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 acute rehabilitation facility services upon discharge. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who has a recent history of meningitis and stroke.The submitted documentation does not support the medical necessity for the requested services in this patients case. The patient has sustained multiple neurological insults, including a cerebral stroke, cerebral meningitis and a cervical spinal cord injury due to abscess. The cervical spinal cord injury has caused left greater than right arm weakness. The cerebral insults have caused cognitive impairments and may have contributed to his weakness. The abscess and osteomyelitis in the cervical spine were surgically addressed, which is critical in the management of this condition. The patient is noted to have residual functional impairments. The patients health and functional status are not noted and notably, there are no indications that this patient is currently medically stable. There are, moreover, no updated physical or occupational therapy evaluations since his surgery in the documentation provided. The only therapy notes provided indicated that he was lethargic at the time.  He was also being physically restrained for his safety at the time. Current standard of care for admission to acute inpatient rehabilitation requires documentation to support that this level of care is medically necessary.  In light of the lack of relevant recent clinical documentation, both with respect to the medical and therapy disciplines, the medical necessity of acute inpatient rehabilitation has not been established at this time.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 physical medicine and rehabilitation 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 Keppra and Trileptal. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested brand name medications in this clinical setting. Several studies have examined brand versus generic anti-epileptic medication regimens. The results of that study showed that generic and brand bioequivalence were similar. Data suggests that generic products of branded modified-release products (e.g., extended release, delayed release) are bioequivalent and safely interchangeable. Results from these studies have shown no difference in bioequivalence when switching from a brand product to a generic product or between multiple generic products. For these reasons, the requested brand name medications, Keppra and Trileptal are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested brand medications 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 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for inpatient hospitalization for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the patient has a history of two prior hospitalizations for impulsive suicidal behaviors. She had recently received partial hospitalization program services. The patient continued to have delusions and was internally preoccupied. The inpatient team was actively titrating her clozapine dose, and the patient continued to disrobe on the unit. During the dates of service in dispute, the patient was unable to attend to her activities of daily living. She had not showered in two days, and she was not grooming her hair or brushing her teeth. She continued to be delusional. The patient continued to isolate. Although the patients parents are supportive, it is unlikely that she would cooperate with partial hospitalization attendance and weekly blood draws for complete blood count monitoring. All told, inpatient hospitalization was and is medically necessary for the treatment of this patient. Final Result: The reviewer 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: The reviewer is board certified in psychiatry with expertise in child and adolescent 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 and prospective authorization and coverage for long term residential psychiatric treatment in the locked facility. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Findings: There is a lack of support for the medical necessity of the services at issue in this clinical setting. The patient was documented as violent, having mood lability, and hearing voices. The patient also reported thoughts of harm to himself and other people. The provider indicated that the patients symptoms remained acute and the patient was not progressing in treatment and recommended treatment at the inpatient level of care. Per the documentation provided for review, the patient has been easily agitated and antagonizing peers and staff. He has threatened harm to himself and others and has required medication for agitation. He has also attempted to elope. Applying the American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) to determine the appropriate level of service intensity for behavioral health treatment, this patient may benefit from a higher level of care at an inpatient level of care facility. The CASII utilizes dimensions including risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services.  Based on the patients clinical history provided and documentation, the patient meets CASII criteria for level 6, which correlates to secure 24-hour services with psychiatric management. This level of care is the most intensive and restrictive level of care, with active psychiatric management and daily contact with the patient. Based on the documentation provided by the staff of the residential facility, the patients clinical status, and current medical literature, this patient demonstrates that he may benefit from a higher level of care at an inpatient level of care facility. Accordingly, treatment at long term residential psychiatric treatment in the locked facility was not and is not medically necessary at this time.Final Result: The reviewer determined that services at issue were not and 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 child and adolescent 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz. The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee who has a history of psoriatic arthritis and alopecia universalis.Findings:  There is support in peer-reviewed medical literature as to the efficacy of the requested medication in this patients case. Alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of alopecia areata which includes hair loss in eyebrows, eyelashes and facial hair. Other autoimmune diseases are also linked with alopecia areata. In addition, treatment is challenging and aims at the regrowth of hair. Although alopecia areata is not life threatening or painful, its onset and erratic nature disrupts and affects an individuals activities of daily living as well as affect their self esteem, body image, and/or self confidence. Xeljanz is an oral JAK 1/3 inhibitor approved for the treatment of moderate to severe rheumatoid arthritis. It has been also studied for treatment of psoriasis, inflammatory bowel disease, and other immunological diseases. Several recent reports in the literature provide evidence for the effectiveness of Xeljanz in the treatment of alopecia areata. The rational for hair regrowth was the data that the JAK inhibitor treats alopecia areata. Therefore, the requested medication Xeljanz is likely to be more effective than the standard therapy available for treating this patients medical condition.Final Result: Two of the three reviewers determined that the requested medication is 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 reviewers are board certified in dermatology and are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of both knees for evaluation of the enrollees bilateral knee pain. Findings:  The physician reviewer found that submitted documentation does not support the medical necessity of the requested diagnostic procedure for evaluation of this patients knee pain. The medical literature supports MRI examination if the patient has not responded to a trial of conservative treatment for approximately three to six weeks. The records indicate that this patient has had symptoms for many years, has not sustained any recent trauma, and there is no indication that he has an infection or other condition that might demand immediate attention. Patients with persistent or recurrent unexplained pain after three to six weeks of conservative treatment may require MRI. The studies have shown that MRI has little to offer patients who have been diagnosed with non-traumatic knee pain, or those who have no mechanical symptoms and no findings of degenerative arthritis on plain films. Accordingly, MRI of both knees is not supported as medically necessary for the evaluation of this patients bilateral knee pain. 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 diagnostic radiology  and is actively practicing. The reviewer is an expert in the evaluation 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 mg-40 mg tablets for eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus, genotype 2b.According to the 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 non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 2 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. The SURVEYOR-2 trial showed a 99% cure rate with eight weeks of treatment.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret is supported as medically necessary for the treatment of this patients hepatitis C infection. For these reasons, the requested treatment with Mavyret 100 mg-40 mg tablets for eight weeks to treat hepatitis C is supported as medically necessary. 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: An enrollee has requested authorization and coverage for mastectomy. The records document that this patient has gynecomastia, which is an abnormal structure of the body. However, the patients medical condition is not attributed to congenital abnormalities, developmental abnormalities, trauma, infection, tumors and disease. Moreover, the records do not document any health or functional problems caused by the patients enlarged breasts. This patients records do not document any concern for breast cancer. The procedure will primarily improve the patients appearance and therefore is cosmetic. Observation, reassurance and use of analgesics are reasonable management approaches for this patients condition. All told, the requested mastectomy is not supported as medically necessary or reconstructive in nature for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 plastic 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: A male enrollee has requested authorization and coverage for hyperbaric chamber treatment. Hyperbaric oxygen therapy is indicated for a Wagner 3 or greater diabetic foot ulcer that has failed local wound care and vascular intervention, if appropriate. The records indicate that this patient has local ischemia and a toe ulcer. The patient is not a candidate for surgery or angiography. Confirmation of osteomyelitis or a deep infection was not noted via imaging, biopsy, or cultures. Hyperbaric oxygen therapy is not indicated for isolated vascular disease. Although studies have indicated that hyperbaric oxygen therapy may benefit diabetic foot ulcers not amenable to vascular surgery, skin perfusion results were not provided along with oxygen response to confirm potential benefit from hyperbaric oxygen therapy. In addition, evidence of chronic osteomyelitis refractory to surgery and antibiotics was not demonstrated. For these reasons, the requested hyperbaric chamber treatment is not 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a multi-chamber programmable lymphedema pump (Flexitouch system). Head and neck lymphedema is a side effect from cancer treatment which is difficult to treat. Early institution of complete decongestive therapy is indicated for head and neck lymphedema. Complete decongestive therapy generally consists of a two-phase treatment program that can be used in both adults and children. The first phase includes a massage-like technique called manual lymphatic drainage and limb compression. The second phase is the maintenance phase and consists of compression garments worn during waking hours, exercises and self-manual lymphatic drainage. Intermittent pneumatic compression (IPC) is another method of compression therapy. IPC may be most effective in addition to a multimodality lymphedema treatment. IPC may also be an alternative maintenance program for lymphedema patients that have difficulty in performing self-manual lymphatic drainage secondary to weakness, fatigue, or range of motion deficits.  The Flexitouch system is an advanced intermittent pneumatic compression device used to self-manage lymphedema and non-healing venous leg ulcers. In this case, the patient has head and neck lymphedema which has not been found to be improved with IPC as much as limb lymphedema. Complete decongestive therapy is indicated for the treatment of this type of head and neck lymphedema. Thus, the multi-chamber programmable lymphedema pump (Flexitouch system) is not likely to be superior over other available methods of evaluating this patient. Findings:  Three physician reviewers found Final Result: The reviewers determined that the requested device is 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 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 Repatha SureClick subcutaneous solution auto-injector 140 mg/mL.Findings: The submitted documentation does not support the medical necessity of the requested medication. This patient has documented cardiovascular disease and a recent LDL that is already close to a goal of less than 70 mg/dl while on atorvastatin 40 mg per day.  Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol despite maximum tolerated medication. In this case, the documentation does not support the patient has heterozygous familial hypercholesterolemia, and it would be reasonable to expect that a higher dose statin medication (atorvastatin 80 mg or rosuvastatin 40 mg) may bring the patients LDL to within a goal of less than 70 mg/dl.  Moreover, the records do not document a trial of adding ezetimibe, which has been shown to be safe and effective at further lowering LDL cholesterol when used with statin medication. Therefore, the requested Repatha SureClick subcutaneous solution auto-injection 140 mg/mL is not medically necessary for the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a seven-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that In the medical literature, Reichow and colleagues reported that ABA is an effective treatment modality for children with autism spectrum disorder. Linstead and colleagues showed that higher intensity ABA consisting of 35-40 hours per week leads to better outcomes in learning and language primarily, but also in behaviors like elopement or tantrum. Given the research showing that higher intensity and longer duration provide better outcomes, 40 hours per week of direct applied behavioral analysis (ABA) provided was and is medically necessary for treatment of this patients autism spectrum disorder. Final Result: The reviewer 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: 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.