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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the residential treatment center services provided from 10/28/17 through 1/26/18. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.  The submitted documentation supports the medical necessity of the requested residential treatment center services provided from 10/28/17 through 1/26/18. The records provided for review document that this patient required a safe and stable living environment in order to develop his recovery skills to prepare him to step down in treatment without high risk of relapse. Given this patients heavy substance abuse, history of withdrawal seizures, bipolar disorder and traumatic loss, he remained at high risk for relapse and harm to self throughout this admission. Thus, the residential treatment center services were in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness.Final Result: The reviewer determined that the requested the residential treatment center services provided from 10/27/17 through 1/26/18 were medically necessary for treatment of this patients behavioral health issues.  Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and 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 Neulasta. The National Cancer Care Network (NCCN) v2.0 2018 guidelines provide criteria for use of myeloid growth factors (MGFs) in patients with cancer receiving chemotherapy. NCCN considers the type of cancer and type of treatment in its criteria, and stratifies by risk of febrile neutropenia into high (>20% risk), intermediate (10-20% risk) and low (< 10% risk.. Recommendations for use of myeloid growth factors in intermediate risk cancer types is further dependent on patient risk factors. These include patients who are 65 years or older, have persistent neutropenia, bone marrow involvement of tumor, recent surgery, liver dysfunction (bilirubin > 2.0), renal dysfunction (creatinine < 50) or prior chemotherapy or radiation therapy. If the patient has 1 or more of these risk factors, then MGFs are recommended.Based on NCCN criteria, this patient falls into the intermediate risk category with colorectal cancer on FOLFOX therapy. In addition, this patient has positive patient risk factors including prior chemotherapy and a prior episode of neutropenic infection. Based upon NCCN recommendation, an MGF is appropriate for this patient. At this time, the patient is receiving filgrastim. Filgrastim is an MGF, and is equally effective in this clinical setting as the requested Neulasta. The only difference between Neulasta and filgrastim is the frequency with which the drugs must be taken  the former is administered once every two weeks, while the latter requires daily dosing. While the less frequent dosing might make Neulasta more convenient than the prescribed filgrastim, it cannot be said that Neulasta is more appropriate for this patient. Therefore, Neulasta is not medically necessary for treatment of this patients condition.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 internal medicine with a subspecialty certificate in medical 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 reimbursement for allergen specific IgG testing. As noted in the medical literature, IgG allergy testing may be indicated for patients with an allergic reaction to determine a possible etiology for their symptoms. However, this patient does not have allergy-type symptoms reported in the records provided for review. All told, the allergen specific IgG testing was not likely to be more beneficial for evaluation of this patients medical condition than any available therapy. Findings:  Three physician reviewers found the allergen specific IgG testing was not likely to be more beneficial for evaluation of this patients medical condition than any available therapy.Final Result: The reviewers determined that the allergen specific IgG testing was not likely to be more beneficial for evaluation of this patients medical condition than any available therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing. The American College of Obstetricians and Gynecologists (ACOG) has issued recommendations for expanded carrier screening for genetic disorders in all women before and during pregnancy. The ACOG guidelines recommend that each healthcare provider should establish a standard approach for ethnic-specific, panethnic, or expanded carrier screening. Women should be screened for common conditions such as spinal muscular atrophy, cystic fibrosis, hemoglobinopathies and fragile X. The guidelines also recommend expanded carrier screening, which tests for as many as several hundred conditions simultaneously, as an acceptable strategy for prenatal carrier screening. Screened conditions should be able to be diagnosed prenatally and have potential opportunities for antenatal intervention to improve perinatal outcomes, changes to delivery management to optimize newborn and infant outcomes, and parental education about special care needs after birth. Given these findings, the gene panel was likely to have been more beneficial than any available standard evaluation for this patients medical condition.Final Result: One reviewer found that the gene panel was not likely to have been more beneficial than any available standard evaluation for this patients medical condition. Two of the three reviewers determined that the service at issue was likely to be more beneficial for evaluation of 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 genetics with sub-specialty certification in clinical cytogenetics and is actively practicing. One Reviewer is board certified in pediatrics with with sub-specialty certifications in genetics and clinical biochemical genetics and is actively practicing. One Reviewer is board certified in pediatrics with sub-specialty certifications in neurodevelopmental behavioral pediatrics and genetics and is 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: 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 biofeedback therapy. The long-term efficacy of biofeedback in addition to standard pelvic floor pelvic therapy for management of patients with urinary incontinence remains unknown. A recent randomized trial concluded that, this preliminary study suggests that pelvic floor muscle training, with and without biofeedback, is associated with increased muscle strength, myoelectric activity, precontraction of pelvic floor muscles, and improved quality of life in postmenopausal women with stress urinary incontinence. Researchers found that pelvic floor muscle training is effective for treatment of stress urinary incontinence. However, the authors cautioned that there was no apparent add-on effect of biofeedback training in short-term follow-up. Thus, the medical literature supports the clinical utility of pelvic floor physical therapy and suggests that the addition of biofeedback does not substantially contribute to improved health outcomes. For these reasons, the requested biofeedback therapy was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested biofeedback therapy was not and 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 requested biofeedback therapy was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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

There is inadequate documentation to support the diagnosis of hypogonadism. The records do not document two morning testosterone levels below reference range prior to initiation of therapy. Current guidelines recommend two morning testosterone levels below reference range prior to initiation of therapy. The guidelines also recommend luteinizing hormone/follicle-stimulating hormone testing to evaluate the type of hypogonadism, and this was not documented in the submitted records. In sum, testosterone pellet 75 mg (Testopel) and implantation were not and are not likely to be more effective than other methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) mutation gene testing.Findings:  Three physician reviewers found the medical evidence does not indicate that MTHFR polymorphism testing is useful in this clinical setting. While many conditions have been associated with these polymorphisms, none have been definitively proven. The homozygous variant has been associated with elevations in homocysteine, which may contribute to venous thrombosis. While this patient has two copies of this variant, she had normal homocysteine levels. The American College of Medical Genetics recommends against testing patients for MTHFR variants, including those with known family history of polymorphisms, as there is a lack of clinical utility in such testing. There was no indication to test this patient for MTHFR variants due to her history of travel or her family history of VTE. There is no known treatment recommended for those who have one or two copies of these polymorphisms. Therefore, MTHFR mutation gene testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined 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 reviewer 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 3 is board certified in clinical cytogenetics and genomics and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous positive airway pressure (CPAP) device (CPT code E0601). The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees obstructive sleep apnea. The submitted documentation supports the medical necessity of the requested device. Based on a home sleep study, this patient has a diagnosis of mild obstructive sleep apnea with a AHI of 9.4. Home sleep studies are known to underestimate the severity of obstructuve sleep apnea. They overestimate sleep time which is the denominator, therefore decreasing the quotient to a smaller number. The American Academy of Sleep Medicine states that CPAP is beneficial for the  treatment of mild obstructive sleep apnea.  Therefore, the requested CPAP device (CPT code E0601) is 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 otolaryngology with sub-specialty certificaiton 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synthroid. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hypothyroidism. The submitted documentation supports the medical necessity of the requested medication. The patient has successfully treated her hypothyroidism in the past with Synthroid brand preparation. It is possible that the patient had a reaction to one of the inactive components of the generic levothyroxine preparation.  According to the American Thyroid Association guidelines, this issue has been controversial and no studies or recommendations have been conclusive. If a patient could be prescribed the same generic formulation from refill to refill, there would be no reason to be concerned about distinction between branded and generic products. However, if prescribing a generic product exposes the patient to switching between generic products, then a potential concern remains. In this patients case, it is not good medical practice to change to a generic preparation or a different brand. She may experience the side effects she had when she tried a generic in the past, and she will require additional testing and office visits that would not be necessary if she were to continue her proven effective therapy with Synthroid. Since the patient has been stable and done well for several years with Synthroid, it is appropriate to stay on Synthroid. Therefore, Synthroid is 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees hyperhidrosis of the face and neck. The submitted documentation does not support that the requested services are medically necessary. In this case, the patient is requesting coverage for Botox injections to the forehead for treatment of hyperhidrosis. The patient was previously treated with Botox injections and did not improve, presumably because the dose was too low. As referenced in the medical literature, Botox does not carry an FDA approval for the treatment of hyperhidrosis of the face, only axillary hyperhidrosis. Consequently, the treatment requested is not FDA approved, and it is not clear that the patient has failed therapeutic doses of first line therapies. Under these circumstances, Botox 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for Lyrica 50mg capsules, once daily to help with fibromyalgia. The current guidelines do not recommend one therapy over another. A study found that the most extensive evidence is available for pharmacological treatment of neuropathic pain, and currently recommended first-line treatments include anti-depressants (tricyclic agents and serotonin-norephinephrine reuptake inhibitors (SNRI)) and anticonvulsants (gabapentin and pregabalin). Given the patients multiple co-morbidities, Lyrica is a reasonable choice to treat both her fibromyalgia pain and her neuropathic pain. Under these circumstances, Lyrica 50mg capsules, once daily, are medically necessary for treatment of the enrollees 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 rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center services provided. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay by moving from program-driven to clinically driven and outcomes-driven treatment. In this case, on admission, the patient was not in withdrawals and not at imminent risk for withdrawals. She was in the process of tapering from OxyContin and Klonopin. She was not a danger to herself or others, and she showed no self-harming behavior. There was no evidence of emotional, behavioral, cognitive, or impulsive factors requiring residential level of care for containment. The patient had a history of at least six prior residential treatments, and reported a 10-year period of sobriety, demonstrating the ability to remain sober independently. Psychiatrically, the patient did not require the containment of a 24-hour/seven day per week environment with 24-hour/seven day per week medical and nursing monitoring. The records did not document monitoring of her weight, and there was no clear detailed description of her eating disorder behaviors beyond the fact that they were intermittent. There was no indication that there were any 12-step groups provided, or any other type of therapeutic intervention beyond the limited therapists notes. There was no description of any relapse prevention plan. There was nothing to suggest that she could not have been treated in an ambulatory setting, as evidenced by the fact that she was already on a taper for both the Klonopin and the Oxycontin. Therefore, residential treatment center services provided were 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 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.