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

Nature of Statutory Criteria/Case Summary: A patient requested authorization and coverage for admittance to residential treatment program. The Health Plan has denied reimbursement as not medically necessary. Findings:  The physician reviewer found that 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) medical, addictive 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 appropriate level of care. For a CALOCUS composite score of 15, the recommended level of care is low-intensity outpatient therapy.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The guardian of an enrollee has requested authorization and coverage for 40 hours per week of skilled nursing care services in the home (CPT code S9124). The submitted documentation supports the medical necessity of the requested services. In this case, home nursing is indicated to monitor vital signs, perform nursing assessment, provide gastrostomy tube care, monitor lungs sounds, assist with range of motion and monitor for skin breakdown. Common indications for private duty nursing often include the administration of medications, monitoring oxygen saturations, and enteral feeding, all of which are required in this case. Researchers evaluated specialist home-based nursing services for children with acute and chronic illnesses. The authors screened 4,226 titles, yielding seven randomized controlled trials with a total of 840 participants. Three studies reported a reduction in parental anxiety, and improvement in child behaviors was reported in three studies. Overall increased parental satisfaction was reported in three studies. Additionally, better parental coping and family functioning was reported in one study. While the family may be able to meet some of the ongoing needs of the patient in the short-term, this is not sustainable. Given the patients global developmental delays and ongoing need for gastrostomy tube care and oral suctioning, the requested services are medically indicated. Therefore, 40 hours per week of skilled nursing care services in the home (CPT code S9124) are medically necessary for the 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 pediatrics 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 a history of opioid dependence, alcohol dependence, cannabis dependence, cocaine dependence, autistic disorder and borderline personality disorder. The patient was admitted to a residential treatment center (RTC) on 8/13/18. The patient was trying to stop heroin without medical assistance, with fear of relapse. The records document that the patient had passive suicidal thoughts, but denied homicidal thoughts, and did not exhibit any psychosis. At the time of admission, the patient was living with their partner. The records report that the patient has a history of four suicide attempts in the past. At issue is whether the residential treatment services that received from 9/10/18 to 10/1/18 were medically necessary to treat this patients medical condition. The American Society of Addiction Medicine (ASAM) criteria proposes six domains that must be met to qualify for residential treatment admission. For an adult, they must meet all six domains to qualify. These domains include: acute intoxication; biomedical conditions, emotional, behavioral cognitive condition; readiness to change; relapse, continued use or continued problem potential; and recovery environment. The patient was exhibiting some anxiety and some passive suicidal thoughts. However, the patient was not showing any medical instability. He demonstrated decreased cravings and struggled with group activities. The patients drug screen was positive for Suboxone. The patient was not showing any withdrawal or any risk for acute or subacute withdrawal. The patient had no biomedical condition that distracted recovery and he did not have any emotional, behavioral or cognitive conditions requiring the RTC level of care. The patient was motivated to change and revealed insight into his condition. The patient did have relapse triggers but was not in any imminent danger or crisis situation. The patient was in a recovery environment that was not considered unsafe but supportive. Utilizing the ASAM criteria, this patient met the criteria for outpatient treatment. Therefore, the RTC services provided from 9/10/18 through 10/1/18 were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 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

An enrollee has requested reimbursement and prospective authorization and coverage for fentanyl citrate lozenge HD. The submitted documentation fails to demonstrate the medical necessity of the medication at issue. Fentanyl transmucosal immediate release agents may be medically indicated for patients with a history of cancer-related pain and/or oral mucositis due to some types of cancers. The review by colleagues indicated that although there is some benefit for short term improvement, there are no placebo-randomized controlled trials supporting the effectiveness and safety of long-term opioid therapy for treatment of chronic low back pain. Moreover, the authors noted the very few trials that compared opioids to non-steroidal anti-inflammatory drugs (NSAIDs) or antidepressants did not show any differences regarding pain and function. This patient has chronic pain, and she reports that she is more functional with the fentanyl citrate lozenge HD. The submitted documentation indicates that the patient has been treated with fentanyl-based medications for several years. The current medical evidence does not support the medication at issue in this clinical setting, as the patient is not terminally ill due to cancer or malignancy. The medication at issue is not an appropriate treatment for this patient with chronic back pain. Other appropriate options in this patients case include cognitive behavioral therapy and buprenorphine. Therefore, fentanyl citrate lozenge HD was not and is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the medication at issue was not and 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient psychiatric level of care. This patient began intensive outpatient program level of care approximately one month prior to the Health Plans denial. The progress notes indicate the patient is cooperative in treatment. She is not aggressive with others in the program. She has not expressed suicidal or homicidal ideation or psychosis. The records do not indicate that she has used substances during the disputed timeframe.In cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. In terms of risk of harm, the records support a score of 1 due to the patients lack of current self-harm ideation. With regards to functional status, the records support a score of 1. The patient has had deterioration in expected level of functioning in relationships with family, but overall appeared functional day to day. In terms of comorbidity, the records support a score of 1. The patient does not have any active serious medical problems or active substance use. With regards to level of stress of the recovery environment, the records support a score of 2. The patient has issues with family relationships family but has a stable housing situation. In terms of level of support of the recovery environment, the records support a score of 1. The patients father is actively involved in treatment and attended family sessions on a regular basis. With regards to level of support of the recovery environment, the records support a score of 1. As noted above, the patients father is actively involved in treatment. In terms of resiliency and treatment history, the records support a score of 2 to 3. Although there is a lack of documented recent treatment, the patients behaviors have improved during her intensive outpatient program sessions. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participates in therapy, but does not appear to be motivated for treatment. In terms of acceptance and engagement of the parent, the records support a score of 2. The patients father has worked actively and constructively with clinicians. Thus, the patient has a composite score of 12 to 13. This score correlates with outpatient services. Therefore, intensive outpatient psychiatric level of care was not and is not medically necessary for the treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for peripherally inserted central catheter (PICC). A PICC line is a peripherally inserted central catheter that is indicated for use for patients with inadequate peripheral venous access, or those who are receiving long-term intermittent or continuous administration of medications such as chemotherapy or parenteral nutrition. There are several complications from the use of a PICC line including serious infections and blood clots around the catheter. In this case, the patient is capable of tolerating oral fluid and food but notes he is only able to tolerate one cup of fluid a day. A PICC line is not indicated for ongoing hydration on an intermittent basis. The patient is requesting placement of a PICC line for weekly IV fluids of one liter to prevent kidney stones and maintain hydration. The risks for potentially life-threatening complications outweigh the benefit of receiving a liter of IV fluids a week. If supplemental hydration is required, an alternative method should be investigated. The requested PICC is not medically necessary for 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 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: The patient has requested Myfortic. Mycophenolic acid is used for immunosuppression to prevent rejection of a transplanted organ, such as the liver. The effect is dependent on the amount of drug present, as an incorrect drug concentration may result in toxicity or organ rejection, even if a second agent such as tacrolimus is being used. However, individual patients respond to the same dose differently. While generic immunosuppressant medications can be effective and dosing may be stable when a generic formulation is used post-transplant, problems such as insufficient dose resulting in organ rejection may occur when the brand name formulation is changed to the generic formulation. For these reasons, continuation of the brand name formulation of Myfortic is supported for the treatment of this patients liver transplant status and risk for transplant rejection. Thus, the requested Myfortic is medically necessary for treatment of this patients medical condition. 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 subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient requested reimbursement for gene testing services (Oncotype DX) that were performed. The Health Plan has denied the services at issue as investigational for evaluation of the enrollees colon cancer. Findings:  Two physician reviewers found that it has not been established if molecular markers are useful in treatment determination and prognosis in patients with colon cancer. In addition, the 12-gene recurrence score Oncotype DX does not have specific U.S. Food and Drug Administration (FDA) approval for use in stage II colon cancer. Furthermore, none of the assays have been able to predict which patients with stage II disease could benefit from adjuvant therapy. It is important to note that the 12-gene recurrence score was created as a prognostic marker. While it may have the ability to better estimate a patient's risk of recurrence, whether such increased risk can be overcome by adjuvant chemotherapy is not clear. A technical brief on gene expression profiling for predicting outcomes in stage II colon cancer concluded that the clinical utility of all of the gene expression assays, including the 12-gene recurrence score, was uncertain. Therefore, the gene testing services (Oncotype DX) that were performed were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One physician reviewer found that the gene testing services (Oncotype DX) that were performed were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 subspecialty certification in medical oncology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for orthoptic and pleoptic training with medical direction that was provided and future services. The Health Plan has denied this request, indicating that the services at issue were and are considered experimental or investigational for treatment of the enrollees convergence insufficiency.Findings:  Two out of three physician reviewers found that there is a lack of consensus regarding appropriate treatment for CI. In a comparison of three treatment approaches, a conclusion was drawn that using multiple methods to treat convergence insufficiency results in more effective orthoptic therapy. Researchers concluded that vision therapy is effective in recovering from symptomatic CI. However, these studies lacked a control group. Overall, there is a lack of scientifically valid studies of the treatment of CI. Home-based therapies and observation for CI are the prevailing treatment options due to the lack of evidence for, and standardization of, office-based treatments. One physician reviewer found that given that this patient was still symptomatic despite home exercises, a trial of office-based orthoptic exercises is warranted.Final Result: The reviewers determined that the services at issue were not and 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 ophthalmology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether the negative pressure wound therapy provided was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy. A review of the records indicates that the patient had an open abdominal wound following a total hysterectomy and bilateral oophorectomy.Two out of three physician reviewers found that there is a lack of support in the literature for negative pressure wound therapy in this clinical setting. The overall wound was not large and the patient was not noted to have high risk factors such as diabetes, obesity, or smoking that are commonly attributed to the failure of traditional treatments. The patient had not failed standard wound treatment. As such, the negative pressure wound therapy was not likely to have been more beneficial than any other available standard treatments. One out of three physician reviewers found that the medical literature supports negative pressure wound therapy (NPWT) systems for the treatment of open wounds as superior to standard wound therapy with respect to speed of closure and in requiring less frequent dressing changes. Therefore, the negative pressure wound therapy provided was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Final Result: Two out of three reviewers determined that the wound therapy 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: Physician reviewers 1, 2 and 3 are board certified in plastic 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.