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 an echocardiogram. The Health Plan has denied this request indicating that the requested test is not medically necessary for treatment of the enrollee's condition. A review of the record indicates that the enrollee has been diagnosed with a small anterior muscular ventricular septal defect (VSD) and patent foramen ovale (PFO). An echocardiogram indicated no PFO was seen and the PFO appeared smaller in comparision to the echocardiogram.At issue in this case is whether the requested echocardiogram is medically necessary for treatment of the patients medical condition. Colleagues note that VSDs are the most common congenital heart defects in newborns. Muscular defects are the most frequent ones with most of them being small. The probability of a VSD spontaneuous closure is high, even after the first year of life. This is a healthy with a trivial heart defect. Initially she had a small PFO which was normal at that age and which subsequently closed on follow up. The VSD was described as small on the initial exam. At her most recent echocardiogram, the VSD had gotten smaller. The VSD was now described as trivial. She never had any symptoms of congestive heart failure and never required treatment. This is the natural history of a muscular VSD, which is very likely to close completely without intervention. A repeat echocardiogram so soon following the 6-month study is not medically necessary and would not alter her treatment. She was never symptomatic and no decisions had to be made regarding her treatment. Therefore, the echocardiogram is not medically necessary.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 pediatric cardiology 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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Dexilant 60 mg. There is sufficient support for the requested medication in this clinical setting. Dexilant, unlike other proton pump inhibitors, is released in an extended fashion. This delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric pH than other proton pump inhibitors. Researchers noted that a significant majority of patients (88%) requiring other proton pump inhibitors twice daily were able to control symptoms on Dexilant once daily. Since this patient has failed two conventional proton pump inhibitors in the past, it is unlikely that she will find relief with one of the alternative proton pump inhibitors. Dexilant, unlike alternatives, has been effective in this case. Therefore, Dexilant 60 mg daily is medically necessary for the treatment of 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 board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for septoplasty or submucous resection (CPT code 30520) and submucous resection inferior turbinate (CPT code 30140). In the peer-reviewed medical literature, researchers reported that OSA is a common condition, primarily caused by narrowing of the nasal and pharyngeal airway. Treatment with continuous positive airway pressure (CPAP) is considered the first-line of therapy. Bilateral submucous resection (CPT code 30140) is a technique to improve the airway and has been beneficial in patients with severe obstruction noted on physical examination. Poirier and colleagues reported that their study demonstrates improved CPAP compliance rates following septoplasty in OSA patients with nasal obstruction. The authors recommended that correction of nasal obstruction should be offered in nasal CPAP-intolerant individuals to improve CPAP compliance. In this clinical case, the patient has had documented evidence of severe left-sided nasal septal deformity and inferior turbinate hypertrophy causing a great deal of the symptoms of obstruction. This patient has been treated with CPAP but became intolerant to the device. Researchers noted that the effect of nasal surgery on obstructive sleep apnea seemed to be greater when there were indications for combined surgery of the inferior turbinates and the nasal septum, compared to when there were indications for septoplasty alone. Given this support, the requested septoplasty or submucous resection (CPT code 30520) and submucous resection inferior turbinate (CPT code 30140) are likely to be more beneficial for treatment of the patients medical condition than any available medical condition.One reviewer found that the requested septoplasty or submucous resection (CPT code 30520) and submucous resection inferior turbinate (CPT code 30140) are not likely to be more beneficial for treatment of the patients medical condition than any available medical condition.Final Result: Two of the three 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:  One reviewer is board certified in otolaryngology with sub-specialty certification in sleep medicine and is actively practicing. One Reviewer is board certified in otolaryngology and is actively practicing.  One Reviewer is board certified in otolaryngology with sub-specialty certification in plastic and reconstructive surgery 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees alcohol dependence, stimulant dependence, major depressive disorder, anxiety, and other psychoactive substance abuse. At issue in this case is whether the requested residential treatment center services provided are medically necessary for treatment of the enrollees behavioral health condition.The American Psychiatric Association treatment guidelines for substance use disorders recommends that residential treatment or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance uselack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. A patient requires safe and stable living environments in order to develop their recovery skills thus qualifying for ASAM Level III treatment at least i.e. residential or inpatient treatment similar to what the patient received at the facility. Patients conditions wax and wane. A relatively positive documentation by one person on one day does not indicate spontaneous cure or that the patient is in the clear, it simply denotes progress and that treatment is working, which is an indication to continue not cease treatment. The purpose of detoxification is to make the patient physically stable and safe. Rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce risk of relapse. Given the severity of the patients illness including the behaviors that put himself and others at risk as well as an unhealthy home environment, residential treatment was in accordance with generally accepted standards of medical practice; clinically appropriate for the patient's illness, and is therefore medically necessary.Final Result: The reviewer determined that the requested services were 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 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: A 49-year-old male enrollee has requested authorization and coverage for substance related addictive disorder treatment at a residential treatment center. The Health Plan has denied this request indicating that the requested treatment was not medically necessary for treatment of the enrollees alcohol dependence.The submitted documentation supports the medical necessity of the requested service. The American Psychiatric Association treatment guidelines for substance use disorders recommends that residential treatment or similar care higher than outpatient, is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use. lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.A patient requires safe and stable living environments in order to develop their recovery skills thus qualifying for American Society of Addition Medicine Level III treatment at least, i.e. residential or inpatient treatment similar to what the patient received at the facility. Patients conditions wax and wane: a relatively positive documentation by one person on one day does not indicate spontaneous cure or that the patient is in the clear, it simply denotes progress and that treatment is working, which is an indication to continue, not cease treatment.The purpose of detoxification is to make the patient physically stable and safe. Rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce risk of relapse, and with rehabilitation typically a 28-day stay. Residential treatment was in accordance with generally accepted standards of medical practice; clinically appropriate for the patient's illness, not more costly than an alternative service for treatment of the patients condition, and is therefore medically necessary.Final Result: The reviewer determined that the requested service was 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 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 reimbursement for an inpatient hospital stay. The Health Plan has denied this request indicating that the requested service was not medically necessary for treatment of the enrollees breast cancer. This patient was diagnosed with breast cancer. It appeared that the patient had extensive disease, though that was not a certainty. Accordingly, suspicious areas in bone, neck, and perhaps the colon would need to be biopsied. In particular, the bone biopsy would have to be done under anesthesia, as the previous needle biopsy was not diagnostic. Since all of these evaluations were necessary before treatment decisions could be made, and anesthesia was required, it is quite reasonable to expedite this needed workup with a brief hospitalization. Furthermore, the patient's pain control as an outpatient was inadequate, such that the patient required parenteral morphine to manage the pain. That alone can justify admission, but even more so in a patient who must undergo multiple consultations and procedures. Per the National Comprehensive Cancer Network guidelines, all of these tests needed to be done prior to real decisions about treatment could be made. Therefore, the inpatient hospital stay was medically necessary. Final Result: The reviewer determined that the requested services were 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two hours of individual speech therapy per week and two hours of social skills group therapy per week. Researcher has found that available evidence shows that highly structured behavioral methods have important positive consequences for children with autism. Colleagues have concluded that behavioral-based interventions are evidence-based to teach speech to non-verbal individuals or individuals with low levels of vocalizations at baseline. In this case, the submitted documentation reflects that the patient continues to have significant language deficits and difficulties and that an increase in speech therapy to two hours of individual speech therapy per week may be expected to improve his speech capabilities as well as have additional positive behavioral consequences. In addition, the patient is noted to have severe deficits in social interaction, and the highly structured behavioral methods provided by two hours of social skills group therapy per week may reasonably be expected to lead to improvement in the patients condition. Accordingly, two hours of individual speech therapy per week and two hours of social skills group therapy per week are medically necessary for treatment of the patients medical condition at this time.Final Result: The reviewer has 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 both 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cognitive behavioral therapy and a neuropsychological evaluation. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation and treatment of the enrollees autism and anxiety. A review of the record indicates that the enrollee has been diagnosed with autism and anxiety with dysfunctional behavior. Previous treatments had included applied behavior analysis (ABA), speech therapy, occupational and physical therapy, and medication therapy. The medical records indicate an abrupt change in staffing increased anxiety and increased inappropriate behaviors and new onset behavior of eating inappropriate substances. Current medication included Melatonin and Cetirizine daily. The enrollees provider has recommended cognitive behavioral therapy, a new order for Sertraline, and a referral to a psychiatrist including neuropsychological evaluation.Cognitive behavioral therapy has been shown to be a beneficial and effective treatment for children and adolescents with anxiety and autism, and is also determined by the reviewer to be medically necessary. Wood and colleagues followed 40 children ages 7-11 with anxiety and autism who were randomly assigned to 16 sessions of CBT or a three-month waitlist. The CBT model emphasized behavioral experimentation, parent-training, and school consultation. In intent-to-treat analyses, 78.5% of the CBT group met Clinical Global Impressions-Improvement scale criteria for positive treatment response at post treatment, as compared to only 8.7% of the waitlist group. CBT also outperformed the waitlist on diagnostic outcomes and parent reports of child anxiety, but not childrens self-reports. Treatment gains were maintained at three-month follow-up. Based on the records provided for review, there is significant scattering in the patients abilities, and he is likely to respond well to CBT. An accurate evaluation of the patients language level and intellectual function will enable appropriate services to be tailored to his needs and abilities. For these reasons, the requested CBT and neuropsychological evaluation are supported as medically necessary for evaluation and treatment of this patients behavioral health issues. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics and 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The American Academy of Neurology 2012 headache guideline, reaffirmed in 2015, provides evidence and recommendations for management of episodic migraine headache prevention that categorizes drugs into five categories, including Level A (highest evidence), Level B (next highest level of evidence), Level C (lowest level of evidence), Level U (evidence against) and Other. Level A includes triptans, antieplipeptics and beta blockers. Level B includes antidepressants and additional triptans. Level C includes angiotensin-converting-enzyme (ACE) inhibitors and alpha agonists. This accepted guideline does not include calcitonin gene-related peptide receptors like Aimovig, which was just approved by the FDA in May 2018. A recent report by the Institute for Clinical and Economic Review (ICER) also concluded that there is inconclusive evidence for the use of Aimovig compared to other established oral agents for the prevention of migraine.Per the patients treating physician, she has tried and failed several drugs for treatment of her migraines. There is no documented evidence of trial and failure of anti-depressants or ACE inhibitors; while the patients concerns about side effects from these drugs are noted, they are considered part of the established treatment protocol for migraine headaches. Most importantly, while it is acknowledged that calcitonin gene-related peptide receptors like Aimovig show promise, their use has not yet been incorporated into national guidelines and is not supported by recent literature. For these reasons, the requested Aimovig injection is not medically necessary at this time.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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Vyvanse 10 mg one tablet daily. Overall, there is a lack of documentation to support a diagnosis of ADD in this patients case. Documentation does not provide detailed ADD symptomatology targeted by the Vyvanse, such as inattention, lack of focus, poor concentration, interrupting others, or inability to complete tasks. Further, the note lacks any report of efficacy of the Vyvanse on such symptoms. All told, the requested Vyvanse 10 mg one tablet daily is not medically necessary for 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Mavyret 100/40mg, three times daily, for eight weeks.  Findings:  The physician reviewer found that submitted documentation supports the medical necessity of the requested medication. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. In this case, the submitted medical records support that the patient has a positive diagnosis of hepatitis C and a failure of a prior medication trial, and therapy with Mavyret would be consistent with AASLD and IDSA guidelines at this time. Accordingly, Mavyret 100/40mg, three times daily, for eight weeks, is medically necessary for treatment of the 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 a subspecialty 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.