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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic low back pain and fibromyalgia.Findings: There is a lack of peer reviewed evidence based studies which support Norco as an effective treatment in this clinical setting. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in the documentation available for review, there were no objective treatment goals for pain and function noted. Several requirements for opioid prescribing were not documented. Thus, the request for Norco as the primary medication treatment strategy for pain has not been established. The Centers for Disease Control and Prevention (CDC) recommends that when opioids are started, clinicians should prescribe the lowest effective dosage. Additionally, the records do not mention if behavior therapy has been performed, despite much research to support its use. As such, the medical necessity of Norco for treatment of this patients medical condition has not been established in this case.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: An enrollee has requested authorization and coverage for hyperbaric oxygen treatment. Many guidelines for hyperbaric oxygen treatment and hearing loss have not been updated to reflect the current medical literature and routine practice of hyperbaric oxygen. Studies found that hyperbaric oxygen treatment and combined therapy offered some benefits in hearing improvement. Combined intratympanic steroids and hyperbaric oxygen treatment may result in recovery of hearing, especially in lower frequencies. Hyperbaric oxygen treatment plus existing conventional treatment has also been associated with a better outcome than conventional treatment alone. Hyperbaric oxygen treatment is a safe and beneficial adjuvant therapy for sensorineural hearing loss patients. Hyperbaric oxygen treatment should help improve hearing in many patients unresponsive to initial therapy. Due to risk or long-term or permanent hearing loss, withholding hyperbaric oxygen treatment would be more harmful. The requested hyperbaric oxygen treatment is medically necessary for treatment of this patients sensorineural hearing loss.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 upheld. Credentials/Qualifications: The reviewer is board certified in family practice with sub-specialty certification in undersea and hyperbaric medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) coronary angiography. The Health Plan has denied this request indicating that the requested diagnostic procedure is not medically necessary for evaluation of the enrollees abnormal chest pain.Based on the records provided the patient has documented coronary disease, but the presenting symptoms do not have features concerning for coronary ischemia. In this circumstance, if further evaluation is indicated, then some form of repeat stress testing would be appropriate. In this case, CT coronary angiography is not medically necessary since it does not assess the functional significance of any stenosis identified and a link has not yet been established between the patients symptoms and coronary ischemia. Moreover, if an assessment of coronary anatomy is indicated, then conventional coronary angiography would be preferred due to improved accuracy of the test relative to coronary CT angiography and the ability to intervene with coronary revascularization during the same procedure. All told, the requested CT coronary angiography is not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Dynasplint.  The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees medical condition. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. In this particular case, there is no documented evidence that this patient has undergone recent orthotic treatments. The records do not document home stretching exercises for the plantar fascia, physical therapy, local steroid injection to symptomatic painful heel area, over-the-counter orthotic therapy, or anti-inflammatory medications. All of the above-mentioned treatments are first-line standard of care treatments for plantar fasciitis. Dynasplint devices may be used to help alleviate significant painful contractures of multiple areas of the body, including the lower extremity, foot and ankle. However, Dynasplint devices are not considered first-line treatment for painful plantar fasciitis. All told, the requested Dynasplint is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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 reimbursement for anesthesia services. The documentation provided for review indicates that this patient had an ASA preoperative physical status classification score of 1. In this clinical setting, intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in the current peer-reviewed medical literature, given a low preoperative physical status classification score. All told, the requested reimbursement for anesthesia services was not medically necessary for evaluation of the patients medical condition.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 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: An enrollee has requested authorization and coverage for anterior lumbar interbody fusion (ALIF) spine surgery and a one day hospital stay. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees low back pain.  Findings: There is support in the medical literature for the medical necessity of the requested services in this clinical setting. ALIF is indicated for advanced degenerative disc disease of the lumbar spine and has a high success rate in these cases. Furthermore, it is associated with higher fusion rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine including those with instability.  There is moderate evidence that for lumbar degenerative disc disease without instability, a standalone ALIF has better clinical outcomes than the anterior lumbar interbody fusion plus instrumented open posterior lumbar fusion. With regard to the type of interbody spacer used, frozen allograft is associated with lower pseudarthrosis rates compared with freeze-dried allograft. Based on these guidelines, the requested ALIF procedure is appropriate for treatment of the patients severe degenerative disc disease that has not responded to non-operative treatment.  As such, ALIF spine surgery and one day hospital stay are medically necessary for treatment of this 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 reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 10-year-old male enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy in a school setting. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.   The request for ABA therapy in a school setting is not medically necessary for the treatment of the patients medical condition. There is a lack of documentation provided to support the requested ABA services in a school setting. The documentation submitted for review does not include clinical documentation from the school that describes information regarding the patients behavior at school. There is a comment that his non-compliance and aggression are worse at school, but no further details are available. Although continued ABA therapy and parent training are clinically indicated for the patient, in addition to speech and occupational therapy, there is a lack of documentation provided to support ABA therapy as medically necessary in a school setting.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a gene test for known or suspected prostate cancer. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees suspected prostate cancer. The gene test for known or suspected prostate cancer was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. PCA3 is an acceptable test in staging for prostate cancer. However, it is not an accepted screening test for prostate cancer. In this case, the patient had a normal PSA. The free PSA of 36% does not suggest a risk for cancer that would support the testing at issue. The PCA3 has the most value as an alternative to a second biopsy when the first was negative and has value to determine the volume, grade and invasion of the cancer.  As such, the PCA3 was not of clinical value in this case. Accordingly, gene test for known or suspected prostate cancer was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the testing 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: All three reviewers 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services. Findings: The physician reviewer found that applying the Level of Care Utilization System (LOCUS) criteria, the RTC services were not medically necessary for treatment of this patients behavioral health issues. The patient presented with a low risk of harm (score 2) as the patient did not have any suicidal or homicidal ideation. In addition, the patient does not have a history of suicide attempts. The patient demonstrated moderate functional impairment (score 3) with a significant deterioration in his ability to fulfill responsibilities. The patient had significant co-morbidity (score 3) with ongoing substance use despite negative consequences. The patients recovery environment was moderately stressful (score 3) since the patient was living off his savings, had many relationships that have ended due to his substance use, and he had easy access to alcohol and drugs. The patient had limited support in the environment (score 3) but he demonstrated significant response to treatment and recovery (score 2) with effective prior treatments resulting 9.5 years without using substances prior to his relapse. The patient demonstrated limited engagement and recovery (score 3) since he was motivated to recover, but he wanted treatment to be done on his terms. He felt that the environment was too restrictive and left against medical advice. These results give the patient a composite score of 19, which is consistent with intensive outpatient program (IOP). Throughout the patients stay, the patient was a candidate for treatment in a less restrictive environment. The patient continued to require treatment for his substance use disorders, but this could have been accomplished in a less restrictive environment. Therefore, the RTC services were not medically necessary. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 magnetic resonance angiography (MRA) performed. This patients records do not document any history of focal neurological deficit, trauma or abnormal carotid ultrasound to indicate a possible vertebral or carotid dissection. Studies have shown a low positive yield for MRA of the head at 0.4% absent any focal neurological deficit. Carotid ultrasound would have been adequate to evaluate the patient for a dissection and most likely would have shown abnormal findings including elevated peak systolic velocities in the carotid arteries or perhaps reversal of flow in the vertebral arteries. In the absence of a focal neurological deficit, trauma or abnormal carotid ultrasound to indicate a possible vertebral or carotid dissection, the MRA performed was not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 of Vemlidy 25 mg tablets. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B virus. Findings: The physician reviewer found that the guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for treatment of hepatitis B but is associated with lower incidence of side effects such as osteopenia and renal disease. Moreover, the patient has demonstrated nausea with Viread. For these reasons, Vemlidy 25 mg tablets is medically necessary for the treatment of this patients hepatitis B. 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 internal medicine with sub-specialty 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: 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 titers testing. The requested testing for TDaP antibody titers is not supported as medically necessary for evaluation of this patients medical condition. Obtaining TDaP antibody titers prior to administration of TDaP vaccine booster is not considered to be the standard of care or routine clinical practice. The Centers for Disease Control and Prevention (CDC) and American Academy of Pediatrics (AAP) policy on immunizations in adolescence routinely recommends TdaP as a single dose for those 11 through 18 years of age with preferred administration at 11 through 12 years of age. There is no indication from CDC or AAP for obtaining vaccine titers prior to administration of routine booster TDaP vaccine. TDaP boosters are necessary every 10 years, taking into account that the estimated duration of immunity against pertussis is no more than 10 years and there is a need to maintain high protective vaccine-induced antibody titers to prevent illness from pertussis infection. Furthermore, protective antibody titers to pertussis would not preclude vaccine booster administration. All told, the requested titers testing is not medically necessary for evaluation and treatment of this patients medical condition.Final Result: The reviewer determined that the requested testing is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 26-year-old male enrollee has requested authorization and coverage for psychiatric intensive outpatient program (IOP) services for treatment of this patients medical condition Findings:  The physician reviewer found that he did not demonstrate suicidal or homicidal ideation, nor did he attest to self-harm urges or behaviors. There were no emotional, behavioral, or cognitive factors precluding him from stepping down to outpatient level of care. He was medically stable. His mood and affect remained essentially unchanged. He participated in his treatment plan, was attending Alcoholics Anonymous (AA) meetings regularly. There was nothing to indicate that he would deteriorate or decompensate if returned to his environment. He was using sober supports of the sober living environment. Goals were met in that he remained sober, his daily living functioning was stable and at baseline. All told, the requested IOP services are not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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.