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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a pelvic varicosity embolization procedure. Findings:  The physician reviewer found that Pyra and colleagues report that embolization is a minimally invasive, effective and safe treatment for pelvic congestion syndrome (PCS). In a study of 113 patients with PCS, Nasser and colleagues report that transcatheter embolization is a safe and effective treatment for PCS. In this case, the patients clinical findings and imaging studies suggest PCS. In this clinical setting, gonadal vein embolization is safe, well-tolerated, and allows for a minimally invasive approach. Therefore, a pelvic varicosity embolization procedure is likely to be more beneficial than any other available standard treatment for the patients medical condition.Findings:  Two of the three physician reviewers found the requested pelvic varicosity embolization procedure is 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 service 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 reviewer 1, 2, and 3 are board certified in obstetrics and gynecology 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 patients parent has requested authorization and coverage for applied behavioral analysis (ABA) therapy services three hours each day, and five days per week at home. The Council of Autism Service Providers guidelines on ABA treatment of autism spectrum disorder note that treatment intensity will vary with each patient and should reflect the goals of treatment, specific patient needs, and response to treatment. The guidelines further note that discharge from treatment can begin when the patient does not demonstrate progress towards goals for successive authorization periods. Papatola and Lustig report that ABA services should be consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research. In this case, the patient has made minimal progress over an extended period of time and continues to display deficits. Given that further treatment is unlikely to ameliorate symptoms, deceasing service intensity is standard of care and the requested services are not medically indicated in this clinical setting. Therefore, applied behavior analysis therapy services three hours each day, and five days per week at home are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed B.C.B.A, board certified in psychology, and is actively practicing 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 cooled radiotherapy for the right knee. Based on the available documentation, this patient presents with chronic superomedial pain in the right knee for at least one year. She complains of sharp pain exacerbated by climbing stairs. Additionally, she has Graves disease and asthma. She has reportedly failed conservative treatment, including acetaminophen, NSAIDs, physical therapy, and corticosteroid injections, which yielded 50% relief. A review of the current medical literature with regard to genicular nerve radiofrequency ablation indicates that it has been used for pain relief and improvement of function in symptomatic individuals with knee osteoarthritis who are not candidates for surgery or have undergone surgery and have persisting pain. Optimal candidates have moderate to severe osteoarthritis (Kellgren-Lawrence grade 3 or 4), for which surgery might be considered, and patients who are not good surgical candidates because of medical comorbidities and/or a high body mass index (BMI). In this case, there are no radiographic reports on which to determine if grade 3 or 4 Kellgren-Lawrence moderate to severe osteoarthritis signs are present (osteophytes, joint narrowing or bone sclerosis). Further, the patient does not have significant comorbidities, such as abnormal BMI, that would limit surgical options. Based on these considerations, cooled radiotherapy for the right knee is not likely to be more beneficial than other available standard treatments. Findings:  Three of the three physician reviewers found the requested cooled radiotherapy for the right knee 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 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam therapy. There are currently inadequate high quality clinical outcomes published in the peer-reviewed medical literature to support the long-term safety and efficacy of proton beam therapy for the management of potentially resectable head and neck cancer, as compared to standard of care photon-based radiation therapy. Proton beam radiotherapy is the subject of ongoing prospective randomized clinical trials in this patients clinical setting, for which this patient may be eligible for enrollment. The American Society for Radiation Oncology (ASTRO) does not recommend proton beam therapy in this patients setting outside the context of a clinical trial. The National Comprehensive Cancer Network (NCCN) guidelines support the use of photon-based radiotherapy in the form of intensity modulated radiation therapy (IMRT) for management of this patients invasive squamous cell carcinoma of the tongue base. All told, the requested proton beam therapy is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiation oncology 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 H.P. Acthar Gel 80 unit/mL-5mL injection.Findings:  The physician reviewer found that there is a paucity of data in the current medical literature supporting the use of H.P. Acthar Gel for the treatment of ankylosing spondylitis. In adults with active ankylosing spondylitis despite treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), Ward and colleagues recommend treatment with tumor necrosis factor inhibitors (TNFi), and with sulfasalazine, methotrexate, or tofacitinib when TNFi are not available. The authors further recommend physical therapy. In a phase 2 randomized trial, Van der Heijde and colleagues reported that tofacitinib 5 mg and 10 mg twice daily demonstrated greater clinical efficacy versus placebo in reducing signs, symptoms and objective endpoints of active ankylosing spondylitis. In this case, the provider reports that the patient has active ankylosing spondylitis symptoms despite treatment with NSAIDs and TNFi therapy. However, the documentation did not note trials of methotrexate or tofacitinib according to treatment guidelines, or participation in a structured land-based physical therapy program. In this clinical setting, current medical literature does not support the efficacy of H.P. Acthar Gel over standard available therapies, such as methotrexate for peripheral joint inflammatory arthritis, tofacitinib, and physical therapy, for the treatment of ankylosing spondylitis. Therefore, H.P. Acthar Gel 80 unit/mL-5mL injection is not likely to be more beneficial than any other available standard therapy for the patients medical condition.Findings:  Three of the three physician reviewers found the requested H.P. Acthar Gel 80 unit/mL-5mL injection 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 medication 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 reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in rheumatology 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 patients parent has requested authorization and coverage for Nutropin AQ Nuspin. This patients clinical course and presentation are consistent with mild constitutional delay of growth and development based on normal growth velocity, height, insulin like growth factor binding protein 3 (IGFBP-3) level, bone age with a positive family history for constitutional delay. Although the patients peak circulating growth hormone of 9 ng/mL was below the cutoff value of 10 ng/mL for classic growth hormone deficiency and one insulin like growth factor 1 (IGF-1) value was documented as low, the patient does not meet the criteria for growth hormone deficiency based on normal growth velocity, normal height, normal IGFBP-3 level, and normal bone age. Since puberty has recently begun based on testicular volume of 4 mL, pubertal steroids have not likely been a major stimulus to growth. Direct measurements of parental heights may revise the midparental target height closer to the predicted adult height. Based on the available documentation the patient does not meet U.S. Food and Drug Administration (FDA) approved criteria for somatotropin therapy. The patient's height is above -2.25 standard deviations (SDs) below the mean, which does not meet key diagnostic criteria for idiopathic short stature. All told, the requested Nutropin AQ Nuspin is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication 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 pediatrics with subspecialty certification in pediatric endocrinology 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 authorization and coverage for bilateral mastectomies (CPT code 19303) and nipple reconstruction (CPT code 15200). Findings:  The physician reviewer found that The World Professional Association for Transgender Health (WPATH) Standards of Care acknowledges that some interventions have a radical and permanent effect on a patients quality of life, and therefore is more medically necessary than for someone without gender dysphoria. Olson-Kennedy and colleagues concluded that, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. The WPATH criteria for bilateral mastectomy and chest reconstruction is persistent, well-documented gender dysphoria, which is well documented in this patient. While this patient has a history of polysubstance use disorder, he has been in remission since November 2018 and chest surgery is likely to make a positive impact. The patients providers report that his mental health issues are well controlled and do not interfere with his ability to follow-up with his providers. Given these findings, the requested bilateral mastectomies (CPT code 19303) and nipple reconstruction (CPT code 15200) are 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 expertise in transgender 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 authorization and coverage for lidocaine patches. Findings: Lidocaine patches provide topical anesthesia to the area that they are placed. In this particular case, the patient demonstrated prior pain relief with the use of the lidocaine patch. Multiple studies demonstrate that lidocaine patches are effective in alleviating a patients neuropathic pain caused by chronic regional pain syndrome. The documentation reviewed supports that this patient presents with complex regional pain syndrome (CRPS) affecting the foot. The provider reports that the patient has been treated with lidocaine patches in the past, which helped alleviate a good portion of her neuropathic pain. The patient is also being treated with Lyrica. On 2/25/20, the provider recommended continued use of lidocaine patches to be applied to the foot daily for three months. Therefore, the requested lidocaine patches are medically necessary for 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 a licensed D.P.M., board certified in podiatry, 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 Aquatic Therapy.Exercise in an aquatic setting is one of several options for exercise that can potentially provide symptom relief for various pain conditions (Verhagen, A., et al.; Baena-Beato, P., et al.). It is thought that the warmth and buoyancy of water may help block nociception by acting on thermal and mechanoreceptors, thus influencing spinal segmental mechanisms (Kamioka, H., et al.). The evidence-based literature, nevertheless, has not demonstrated that aquatic exercise is an effective intervention for back pain overall (Kamioka, H., et al.; Morelhao, P., et al.). There are no proven or expected marginal benefits of formal aquatherapy programs over water-based exercises that are pursued independently or performed in informal group exercise settings. Various water-based exercise programs not requiring formal therapy have been reported to be effective and can be pursued empirically (Keane, L.). Formal aquatic therapy (i.e., as opposed to generalized water-based exercise) is medically necessary only for individuals in specific circumstances, i.e., for patients who require therapy in a partially body weight unloaded environment (e.g., persons with fractured limbs and significant weight-bearing restrictions, or profound neurological weakness such as tetraplegia). These candidates are unable to perform the applicable exercises safely and effectively without formal therapist guidance, instruction and supervision, and cannot be safely and effectively overseen, supervised and instructed by persons without formal therapy training.In this case, the records do not establish that the patient has condition(s), impairment(s) or restriction(s) that would preclude an appropriate informal water-based or low-impact land-based exercise program. There are no documented, objective indications that the patient could not exercise in a pool on his own (e.g., basic pool walking, stretching, strengthening and/or swimming), in a group exercise setting, or with an exercise coach (without a physical therapist's license) if he elected to do so. The submitted records do not establish that a formal aquatic therapy program is medically necessary for this patient. Accordingly, the requested Aquatic Therapy is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia services provided her routine colonoscopy. Researchers note that the overall risk of complications after colonoscopy increases when individuals receive anesthesia services. In this case, the patient underwent a routine colonoscopy. She was noted as ASA Class 2, with a Mallampati score of 2. She had a BMI of 22.2, and as such 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, anesthesia services provided during the patients routine colonoscopy were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue 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 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 patients parent has requested authorization and coverage for 10 hours of 1:1 applied behavior analysis (ABA) therapy. The records provided for review document that this patient presents with a history of autism, attention-deficit/hyperactivity disorder (ADHD), and associated behavioral issues. The provider has charted minimal goals in the current treatment plan and the patients challenging behaviors are at near zero levels. The provider has recommended four hours of ABA services per week, which is appropriate given the patients current goals and behavioral issues. The patients caregivers have requested an increase in service intensity. However, there is a lack of supporting assessments or documentations that support an indication for 10 hours of ABA services per week. The Council of Autism Service Providers (CASP) highlighted the scope of focused treatment. Per CASP, treatment intensity will vary with each client and should reflect the goals of treatment, specific client needs, and response to treatment. According to researchers, medically necessary ABA services are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on this definition, the patient fails to meet criterion (c) and (d). Specifically, the caregivers request for 10 hours per week is not consistent with the providers request for four hours per week. In this situation, the providers request is within the treatment guidelines outlined by CASP. For these reasons, the requested 10 hours of 1:1 ABA therapy is not medically necessary for this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is licensed B.C.B.A, board certified in psychology, 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.