Persius/hicric huggingface dataset:
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 speech therapy. The requested speech therapy is not medically necessary for the treatment of the patients autism spectrum disorder. Serial evaluations by the speech therapist indicate that the patient has plateaued in his scores on both the receptive and expressive sections of the OWLS and on the GFTA-2. While speech therapy can be beneficial to younger children on the autism spectrum, highly structured behavioral and speech therapy interventions are of limited value in the maintenance and generalization of skills in adolescents. All told, the requested speech therapy services are 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: An enrollee has requested authorization and coverage for continued lumbar epidural steroid injections for treatment of the patients pain management.  Findings:  The physician reviewer found that the peer-reviewed medical literature, epidural steroid injections may be appropriate for patients with radicular pain. However in this case, there is no current radicular pain complaints noted and epidurals are not recommended for non-radicular pain as a first-line treatment. Further, while the patient has been treated with physical therapy in the past, there is no documentation of recent physical therapy and home exercise program to address the patients current complaints. The literature does support and state that a home exercise program after physical therapy independent of an epidural can provide a patient with lasting results. Also, standard of care in this setting suggests another type of procedure may be more beneficial in this situation since the patient obtained 50% relief from one medial branch block at L2-5 and 50% relief from a sacroiliac joint injection (Derby, et al; Falco, et al). Finally, other medications have yet to be tried or optimized for his pain. For these reasons, the requested continued lumbar epidural steroid injections are not medically necessary for treatment of the 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 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: An enrollee has requested authorization and coverage for Orthovisc injections. The Health Plan has denied this request and reported that the requested services are not medically necessary for treatment of the enrollees medical condition. Findings: Clinical examination findings have been consistent with mild to moderate medial joint space narrowing in the left knee. Reasonable conservative treatment, including NSAIDs, activity modification, and corticosteroid injections have failed to provide adequate symptom relief. Records documented short-term pain relief for less than one month with prior viscosupplementation injections in March and April 2017 as well as October 2017. The evidence based medical peer-reviewed 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. Current evidence based medical guidelines recommend repeat injections when there is documented significant improvement in symptoms or six months or more. In this patients case, given the previous short-term response, repeat viscosupplement injections are not indicated. Therefore, the request for Orthovisc injections have not been demonstrated as medically necessary for treatment of the 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: The parent of a male enrollee has requested authorization and coverage for Nutramigen infant formula. The Health Plan has denied this request indicating that the requested formula is not medically necessary for treatment of the enrollee who has a history of severe constipation.Findings: The medical studies show that adverse reaction to cows milk protein is common in infants. The prevalence of cows milk protein allergy (CMPA) ranges from 2% to 7.5%. Immediate symptoms may include vomiting, urticarial, angioedema, wheezing, rhinitis, and dry cough. Later symptoms may include moderate to severe atopic dermatitis, diarrhea, and blood in the stool, gastroesophageal reflux and constipation. A comprehensive history is crucial in making the diagnosis of CMPA, including family history, because the risk is increased in the presence of familial atopic diseases. Because cows milk sensitivity may be associated with sensitivity to soy, soy-based formulas are not recommended. An elimination diet is appropriate to confirm the diagnosis when a patients clinical history is highly suggestive. The literature supports the use of amino acid-derived formulas in severe cases. Hydrolysate formulas such as Nutramigen are medically indicated for infants under one year of age with CMPA. The studies have shown that about half of infants resolve this allergy by the age of twelve months, and the majority within their fifth year. For patients that require formula, Nutramigen Toddler with Enflora LGG is a hypoallergenic formula designed to meet the nutritional needs of older infants and toddlers with CMPA from nine months to 36 months. In this case, the records show this patient has significant developmental delay, refractory constipation with a behavioral component, need for adult dose cathartic medications, and atopic disease (asthma, allergic rhinitis). Accordingly, Nutramigen infant formula is medically necessary for treating this patients medical condition. Final Result: The reviewer determined requested formula 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 pediatrics with sub-specialty certification in pediatric critical care 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 21-year-old male enrollee has requested authorization and coverage for EXONDYS 51 (eteplirsen). The submitted documentation supports the medical necessity of the requested medication. Based on the review of the medical data presented in this clinical setting, the requested medication, EXODYNUS 51, is medically appropriate and indicated for the treatment of Duchennes muscular dystrophy for this patient. The provider presents supporting evidence that the patient has demonstrated a measurable clinical benefit since participating in the EXONDYS 51 (eteplirsen) clinical trial as evidenced by a higher preservation of pulmonary function vital capacity and upper limb strength compared to historical data of those with Duchenne's muscular dystrophy not taking EXONDYS 51 (eteplirsen). 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive outpatient services on the basis that the services were emergent. A psychiatric emergency exists when a patient is an imminent danger to herself or to others. This can be due to a variety of things including, mania, psychosis, suicidal ideation, homicidal ideation, delusions and delirium. This patient did not have any of these symptoms with the exception of suicidal ideation. While the patient did have suicidal ideation, the patient did not have an intent or plan. The enrollee was not an imminent danger to self or others. The patient was attending to activities of daily living. Further, intensive outpatient programs are not considered emergency services as the patient leaves the facility after the treatment has been administered. If it were determined that the patient was experiencing a psychiatric medical emergency, standard of care would have been to transfer her to an Emergency Room or an inpatient psychiatric facility. This did not occur. Although the patient did require treatment for severe OCD symptoms, the treatment rendered does not meet criteria for psychiatric emergency services and care as defined above.Final Result: The reviewer determined the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 64-year-old male enrollee has requested authorization and coverage for a supervised sleep study. In this case, the patients clinical presentation is suggestive of a sleep related breathing disorder, specifically obstructive sleep apnea (OSA). Testing is indicated to confirm the presence of OSA. However, an attended sleep test is not the most appropriate level of service which can be safely provided to this patient. The utility and validity of home sleep testing for the diagnosis of OSA has been well documented in the peer-reviewed medical literature. In addition, current clinical guidelines, technology assessments, and review articles state that portable or home polysomnogram may be used as an alternative to an attended sleep study for diagnosis of OSA in patients with a high likelihood of moderate to severe OSA and no contraindications, such as comorbid sleep disorders or major comorbid medical disorders. In this case, a home sleep test followed by the use of AutoPAP, if the home study is positive, it is the appropriate testing rather than an attended test. In this setting, the requested attended study would exceed the patients clinical needs for the evaluation of his condition. All told, the requested supervised sleep study 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 neurology with sub-specialty certification in sleep 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: 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) utilizing the EsophyX device. The efficacy of TIF has been studied in randomized controlled trials. However, the conclusions are contradictory. An American College of Gastroenterology (ACG) guidelines for treatment of GERD report that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy. further studies are required to define optimal techniques and most appropriate patient selection criteria, and to further evaluate device and technique safety.` Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) do not recommend endoscopic procedures for patients with complicated GERD which the guideline defines as dysphagia or Barretts esophagus and report that the long-term follow-up data for TIF is limited. For these reasons, the requested TIF with the EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested TIF with the EsophyX device is 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 requested procedure is 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested reimbursement for lipoprotein testing (CPT 83704 Cardio IQ Advanced Lipid Panel and CPT 83695 Cardio IQ Lipoprotein Fractionation, Ion Mobility). Findings: Three physician reviewers found the patient has intermediate-high risk of developing symptomatic cardiovascular disease over the next 10 years based on his clinical risk factors. However, he has a very substantial negative risk factor for coronary artery disease given the recent coronary artery calcium score of zero. He has no known history of coronary artery disease and no other clinical risk factors except age and moderate hyperlipidemia. It had already been decided that Crestor would be restarted based on the clinical risk profile and the standard lipid profile testing. In this clinical setting, there was no additional information from advanced lipoprotein testing which would significantly add to risk prognosis based on current guidelines and available data. This is especially true in this clinical situation, where the treatment decision to use statin pharmacotherapy has already been made. Therefore, lipoprotein testing (CPT 83704 Cardio IQ Advanced Lipid Panel and CPT 83695 Cardio IQ Lipoprotein Fractionation, Ion Mobility) was not likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: 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: The parent of a 14-year-old male enrollee has requested reimbursement for the residential treatment services. Applying the child and adolescent level of care utilization system (CALOCUS), the residential treatment services were not medically necessary for treatment of this patients behavioral health issues. The patient presented with some risk of harm (score 2) due to his history of impulsive actions and running from home which could place the patient at some risk for unintentional self-harm. However, the medical records indicate that the patient was not actively suicidal. The patient demonstrated moderate functional difficulties (score 3) with a history of school disruption due to substance use. The patient had mild co-morbidity (score 2) as he did not have active serious medical problems but had a history of substance use. The patients recovery environment was mildly stressful (score 2) given his positive recovery environment and stable housing situation. The patients recovery environment was supportive (score 2) as the patients father was actively involved in treatment. The patient had limited response to prior treatment (score 3) with minimal history of outpatient treatment consisting of three months of treatment and no community-based intensive forms of treatment. The patient was constructive in treatment (score 2) as he was noted to participate in therapy and used coping skills learned in therapy. The patients parents were constructive (score 2) as they worked actively and constructively with the patients providers. This gives the patients presentation a composite score of 18 which correlates with intensive outpatient services. According to the CALOCUS, the patient would need to have a score of 23-28 in order to require treatment in an RTC. In summary, the patient could have been safely and effectively treated in a less restrictive setting. Thus, the services at issue were not medically necessary. 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a replacement powered wheelchair with a larger seat. The request for a power operated wheelchair is not medically necessary. The documentation reveals that the patient has a mobility deficit and is requesting a wider wheelchair to accommodate her leg swelling. The documentation indicates that the patients home has been modified to fit a wider power operated mobility device. However, the documentation does not demonstrate that the power operated vehicle will significantly improve the patients ability to perform ADLs as the documentation does not reveal a reassessment of the patients wider modified home. The documentation does not include objective evidence of the patients home revealing adequate access between rooms, maneuvering space, and surfaces for the operation of the power operated vehicle. In the absence of objective evidence of a properly modified home and assessment, it has not been demonstrated that the patient can safely operate the power operated vehicle in her home. All told, the requested replacement powered wheelchair with a larger seat is not medically necessary for treatment of the patients medical condition.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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha SureClick for evaluation of the enrollees colon polyps. Findings:  The physician reviewer found that based on the records provided, the patient presents with documented obstructive coronary disease, intolerance to multiple statin medications, and LDL that is significantly above a goal of less than 70 mg/dL while on Zetia medication. Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria and statin intolerance is well documented. In this clinical setting, the addition of a PCSK9 inhibitor such as Repatha has been shown to be safe and effective at lowering cholesterol and has been associated with improved cardiovascular outcomes. Therefore, Repatha SureClick 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 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.