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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for omeprazole 40 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients abdominal pain. The submitted documentation does not support the medical necessity of the requested medication. American College of Gastroenterology guidelines for gastroesophageal reflux disease (GERD) recommends proton pump inhibitor (PPI) therapy for patients with GERD. Researchers found there to be no difference in the multiple formulary PPIs, such as those attempted by this patient, which include omeprazole, lansoprazole, rabeprazole, and pantoprazole in the control and healing of GERD. Clinical guidelines for dyspepsia, also characterized by abdominal pain, recommend an attempt of proton pump inhibitor therapy. However, the requested prescription omeprazole is not supported as superior to over-the-counter omeprazole or other PPI alternatives. For this reason, omeprazole 40 mg is not 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: 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 social skills group therapy. The patient currently receives one-to-one applied behavioral analysis (ABA) services and speech and language services weekly. According to medical researchers, ABA has the most evidence supporting its effectiveness for treatment for children on the autism spectrum, and the patient is currently accessing these services and making significant gains. Further, the ABA provider highlighted that social interaction skills were a relative strength, and the speech evaluation identified auditory comprehension, expressive communication, and pragmatic judgment were within average limits. Based on this information, the requested social skills services group therapy is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested service 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 psychology and am a board certified behavioral analyst 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 Mavyret 100-40 mg for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus, genotype 3. The submitted documentation supports the medical necessity of the requested medication regimen. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 3 patients should be treated with Mavyret 100-40 mg (three tables daily) for eight weeks. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg for eight weeks is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Claravis 40 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients cystic acne vulgaris with hyperpigmentation. The submitted documentation supports the medical necessity of the requested medication. According to the records submitted for review, this patient has cystic acne. The patient has failed treatment with traditional therapies including topical retinoids, and adapalene. Isotretinoin is appropriate for patients with cystic acne. Claravis is approved by the Food and Drug Administration and is standard of care for this condition. According to the American Academy of Dermatology guidelines of care for the management of acne vulgaris, oral isotretinoin is appropriate for the treatment of moderate acne that is treatment-resistant. This patient has already tried and failed the formulary alternative, tretinoin, as well as adapalene, which is another topical in that class of drugs. Thus, Claravis 40 mg 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 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: A enrollee has requested authorization and coverage for Orthovisc injections. Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Sources reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Orthovisc injections are supported as medically necessary for treatment of this patients knee osteoarthritis. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for right hip replacement. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients right hip osteoarthritis. The submitted documentation supports the medical necessity of the requested services. It is well documented that the patient has a history of chronic right hip pain, which has failed less invasive treatment in the past, including arthroscopic surgery for femoroacetabular impingement. A corticosteroid injection into the right hip resulted in a significant response with the pain level decreasing to eight out of a scale from one to ten, from ten out of a scale of one to ten. This confirmed that the patients pain source is the right hip joint and not the sacroiliac joint or the lower back. The documents indicate that the patient has pain with range of motion of the right hip along with some loss of internal rotation. The pain questionnaires completed by the patient indicate severe interference with activities of daily living. The provider recommended a total hip arthroplasty for the treatment of the patients right hip osteoarthritis. The pain source was confirmed as contralateral hip. Current medical literature indicates it is appropriate timing for a total hip arthroplasty, with respect to the severity of the patients osteoarthritis and the degree of pain. The quality of life and the degree of disability due to the subjective reports are important factors in this patients case. Therefore, although there is a lack imaging evidence of severe end-stage osteoarthritis, the degree of pain, and the quality of life of this patient are important factors, which should be addressed. As such, right hip replacement is reasonable, appropriate, and 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 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 an enrollee has requested authorization and coverage for autonomic neuropathy assessment (cardiovascular testing with head-up tilt, the Valsalva maneuver, deep breathing, thermoregulatory sweat test, and quantitative sudomotor axon reflex test). The diagnosis of autonomic neuropathy in young patients, particularly in the setting of diabetes, is characterized by orthostatic hypotension, exercise intolerance, gastroparesis, diarrhea, constipation, and urinary incontinence. While this patient does not carry a diagnosis of diabetes type 1, she does have multiple neurologic and psychiatric diagnoses. From the history and records from her providers, the patients psychiatric diagnoses outweigh neurologic diagnoses in terms of clinical importance and interference with her ability to perform activities of daily living. The lack of objective findings on examination and laboratory evaluations has not pointed to a known neurologic disease. Thus, these findings do not substantiate the noted clinical diagnosis. Based on these findings, the requested autonomic neuropathy assessment (cardiovascular testing with head-up tilt, the Valsalva maneuver, deep breathing, thermoregulatory sweat test, and quantitative sudomotor axon reflex test) are not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested services are 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 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: An enrollee has requested authorization and coverage for left heart artery/ventricle angiography (CPT code 93458). Current guidelines for recommending invasive diagnostic testing with cardiac catheterization and coronary angiography for patients with known or suspected stable ischemic heart disease, such as this patient, include patients who have features on noninvasive diagnostic testing of potentially high risk coronary disease. This includes findings on myocardial perfusion imaging of large areas or multiple areas of reversible ischemia which would correspond to a summed difference score of greater than 8. The patient was found to have a small area of lateral wall ischemia with the summed difference score of 1. In an otherwise stable patient, this finding does not indicate high-risk anatomy that warrants an invasive procedure such as cardiac catheterization. No other findings on clinical examination or other noninvasive testing support cardiac catheterization in this patient. Given these findings, the requested left heart artery/ventricle angiography (CPT code 93458) is not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested services are 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 20 days of partial hospitalization program (PHP). The submitted documentation fails to demonstrate the medical necessity of the requested services. The progress notes do not document active suicidal or homicidal ideation. There is no indication that the patient was experiencing psychosis. The patient was noted to be cooperative with treatment. The progress notes do not indicate that the patient was engaging in self-harm or aggression. The literature indicates that therapy on a consistent basis along with medication treatment is the most successful for eating disorder treatment overall. Due to the fact that the patient was overall cooperative in treatment and not experiencing severe psychiatric symptoms, regular outpatient therapy would be effective, safe and appropriate. The patient is also noted to have a diagnosis of borderline personality disorder. The records do not indicate that the patient had current significant symptoms of her borderline personality disorder, such as self-harm or severe affective lability. Per the records, the patient could be safely and effectively treated in a less restrictive setting. Thus, 20 days of PHP is 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
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 genetic testing (procedure codes 81415, 81416 and 81460). There is sufficient support for the requested services in this patients case. When determining the appropriateness of genetic testing, the first essential step is clinical evaluation. In instances where phenotypic presentation does not yield a diagnosis, exome sequencing may be appropriate. Currently, exome sequencing is generally indicated for undiagnosed neurologic disorders with nonspecific or clinically heterogeneous phenotype, following expert evaluation with detailed history and examination, and negative initial genetic testing when deemed appropriate. For this patient with gross motor delay, speech delay, dysmorphic features, and family history, exome sequencing is indicated based on the current literature. Therefore, genetic testing (procedure codes 81415, 81416 and 81460) is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic esophageal sphincter augmentation (LINX). Findings:  Three physician reviewers found there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. The American College of Gastroenterology guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. For these reasons, the requested magnetic esophageal sphincter augmentation (LINX) is not likely to be of greater benefit than other treatment options. Final Result: The reviewers 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 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: A enrollee has requested reimbursement for the blood test. Findings:  The physician reviewer found that per guidelines, actionable mutations approvable are EGFR, ALK, ROS1, BRAF, Her 2 neu, RET, and MET testing. Genetic testing provided a comprehensive panel of molecular genetic markers on an individual patients tumor with the hopes of identifying markers than can help guide therapy decision making. For these reasons, the ALK, EGFR, BRAF, ROS1, RET, MET, and Her 2 neu portions of the blood test were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the blood test performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that a portion of 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 partially overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 authorization and coverage for laparoscopy, surgical, esophageal sphincter augmentation procedure (CPT code 43284). Findings:  Two of the three physician reviewers found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. Thus, laparoscopy, surgical, esophageal sphincter augmentation procedure (CPT code 43284) is not likely to be of greater benefit than other available treatment options. Final Result: The reviewers 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 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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.