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 modafinil. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested medication in this clinical setting. Modafinil is a medication that promotes sleep, and when used in patients who are sleep-deprived, can improve mood, fatigue, sleepiness, and cognition. However, at this time, modafinil is not approved for use in children under the age of 17. It has been approved by the U.S. Food and Drug Administration for use in narcolepsy, shift-work sleep disorder, and obstructive sleep apnea with residual excessive sleepiness not resolved by use of continuous positive airway pressure. While there are clinical trials at major study centers looking at its use in children, currently, modafinil cannot be recommended for use in this patients case. Other treatment options should be investigated. For these reasons, modafinil 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 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 reimbursement for the gene panel testing performed. Findings:  The physician reviewer found that the patient had a stroke at the age of 18 and a strong family history of early strokes. While the patients physical examination was unremarkable for Marfan, classic Ehlers-Danlos or Shprintzen syndromes, up to 20% of individuals with thoracic aortic aneurysm and dissection (TAAD) do not have classic features of these conditions. Furthermore, approximately 30% of families with heritable thoracic aortic disease (HTAD), a familial version of TAAD, who do not have a clinical diagnosis of Marfan syndrome or another syndrome possess a causative pathogenic variant in one of the known HTAD-related genes. These genes are part of the Marfan/TAAD sequencing panel. A gene specific diagnosis will inform the patient of recurrence risk and it will also change the management strategy for the patient.  Final Result: The reviewers determined that the testing 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: the reviewers are board certified in pediatrics and clinical genetics 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 172 hours per month of one-on-one applied behavioral analysis (ABA) therapy, 17 hours per month of supervision and six hours per month of parent training. Findings:  The physician reviewer found that The Health Plan has authorized 35 hours per week of direct ABA therapy, 15 hours per month of supervision and six hours per month of caregiver training. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30-40 hours of treatment per week. In this case, the patient has made progress in many areas as evidenced by the progress report, but he continues to demonstrate impairment in several areas including aggression, self-injury, tantrums, property destruction and non-compliance. The patient has failed to respond adequately to medications, increasing the likelihood of outburst behaviors and regression with decreased ABA hours. Based on the documentation submitted for review, the request for 172 hours per month (40 hours per week) of one-on-one ABA therapy, 17 hours per month of supervision and six hours per month of parent training were and are medically necessary for treatment of the patients medical condition.Final Result: The reviewers determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for stereotactic body radiotherapy.  Findings:  The physician reviewer found that the patient has a recurrence of ovarian cancer following standard chemotherapy.  Standard treatment in this setting is with second-line chemotherapy.  There are cases when patients with certain histologies with limited metastatic disease are eligible for SBRT.  However, an oligometastatic state for ovarian cancer has not been described in the medical literature.  There is a lack of convincing medical evidence which suggests that patients with ovarian cancer benefit from SBRT. The primary pattern of failure for patients with ovarian cancer is systemic, which is why treatment is with chemotherapy.  Thus, SBRT is not likely to be of greater benefit than other methods of treating this patient.  Final Result: The reviewers 2 of 3 determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in radiation 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 108 hours per month of one-on-one applied behavioral analysis (ABA) and 13 hours per month of supervision. Findings:  The physician reviewer found that there is sufficient peer-reviewed literature supporting the correlation between treatment outcomes and treatment intensity for children with autism. In this case, the patient has made progress in many areas over the last several years, but he continues to demonstrate impairment in several areas including aggression and self-injury. The Health Plan has authorized approximately 17 hours per week of direct ABA therapy. Several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes. Given the patients increasing behaviors of self-injury and aggression, the request for 108 hours per month of direct ABA and 13 hours per month of supervision are medically necessary for treatment of the patients medical condition. 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 physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral 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: An enrollee has requested reimbursement for carotid duplex scan. Findings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting.  The records noted increased cardiovascular risk.  The report also noted a history of dizziness.  There is no documentation to support known carotid stenosis, focal neurologic symptoms, focal neurologic abnormalities on physical examination, carotid bruits or other standard accepted indications to perform a carotid ultrasound.  Screening carotid ultrasounds in this clinical setting are not supported by current guidelines.  In addition, a carotid ultrasound to evaluate for nonspecific dizziness without documented focality or other concern for carotid stenosis is not considered standard accepted practice in the medical community.  Therefore, carotid duplex scan was not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endoscopic Maze ablation reconstruction of the atria. Findings:  The physician reviewers found that the surgical Maze procedure is indicated in atrial fibrillation in patients whose atrial fibrillation cannot be controlled with medication. The technique has evolved such that thoracoscopic procedures are preferred in terms of patient outcome. Patients with persistent atrial fibrillation are at higher risk of stroke and embolic events, and this patient has failed medical management and cardioversion. Hence, for this patient, endoscopic Maze ablation reconstruction of the atria is likely to be more beneficial for treatment of the patients medical condition than other standard procedures. Final Result: 3 of 3 reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in thoracic 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: An enrollee has requested authorization and coverage for zoledronic acid (Reclast). Findings:  The physician reviewer found that the medical records fail to demonstrate the medical necessity of the requested medication in this clinical setting. There was no reason provided as to why this patient was not or could not try oral bisphosphonate therapy. Oral bisphosphonate has been largely used for treatment of postmenopausal osteoporosis. Therefore, the records provided have not established that the intravenous bisphosphonate is needed in this patients case.  Instead, oral medications should be tried as a first line therapy in the treatment of this patients osteoporosis. In sum, zoledronic acid (Reclast) is not medically necessary for treatment of this patients medical condtition. 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 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 Flector patch. Findings:  The physician reviewer found that the documentation does not support the medical necessity of the requested medication in this clinical setting. The medical literature indicates that non-steroidal anti-inflammatory medications (NSAIDs) are contraindicated in patients who experience side effects of gastrointestinal irritation due to increased risk of gastric ulcers and gastric perforation. In this patients case, there is no documentation of gastrointestinal irritation with NSAIDs. Authors of a study performed a systematic review to address and summarize the evidence of the effectiveness and safety in topical NSAIDs. The authors concluded that topical NSAIDs may vary significantly in their absorption kinetics and pharmacodynamic effects, based on their molecule and the formulation chosen. In acute and chronic low back pain, widespread musculoskeletal pain and in peripheral neuropathic pain syndromes, the current evidence does not support the use of topical NSAIDS. The authors performed a meta-analysis of randomized controlled trials comparing topical NSAIDs with placebo. They found that there was limited trial data to support the long-term use of topical NSAIDs in osteoarthritis. Therefore, Flector patch is not medically necessary for the treatment of this patients medical 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for continuation of 20 hours per week of direct applied behavioral analysis (ABA) and 12.5 hours per month of supervision. Findings:  The physician reviewer found that a study of 726 children, ages 1.5 to 12, evaluated the relationship between ABA treatment intensity and treatment outcomes for individuals with ASD. The authors reported that a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress was demonstrated. The authors concluded that These results add to the existing support for higher intensity treatment for children with ASD. In this case, the patient has made progress in many areas as evidenced by the progress notes. However, she continues to demonstrate impairment in self-injury, stereotypies and ritualistic behavior. The patients impairments make it increasingly difficult for her to be successful in more generalized environments. The providers recommendation of 20 hours per week of direct ABA and 12.5 hours per month of supervision is medically necessary and recommended for an optimal response. 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 physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for arthroscopic hip surgery for labral tear, loose body removal and chondroplasty. Findings:  Three physician reviewers found that the medical literature does not support the superior efficacy of the services at issue in this clinical setting. The published studies available are generally retrospective in nature with very few being well-controlled. Although there is some evidence suggesting short to medium term benefit, there is a lack of long term follow-up evidence to determine impact, if any, on osteoarthritis progression. Hip arthroscopy in presence of degenerative changes in excess of grade one is of questionable benefit. In addition, evidence supporting surgery for femoral-acetabular hip impingement is somewhat uncertain at best. The studies indicate that hip replacement surgery is the standard treatment option in this clinical setting. Therefore, arthroscopic hip surgery for labral tear, loose body removal and chondroplasty was not likely to have been more effective than the available treatment option of treatment this patient. Final Result: 2 of 3 reviewers determined that the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 40 hours per week of one-on-one applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that the medical necessity of ABA services is supported in the peer-reviewed literature as the standard of care for the treatment of individuals with autism. There is sufficient evidence supporting the correlation between treatment outcomes and ABA treatment intensity. In this case, the patient continues to demonstrate impairment in several areas including tantrums and self-injury and he has not met the majority of his ABA treatment goals. The Health Plan has been authorized for 29 hours per week of direct one-to-one ABA services, which is on the low end of what is typically recommended for optimal response. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30-40 hours of treatment per week. Given the patients tantrum and self-injurious behaviors, the request for 40 hours per week of ABA has been established as medically necessary in this clinical setting. Final Result: The reviewers 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: Physician reviewer number one is board certified in pediatrics with sub-specialty certification in developmental-behavioral 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Santyl ointment. Findings:  The physician reviewer found that this patient has a history of a diabetic foot ulcer for 1.5 weeks. He was evaluated and reported no improvement with home health treatment. On physical examination, he was found to have an ulcer with diabetes. He also has a history of neuropathy. Santyl ointment is indicated for diabetic patients with foot ulcers. In addition, Santyl ointment has been shown to be effective in chronic wounds. Given the lack of improvement with home health services, the requested Santyl ointment is medically necessary 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 sub-specialty certification in infectious 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vein ablation. Findings:  The physician reviewer found that the documentation does not support the medical necessity of the requested vein ablation. Most significantly, there is documented competence of the left SSV, which does not support an indication for ablation. Additionally, the patient has multiple risk factors for lower extremity arterial disease including severe coronary artery disease and atrial fibrillation with atrial thrombus. Overall, it is not clear that the patients symptoms are due to her varicose veins. Although mentioned by the patient, the records do not document varicose bleeding, which would be an indication for treatment with thorough assessment of arterial perfusion and direct treatment of the involved vein, not ablation of a competent vein. All told, the records provided for review do not demonstrate that the requested vein ablation is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested service 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 surgery with sub-specialty certification in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.