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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Ajovy. The patient has experienced migraines since the age of five. The patient has used multiple abortive and preventive medications, but reports they were not effective. The patient reports her headaches are severe and that symptoms have been present for ten years. The headaches occur four to six times per week and last 25-48 hours. The patient is currently on metoprolol and Botox injections, but the provider wants better control and is requesting Ajovy. Ajovy is approved by a governmental body for the prevention of migraine headaches. The medical literature notes medication Ajovy is recommended for the treatment of chronic migraine headaches. Literature also noted that patients who had failed up to four classes of medications found Ajovy effective. The patient's symptoms were inadequately controlled with metoprolol, Botox, Topamax, tramadol, Wellbutrin, Tylenol Ibuprofen, and Imitrex.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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 bilateral occipital nerve block procedure with ultrasound guidance (CPT 64405 x 2, 64450 x 2, and 01992). According to the International Classification of Headache Disorders, occipital neuralgia is associated with unilateral or bilateral paroxysmal, shooting, or stabbing pain in the posterior part of the scalp, following the distribution of the greater occipital nerve and/or the lesser occipital nerve. In this case, the patients symptoms and physical examination findings are consistent with occipital neuralgia. Her pain has been refractory to medical management. However, she underwent treatment with bilateral occipital nerve blockade with ultrasound guidance with improvement of pain and reduction of use of pain medications. Treatment with use of bilateral occipital nerve blockade with ultrasound guidance in this clinical setting is consistent with the current medical literature. Authors concluded that occipital nerve block is a safe, technically simple, and effective method that carries a minimal risk of side effects and can be applied for patients that do not achieve desired pain relief using conventional pain management methods. All told, the requested bilateral occipital nerve block procedure with ultrasound guidance (CPT 64405 x 2, 64450 x 2, and 01992) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested bilateral occipital nerve block procedure with ultrasound guidance (CPT 64405 x 2, 64450 x 2, and 01992) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in neurology 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: Overturned Decision of Health Plan

The parent of an enrollee has requested authorization and coverage for Humatrope 24 mg cartridge.The submitted documentation supports the medical necessity of the requested medication. This patients height was below standard deviations the mean for his age and sex. The medical evidence supports the use of growth hormone therapy for the diagnosis of idiopathic short stature when a patients height is greater than 2.25 standard deviations below the mean for their age and sex. This patient meets this criterion for growth hormone therapy. Although he has entered puberty, his growth velocity has deteriorated, and he is now below the third percentile. Puberty is the time when most growth velocity occurs, and the fact that this patient actually deteriorated during that time signifies abnormal growth. This patient has a normal body mass index and a normal work-up otherwise. Thus, there is no other obvious reason to explain the patients poor growth. Therefore, Humatrope 24 mg cartridge is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for 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 endocrinology, 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

An enrollee has requested reimbursement for the Optune device. Tumor treating fields are a non-invasive antimitotic therapy that delivers alternating electric fields via the Optune device. Although data on its use is limited, the Optune device has been demonstrated to be effective in a large number of patients with glioblastoma. One trial in newly diagnosed glioblastoma showed significantly improved progression-free, overall and long-term survival when Optune was combined with maintenance temozolomide compared with temozolomide alone. The records provided for review document that resection, radiation, and chemotherapy have not been adequate to control this patients disease. Given the support in the medical literature, the Optune device was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the device at issue was 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: Physician reviewers 1, 2, and 3 are board certified in neurological surgery 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: Upheld Decision of Health Plan

An enrollee has requested reimbursement for testosterone implants (Testopel). The treatment goal in androgen replacement is a return of testosterone levels to the normal range with a planned benefit of relief of associated symptomatology. However, there is a paucity of medical literature or clinical reports demonstrating superior health outcomes when the route of hormone administration is changed when normal range has been achieved without adverse effects. In this patients case, there is a lack of documentation to support treatment with testosterone implants in lieu of standard therapies. Given these findings, the testosterone implants (Testopel) were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks.Epclusa 400-100 mg tablets for 12 weeks is one of two recommended therapies for hepatitis C, genotype 2 without associated cirrhosis. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommend treatment of all patients with documented hepatitis C without regard to their level of fibrosis. The AASLD/IDSA guidelines note, Therefore, the panel continues to recommend treatment for all patients with chronic hepatitis C infection, except those with a short life expectancy that cannot be remediated by hepatitis C treatment, liver transplantation, or another directed therapy. The current medical evidence supports the requested medication regimen in this clinical setting. Therefore, Epclusa 400-100 mg tablets for 12 weeks are medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patients parent has requested authorization and coverage for orthodontic treatment. Based on the available documentation, this patients clinical presentation does not support an indication for orthodontic treatment. To assess the need for orthodontic treatment there are many tools to quantify the degree of handicap caused by the malocclusion. One commonly used tool is the Handicapping Labiolingual Deviation (HLD), as used here. A score of over 25 on the HLD is a severe malocclusion requiring orthodontic intervention. In this case, the patients HLD score is below the cut off for orthodontic services. Additional issues such as bite impinging on the palatal tissue, spacing or occlusion, which prevents normal chewing, are further indications for orthodontic treatment. However, none of these conditions was documented in this patients chart. Given the patients Class I malocclusion, HLD index score, and no significant medical condition to lead to a medical exception, orthodontic services are not supported as medically necessary. Therefore, the requested orthodontic treatment is not medically necessary for 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 dentistry 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

An enrollee has requested reimbursement for lower left extremity sclerotherapy and right lower extremity sclerotherapy.The submitted documentation does not support that the services at issue were medically necessary. Lower extremity sclerotherapy is medically necessary for patients with documented lifestyle limiting pain or discomfort due to enlarged veins of the lower extremity. Typically, veins would be 3 or 4 mm in diameter, or greater. In addition, there should be documentation that truncal vein reflux (such as in the greater saphenous vein) was either successfully treated, treated at the same time, or non-present. There should be documentation of an absence of deep venous obstruction and documentation of satisfactory arterial perfusion. Documentation of failed concerted efforts of a conservative, non-interventional approach would also support medical necessity. In this case, office visit notes indicate that the patient presented with bilateral varicose veins that were asymptomatic. The patient denied significant swelling, night cramping, a history of dermatitis, a history of stasis ulcer, and episodes of superficial thrombophlebitis. Records indicate that the patient had cosmetic varicose veins for which cosmetic sclerotherapy was planned. The services at issue were not performed to treat pain or dysfunction. Under these circumstances, lower left extremity sclerotherapy and right lower extremity sclerotherapy were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat the patients medical condition. The reviewer also determined that the patients varicose veins did not constitute an abnormal structure of the body and that the services at issue were thus not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in general surgery and vascular 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

The patients parent has requested reimbursement for inpatient psychiatric treatment program services.  The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, 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) developmental, medical, substance use 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 CALOCUS criteria, this patient met the criteria for inpatient psychiatric treatment program services. The patients composite score is consistent with medically monitored residence based services. However, the patients score for risk of harm and functional status, supports treatment at the inpatient psychiatric level of care. Given these findings, the inpatient psychiatric treatment program services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue 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 with subspecialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for a Cologuard colon cancer screening test.The submitted documentation supports that the requested services are medically necessary. The Cologuard colon cancer screening test is an FDA-approved test for colon cancer that has been proven to be 92% sensitive for detection of colon cancer, and can detect most (but not all) adenomas if they have high-grade dysplasia. The test is recommended as a first-line test for colorectal cancer screening by the American Cancer Society. In this case, the patient is in the adult population aged between 50 and 75 years, for whom the U. S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer. The patient also does not have a family history or personal history that would place him at elevated risk for colorectal cancer. Under these circumstances, the requested Cologuard colon cancer screening test is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the 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 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Safety Sleeper Bed by Abrams with camera vision netting. This patient has a well-described history of nocturnal wandering and autism spectrum disorder (ASD). Sleep disturbances are common in young patients with autistic spectrum disorders. There is a lack of support for the long-term use of pharmacologic intervention with medications with sedative qualities. Researchers found that sleep problems worsen daytime behaviors and core symptoms of ASD and contribute to parental stress levels. This patient has exhibited self-destructive behaviors during the night, which supports the need for the requested medical equipment. Thus, the request for a protective safety bed is reasonable and in the best medical interests of the patient. All told, the requested Safety Sleeper Bed by Abrams with camera vision netting is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 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

The patient has requested authorization and coverage for bilateral transforaminal lumbar epidural steroid injection with fluoroguide and moderate conscious sedation.Conservative treatment has included multiple previous transforaminal epidural steroid injections at the L4-5 level with reported excellent pain relief for several months. Recent conservative treatment had included activity modification, medications, and home therapy. The Agency for Healthcare Research and Quality (AHRQ) comparative effectiveness study on injection therapies for low back pain concluded that epidural steroid injections for radiculopathy were associated with immediate improvements in pain. However, the AHRQ concluded that the benefits were small and not sustained, and there was no effect on the long-term need for surgery. The records do not include current clinical evidence of focal neurologic deficits correlated with imaging studies consistent with lumbar radiculopathy due to disc herniation. Additionally, the patient reports her current chief complaint as back pain, which is not a supported indication for an epidural steroid injection. All told, the requested bilateral transforaminal lumbar epidural steroid injection with fluoroguide and moderate conscious sedation is not medically necessary for 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 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 patients parent has requested authorization and coverage for general anesthesia (CPT 00170 and 41899) for dental procedures. The American Academy of Pediatric Dentistry states that indications for general anesthesia include patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability. The American Dental Association (ADA) supports deep sedation or general anesthesia for mentally or physically challenged patients (Cote, et al.). In this case, the patient requires placement of amalgam fillings, resin, and therapeutic pulpectomy. However, there is a lack of documentation from the providers to support an indication for general anesthesia for the performance of these procedures. There is no documentation of previous difficulty with dental procedures. In addition, the records do not state that the patient has other medical or behavioral health conditions, which would require general anesthesia in order to complete the proposed dental procedures. Moreover, the providers did not report that there were previous attempts to complete the proposed dental procedures in an office setting. All told, the requested general anesthesia (CPT 00170 and 41899) for dental procedures is not medically necessary for 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.