapies, intensity of therapy, and the level of medical and nursing support.  Long-term acute care hospitals (LTACH) offer physical and occupational therapy, 24-hour skilled nursing care and a clinician available 24 hours per day.  The medical providers are able to care for active/ongoing medical conditions requiring a clinician-level care. In this case, the patient had pneumonia that caused her to require increased ventilator support and work-up for a fever starting 4/13/18.  It was medically reasonable for her to remain in the acute hospital during this time, as she had multiple complications, including fever, anemia and acute-on-chronic respiratory failure. By 4/18/18, the documentation supports that her respiratory status had stabilized. Although she continued to have low-grade fevers, further care could have been provided at a lower level of care. As of 4/18/18, the patient was stable from a respiratory and hemodynamic standpoint to be transferred to LTACH. Therefore, inpatient hospitalization services from 4/13/18 through 4/17/18 were medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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

The enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization treatment. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Findings: There is sufficient support in the documentation provided for the medical necessity of the services at issue in this clinical setting. The records indicated that the patient continued to be symptomatic.  The patient was described as disorganized, inattentive, and hyper-religious with persistent delusions and anxiety.  The patient was also noted to have sinus tachycardia with a documented heart rate of 130. During admission, the patient was prescribed clozapine. It should be noted that clozapine is typically reserved for use in treatment refractory cases. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP, 2014).  The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services.  Based on the patients clinical history and the documentation as outlined above, the patient met CASII criteria for level 4 integrated services without 24 hour psychiatric monitoring.  This level of care is higher than intensive outpatient services.  The patients clinical status, in addition to current medical literature, support the treatment at a partial hospital program level of care as medically necessary for this patient (AACAP, 2014).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 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: The parent of a seven-year-old female enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy (CPT code H2019) In the medical literature, Orinstein and colleagues 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. The records provided for review document that this patient has been approved for 30 hours of one-to-one direct ABA services, which is an appropriate level of service. The patient has had a significant decrease in behaviors since ABA therapy was introduced. Moreover, there has been a plateauing of progress over the past few months. Given these findings, the ABA therapy (CPT code H2019) was not and is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 with special qualification in pediatric 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for wearable cardioverter defibrillator rental. Findings:  Two of the three physician reviewers found there is sufficient support for the requested device in this clinical setting. This patient is being treated with guideline directed optimal medical therapy for his cardiomyopathy. There is some likelihood of recovery of left ventricular function in this instance over the initial three-month period with evidence-based medical therapy. Although implantable cardioverter defibrillators have been shown to be beneficial in both ischemic and non-ischemic cardiomyopathy, he does not meet criteria for an implantable cardioverter defibrillator at this point as he requires a minimum of three months of medical therapy for left ventricular dysfunction, and then reassessment of ejection fraction. He is at risk for malignant arrhythmia and sudden death while his ejection fraction is low. He also has evidence of ventricular tachyarrhythmia on his recent Holter monitor. A wearable cardioverter defibrillator can provide temporary protection from sudden death due to arrhythmia in this patient population during this interim period. Therefore, the requested wearable cardioverter defibrillator rental is likely to be superior over other treatment options.Final Result: The reviewers determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular 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: A 27-year-old male enrollee has requested authorization and coverage for high frequency chest compression device. Cystic fibrosis is caused by a genetic mutation and is a multisystem disorder that affects both the gastrointestinal and respiratory systems. Patients with cystic fibrosis have a chronic course with a gradual decline in pulmonary function with intermittent acute exacerbations. There are many forms of chest physiotherapy to decrease obstructing respiratory secretions including aerobic exercise, autogenic drainage, postural drainage and percussion methods. High frequency chest wall oscillation is not considered a first-line method for airway clearance. The evidence shows that this modality is not as effective as other airway clearance techniques. There has not been a significant difference in lung function shown with patients using high frequency chest wall oscillation versus other methods for chest percussion therapy. In this case, the patient has a stable above normal FEV-1. Moreover, there is no documentation to support that he has complaints of chronic cough with sputum production or that he has failed alternative types of airway clearance. Accordingly, the requested high frequency chest compression device is not supported as medically necessary for treatment of this patients cystic fibrosis. Final Result: The reviewer determined that the requested device 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 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 Hyalgan 20 mg/2 mL syringe, once weekly for three weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients osteoarthritis. The submitted documentation supports the medical necessity of the requested medication regimen. A study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. There is no maximum amount of injections established by high quality scientific evidence. This patient presents with chronic right knee pain and functional limitations in activities of daily living. The clinical examination findings are consistent with x-ray evidence of severe osteoarthritis with bone-on-bone findings in the medial compartment. The record indicates that reasonable conservative treatment, including medications, nonsteroidal anti-inflammatory drug therapy, and corticosteroid injections have failed to provide adequate symptom relief. The medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the requested Hyalgan 20 mg/2 mL syringe, once weekly for three weeks is medically necessary for 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for autologous chondrocyte transplant and right tibial osteotomy.Findings:  Two of the three physician reviewers found this patient presented with a history of chronic persistent right knee pain with associated swelling, popping, clicking, and locking. Clinical examination findings were reported by the treating provider to be consistent with chondromalacia patella and maltracking of the patella. However, documented clinical findings did not evidence patellar malalignment or maltracking. The medical literature supports autologous chondrocyte implantation for large chondral lesions in patients who failed operative and nonoperative treatment. A tibial tubercle osteotomy is recommended at the time of autologous chondrocyte implantation to achieve realignment. However, in this case, the patient does not have a large chondral lesion or significant evidence of malalignment consistent with evidence-based medical literature criteria. Therefore, the requested autologous chondrocyte and right tibial osteotomy 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 orthopedic 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 corneal collagen cross-linking procedure of the left eye. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral keratoconus.Findings:  Treatment for the patients condition with corneal collagen cross-linking is supported as an effective treatment option to halt the progression of keratoconus. Based on the patients vision loss and progression, the cross-linking procedure was the most appropriate and effective treatment available. There is relatively strong evidence indicating the efficacy of corneal collagen cross-linking procedures for treatment of keratoconus.  The deficiencies of the individual studies are not grounds to disregard the body of evidence that shows corneal collagen cross-linking as a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. Furthermore, corneal collagen cross-linking for corneal ectasias fulfills an unmet need due to the lack of treatment options available to slow or halt disease progression. Accordingly, the corneal collagen cross-linking procedure of the left eye was likely to have been more efficacious for the treatment this patients medical condition than any available standard therapy.Final Result: All three reviewers determined that the procedure at issue was 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:  All three reviewers are board certified in ophthalmology and are 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: The enrollee has requested authorization and coverage for ablation therapy, bilateral sclerotherapy, and ultrasounds. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees varicose veins.Findings: The documentation provided does not support the requested services in this clinical setting. The records do not show that this patient has had resolution of his peripheral artery disease issues.  On the left side, it is documented that the pedal pulses are no longer palpable. There is no documentation of palpable pedal pulses on the right at the most recent visit.  The records provided do not include formal Doppler pressure study such as an ankle brachial index (ABI). As the patient continues to have bilateral cramping pain in his calves and a history of peripheral artery disease, ABIs demonstrating satisfactory bilateral lower extremity perfusion would be a requirement for the requested procedures. Perforator vein ablation would not be medically necessary in the absence of ulceration. As to the right side, the ablation of the right greater saphenous vein is not medically necessary without clear documentation of absent peripheral artery disease on that side. With respect to sclerotherapy, the documentation provided does not support bilateral sclerotherapy at this time. Sclerotherapy for the left side would be medically indicated if performed concomitantly with the left short saphenous vein ablation once coverage of that procedure is approved. Similarly, on the right, if the absence of peripheral artery disease is satisfactorily demonstrated, sclerotherapy performed concomitantly with greater saphenous vein ablation would be considered medically necessary. With regards to the request for ultrasound, unless there was an intervention or change since the November 2017 study, the request for another ultrasound has not been demonstrated as medically necessary at this time. In summary, coverage for further venous treatments requires demonstration of adequate arterial perfusion and a patent left femoral popliteal artery bypass graft in the form of formal ABIs. Additionally, there is a lack of documentation of ulceration that would support perforator vein ablation at this time. For these reasons noted above, the request for ablation therapy, bilateral sclerotherapy, and ultrasounds has not been demonstrated as medically necessary for treatment of this patients medical condition at this time.Final Result: The reviewer determined that 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 vascular 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: A represented minor enrollee has requested reimbursement and prospective authorization and coverage for intrapulmonary percussive ventilation (IPV) system. Findings:  The physician reviewer found that there have been few long-term studies that compare the home use of IPV devices with other means of airway clearance for patients with cystic fibrosis. There are various means of airway clearance used in cystic fibrosis. However, the medical literature does not appear to indicate one modalitys superiority over another. Instead, the efficacy and preference for a specific treatment modality is best provided by the individual patient. The data seems to suggest the type of equipment used for treating patients diagnosed with cystic fibrosis depends on the ability and preference of the individual patient. In this patients case, the patient, his parents and the treating provider, all report improved lung function since the patient had started using IPV. Accordingly, the IPV system was and is likely to be of greater benefit in treating this patients medical condition when compared to available standard therapy.Final Result: All three reviewers determined the equipment at issue was and is likely to be more beneficial for treating 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 pediatrics and pediatric critical care and is actively practicing. Two reviewers are board certified in pediatrics and are 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.