Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for transanal hemorrhoidal dearterialization (THD) (CPT code 0249T). The enrollee had bleeding hemorrhoids and a family history of colorectal cancer.  Enrollee underwent a colonoscopy, which revealed internal hemorrhoids and diverticulosis. His hemorrhoids caused discomfort and rectal bleeding and the physician treated them with sclerotherapy, but his symptoms returned. He has also tried medications and a high fiber diet.  His colorectal surgeon states the enrollee had grade III  IV internal hemorrhoids that had failed conservative management.  He underwent transanal hemorrhoidal dearterialization (THD).  His surgeon states that the procedure done was ambulatory and the enrollee had immediate and effective symptom control.  At a follow-up visit. the enrollee reported no pain or bleeding since the procedure. Transanal Hemorrhoidal Dearterialization (THD) has been studied with randomized controlled trials and long-term follow-up supports the benefit in appropriately selected enrollees, such as this one. Findings: the physician reviewer found that the medical literature assessed the current evidence regarding THD to evaluate the safety and efficacy of the technique, define its indications, and identify its possible advantages and limitations.  The results were that THD is a viable treatment option for second-degree and third-degree hemorrhoids. Studies using Doppler-guided hemorrhoidal ligation demonstrated favorable results. A clinical trial found there were no major complications in the course of 50 patient treatments. Patients pain scores improved compared to traditional hemorrhoidectomy, and similar long-term cure rates were demonstrated when compared to excisional hemorrhoidectomy.  Based on the current body of peer reviewed literature regarding THD, this procedure has withstood adequate peer reviewed scrutiny, has been evaluated with prospective randomized controlled analysis, and is likely to be more beneficial for appropriately selected patients as in this case.Final Result: Two of the three reviewers determined the requested service is likely to be more beneficial than any other available standard service for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in surgery and one reviewer is board certified in colon and rectal surgery. All 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested authorization and coverage for 40 hours per week of Applied Behavioral Analysis (ABA) Services for the enrollee who has autism spectrum disorder.  He has received early intervention services, home visitation, therapeutic services, and developmental specialist services. He has stereotypic/repetitive movements, echolalia, and is bothered by loud noises.  During the evaluation, he presented as withdrawn and difficult to engage.  He was observed to rarely use words for communication, to have inconsistent eye contact, and a strong preference for independent play.  He responded to his name inconsistently, but was able to follow some one-step directives given gestures.  His Childhood Autism Rating Scale result indicated that he is demonstrating significant impairments in social interaction and communication, as well as restricted, repetitive patterns of behavior that interfere with his functioning.  The psychologist noted that these results along with clinical observations and developmental history indicate the enrollee meets diagnostic criteria for autism spectrum disorder.  In this enrollee, several challenging behaviors were targeted with associated goals for improvement.  Early intensive ABA-based interventions are well-documented throughout the past five decades to show substantial and sustained gains in IQ, language, academic performance, and adaptive behavior, as well as some improvement as it relates to social behavior, with outcomes that are significantly above those of children who do not receive this level of treatment.  Consensus guidelines in non-medical  interventions address cognitive function and core deficits in children  with autism as based upon a systematic overview  of research findings and concluded that children with ASD should have comprehensive intervention, such as ABA to address social communication, language, play skills, and maladaptive behavior.  Forty hours per week of ABA is typically required when patients are in the severe range in all domains and with full clinical presentation of ASD, Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is a board certified  psychologist 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees representative is requesting reimbursement for and future authorization and coverage for the medication, Xifaxan. Findings:  The physician reviewer found that the enrollee is diagnosed with small intestinal bacterial overgrowth (SIBO) and irritable bowel syndrome (IBS) with diarrhea.  Her symptoms include bloating, aching, and eructation.  She has been taking omeprazole, but symptoms persist. An (EGD) esophagogastroduodenoscopy demonstrated gastric erosion.  Her gastroenterologist recommended 550mg Xifaxan (rifaximin) three times per day for 14 days. The medical literature notes that Xifaxan is indicated for treatment of irritable bowel syndrome with diarrhea (IBS-D) in adults. It is also recommended for patients with hydrogen predominant bacterial overgrowth. Antibiotic therapy is typically begun on an empiric basis and studies suggest that clinical response rates may be higher with rifaximin (Xifaxan) than with other antibiotics. Shayto and colleagues indicate that rifaximin has been shown to improve symptoms in small intestinal bacterial overgrowth. The FDA has approved Rifaximin for IBS with diarrhea. The medical literature supports the use of rifaximin for small intestinal bacterial overgrowth. The alternative antibiotics that have been offered are not as effective for small intestinal overgrowth. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for Oncotype DX testing. The enrollee is diagnosed with left breast cancer, estrogen and progesterone positive and HER-2 negative, after biopsy.  She underwent a bilateral mastectomy aan pathology confirmed the diagnosis and showed two positive lymph nodes.  She then had Oncotype DX testing for the purpose of determining a treatment plan.  Her Oncotype DX score was low and she is being treated with Tamoxifen.  The enrollee indicates the results from the Oncotype DX test demonstrated that she did not need chemotherapy and without it, she would have been subjected to treatment that would not have reduced her risk of recurrence. The medical literature recommends utilizing Oncotype DX to help guide therapy with chemotherapy, hormone therapy or both in node-negative patients. The patients final pathology report showed 2/5 lymph nodes were positive. Thus, the Oncotype DX is not indicated.Final Result: The reviewer determined that the service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in surgical 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydrocodone. Medical guidelines require regular checks of the prescription drug monitoring system and utilization of urine drug testing as part of chronic opioid therapy. This patients provider generated a CURES report and confirmed that the patient has been receiving prescriptions of hydrocodone from his previous provider. A urine drug screen demonstrated nor-hydrocodone in the urine, which is consistent with regular usage of hydrocodone. Moreover, the requested medication is consistent with medical guidelines, which state that providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The providers notes do not document any drug seeking behavior or concern that the risks associated with opioid therapy outweigh the possible benefits. The primary reason for the Health Plans denial of the hydrocodone is due to a lack of documentation that the patient has been receiving chronic opioid therapy. The CURES report generated by the provider shows that the patient has been receiving hydrocodone from the same provider without interruption. Based on the available records for review and the current guidelines, the requested hydrocodone is medically necessary for 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 anesthesiology with subspecialty certification in pain management 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 patient has requested authorization and coverage for Votrient 200 mg tablets, Mekinist 0.5 mg tablets, and Ibrance 75 mg capsules. There is a lack of support for Votrient, Mekinist and Ibrance in the treatment of this patients metastatic cancer of probable ovarian origin. However, these agents have not received U.S. Food and Drug Administration (FDA) approval for this patients diagnosis. Clinical trials have not found the medical regimen consisting of Votrient, Mekinist, and Ibrance to be safe and effective for this patients diagnosis. Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) states that Votrient is an option for soft tissue sarcomas, Mekinist in certain melanomas, and Ibrance is useful in breast cancer. Moreover, there is a lack of data supporting selection of a medication regimen based on the results of genetic testing.One randomized study reported no substantial benefits with choosing a therapeutic regimen based on genomic assay versus a providers clinical judgment. Therefore, the requested Votrient 200 mg tablets, Mekinist 0.5 mg tablets, and Ibrance 75 mg capsules are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a magnetic resonance imaging (MRI) of the right knee. Findings:  The physician reviewer found that the American College of Radiology (ACR) appropriateness criteria for chronic knee pain recommends standard x-ray of the knee as the initial imaging study. Since the most common cause of chronic knee pain in the adult patient is osteoarthritis, conventional radiographs can diagnose joint space narrowing, osteophytes, subchondral cysts, and subarticular sclerosis. Initial knee radiographs allow for precise determination about whether secondary imaging is necessary. Current radiographs, obtained within the prior year, are required before performance of an MRI for chronic knee pain. This patients records do not include documentation of a standard radiograph of the right knee within the last year with findings to support an indication for MRI. Therefore, an MRI of the right knee is not medically necessary for evaluation of this patients chronic knee pain. 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 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: The patient has requested authorization and coverage for a full 28-day partial hospitalization program (PHP) at a facility that specializes in obsessive-compulsive disorder (OCD) and utilizes Exposure and Response Prevention (ERP) therapy. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Based on the records provided for review, this patient is at moderate risk of harm (score 3) due to past and current self-harm as well as reports of suicidal ideation. The patients functional status is seriously impaired (score 4) due to inability to complete activities of daily living  as well as inconsistent eating due to mental illness. The patient presents with no serious medical, addictive or psychiatric comorbidity (score 1) due to overall medical stability and no mention of substance use. The patients recovery environment is mildly stressful (score 2) but includes a stable living situation. His recovery environment is supportive (score 2) due to family support and availability of treatment resources. The patients treatment and recovery history has been poor (score 4) is due to minimal past treatment response and failure to maintain symptom resolution. He appears to have recalcitrant symptoms that have been difficult to control. The patients treatment history includes residential treatment, ECT, and recent inpatient psychiatric care. The patients engagement in treatment has been limited (score 3) due to fair cooperation in treatment and poor insight into his need for treatment. This provides a composite score of 19, which correlates with medically monitored residential services. As this score supports PHP level of care and the patients condition has been resistant to standard therapies, a full 28-day PHP at a facility that specializes in OCD and utilizes ERP is medically necessary for 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 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: The parent of an enrollee has requested authorization and coverage for air ambulance transportation. For infants born extremely prematurely and/or at very low birth weight, the medical evidence supports skin-to-skin contact. Contact with a parent, in particular the mother, promotes bonding and later breastfeeding, and enhances neurodevelopmental and physiologic organization. In this case, the mother went into preterm labor and delivered very early in the pregnancy. The baby had numerous complications as detailed above, requiring involvement of multiple sub-specialists. He continues to have complex medical needs, with an anticipated NICU stay. The current plan is to transfer him to a facility closer to home that can meet his needs while allowing active parent and family participation in his care, continued parent-infant bonding, and necessary family teaching. With transfer to the closest appropriate facility near the family home, this patient could have much needed contact with the parents and the rest of the immediate family, while continuing to receive the necessary level of care and sub-specialist involvement. This is consistent with current standard of care. Air ambulance is the appropriate form of transportation due to the patients condition and the distance. The literature supports active family involvement in the neurodevelopmental progress of neonates. The current standard of care includes active participation of both parents, maximizing interaction and skin-to-skin contact as frequently as the infants condition allows. Therefore, air ambulance transportation is 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 pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ProAir albuterol HFA inhaler. Based on the American Academy of Allergy, Asthma, and Immunology (AAAAI) guidelines, ProAir is a safe and effective version of albuterol. ProAir is a short-acting beta agonist, which continues to be a mainstay in the treatment of asthma and COPD. There is a lack of data that ProAir has a more effective delivery mechanism than other metered dose inhalers. However, when this patient was treated with Ventolin in early of 2017, he experienced exacerbations. The provider reports that the patient has been stable on ProAir since the end of 2017. Therefore, the requested ProAir albuterol HFA inhaler is medically necessary for 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 subspecialty certification in pulmonary 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 enrollee is requesting authorization and coverage for the medication, Sildenafil six tablets every thirty days. Findings:  The physician reviewer found that according to the record, the enrollee has a history of obesity and erectile dysfunction, testicular hypofunction and sleep apnea. Sildenafil for erectile dysfunction has been prescribed by his current physician for many years. He was seen by his physician and a refill of his sildenafil citrate 100mg tabs was prescribed with instructions to take one half to one tablet, as needed approximately one hour before sexual activity. The medical literature indicates that phosphodiesterase type-5 inhibitors, which include Sildenafil, are considered a first-line treatment for erectile dysfunction (ED) because of their safety and efficacy. The authors also note that obesity increases the risk factors for ED. This enrollee has a diagnosis of erectile dysfunction and sildenafil is medically necessary to treat this condition. Sildenafil is not indicated for daily usage, but for the on-demand treatment of erectile dysfunction. The medication is approved by the FDA for as needed treatment of erectile dysfunction, such as has been requested in this case.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in urology and isactively 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 similar medical condition.