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

Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for Lynparza.  Findings:  The physician reviewer found that Lynparza is one of a newer class of drugs referred to as poly-ADP-ribose polymerase (PARP) inhibitors. Their use has particularly focused on cancers that arise in BRCA positive patients. Indeed, the drug is quite useful in BRCA positive ovarian cancer, as well as metastatic breast cancer. Efforts directed at exploring its use in cancers other than breast and ovarian cancers are underway. Responses have been reported in pancreatic and prostate cancers. However, there is minimal evidence for the efficacy of Lynparza in patients with lung cancer. Therefore, Lynparza 100 mg tablets #180 for 30 days x 11 refills is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Findings:  Two physician reviewers found Lynparza 100 mg tablets #180 for 30 days x 11 refills is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that Lynparza 100 mg tablets #180 for 30 days x 11 refills is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and are actively practicing. Physician reviewers 1 and 3 are board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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

Nature of Statutory Criteria/Case Summary: The patient is a 14-year-old female who has been diagnosed with a maxillofacial skeletal deformity, specifically maxillary and mandibular hypoplasia. Findings:  The physician reviewer found that s a result of this deformity, the patient has experienced difficulty with mastication. Her orthodontist and surgeon have recommended orthognathic surgery to correct her deformity. She is planning to undergo presurgical orthodontics and the surgical plan at this time is for a multi-piece LeFort osteotomy, BSSO of her mandible and possible anterior mandibular osteotomy (genioplasty). Per the Health Plan, the request for a LeFort 1 surgery CPT code 21147 has been approved. At issue is whether the requested reconstruction of the upper jaw and chin is medically necessary and reconstructive in nature for this patient.The requested reconstruction of the upper jaw and chin is medically necessary to treat the patients medical condition. The patient has a maxillofacial skeletal deformity that cannot be corrected with orthodontics alone. The surgery will result in improved musculoskeletal and dento-osseous relationships, and improvement in mastication and associated temporomandibular joint and associated muscular disorders. Given the patients findings, reconstruction of the upper jaw and chin are medically necessary to optimize functional outcomes.In addition, the requested procedures are reconstructive in nature for treatment of the patients abnormal structure. The patients maxillofacial skeletal deformities were caused by a congenital or developmental deformity. Deformities may be evident at birth or may manifest during subsequent growth and development, creating functional, degenerative, cosmetic, and/or psychosocial problems. Moreover, the requested surgery will provide more than a minimal improvement in the appearance of the patient. For these reasons, requested reconstruction of the upper jaw and chin is supported as medically necessary and reconstructive in nature for treatment of this patients medical condition. 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 oral facial and maxillary 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 patient is a 37-year-old male with chronic pain syndrome. The providers notes indicated the patient was maintained on pain medications, which included one Lyrica 225mg tablet twice daily, three Lyrica 75mg tablets twice daily, and gabapentin 600mg twice daily. The records submitted indicate the patient was being treated for lumbar post-laminectomy syndrome and chronic pain. The U.S. Food and Drug Administration (FDA) approved indications for Lyrica include neuropathic pain associated with diabetic peripheral neuropathy (DPN), post-herpetic neuralgia (PHN), adjunctive therapy for adult patients with partial onset of seizures, fibromyalgia, and neuropathic pain associated with spinal cord injury. The American Pain Society (APS) guidelines state that, the efficacy of anti-epileptic drugs specifically, for radicular (or non-radicular) low back pain has not been well studied. In this case, the patient presents with chronic low back pain and has been diagnosed with lumbar post-laminectomy syndrome and chronic pain disorder. He was prescribed oxycodone-acetaminophen 10-325mg, one tablet every six hours, and Lyrica for chronic pain disorder. However, the FDA does not list chronic pain disorder as an approved indication for Lyrica. Furthermore, the APS guidelines indicate that anti-epileptic drugs such as Lyrica have not been studied for use in low back pain with or without radiculopathy. Based on these criteria, Lyrica 75mg, three (3) capsules three times daily for treatment of this patients diagnosis of chronic pain syndrome is not medically necessary. 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 anesthesiology with a subspecialty certification in pain 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: A 62-year-old male who has requested reimbursement for advanced lipoprotein testing (CPT 82172, 83704 and 83698) provided on 10/25/18. Findings:  The physician reviewer found that a review of the records indicates the patient was seen on 10/25/18 for a history and physical examination. The records noted a history of hypertension, vitamin D deficiency, vitreous separation, and lumbar spine disease. The patients family history was notable for a history of myocardial infarction in his mother, as well as hypertension in his mother and brother. A physical examination noted no significant findings. His electrocardiogram was within normal limits. The patients cholesterol was 235, triglycerides 81, high-density lipids 80, and low-density lipids 139. There is no discussion in the records regarding dietary changes, medications for cholesterol or the enrollees elevated cholesterol levels. The treatment plan included checking lab work and advanced lipid testing.Findings:  Three physician reviewers found that advanced lipoprotein testing (CPT 82172, 83704 and 83698) provided on 10/25/18 was not likely to have been more beneficial for evaluation of the enrollees condition than any available standard therapy. Final Result: The reviewers determined that the requested testing was not likely to be more beneficial for evaluation 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a male with lower back pain. His pain worsens with physical activity and improves with rest. Pain radiates down his left leg intermittently and pain is beginning to affect the right leg. The patients symptoms have progressed despite epidural steroid injections and physical therapy. Magnetic resonance imaging of the lumbar spine showed narrowing and desiccation at L5-S1, which is consistent with degenerative disc disease and paracentral disc protrusion on the left that contacts the traversing S1 nerve root. The disc collapse also caused left sided neural foraminal narrowing. The patient has requested authorization and coverage for spine surgery. The Health Plan has denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether spine surgery is medically necessary for the treatment of this patients medical condition. This patient has mechanical lower back pain, which increases with activity and improves with rest. His back pain is due to degenerative disc disease at L5-S1. Decompressive surgery such as a laminectomy or microdiscectomy will not address back pain due to degenerative disc disease. The options for treating degenerative disc disease include lumbar fusion versus lumbar disc arthroplasty. Given his young age, a fusion would likely cause acceleration of degenerative changes at adjacent levels, possibly leading to a subsequent fusion operation or other surgeries. Lumbar disc arthroplasty would preserve motion at the L5-S1 level and not increase stress at adjacent levels. Medical evidence supports the requested services in this clinical setting. Therefore, the requested spine surgery 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 neurological 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 patient has requested reimbursement for inpatient rehabilitation services. The Health Plan has denied this request indicating that the requested inpatient rehabilitation services were not medically necessary for treatment of the patients medical condition. The submitted documentation does not support that the services at issue were medically necessary. In this case, the patient sustained multiple injuries to his body and brain as a result of aortic dissection and accompanying stroke. He underwent emergent surgical repair of the dissection and had subsequent sternal precautions. His stroke-related deficits were relatively mild and he recovered significant motor function. The patients hospital course was complicated by urinary retention, which required persistent intermittent catheterization. The patients comorbidities included atrial fibrillation that required anticoagulation and obstructive sleep apnea. Records indicate that the patient stopped using CPAP (Continuous Positive Airway Pressure) therapy at home prior to the hospitalization and that the patient did not tolerate CPAP therapy at the rehabilitation facility. The patient otherwise progressed medically and functionally to the degree that further care could have been provided in the community setting. There are no indications in the patients records that he required ongoing inpatient hospitalization on any skilled nursing or medical issues. Under these circumstances, the acute inpatient rehabilitation services were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested reimbursement for inpatient rehabilitation services were 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 & 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 requested authorization and coverage for brand name Adderall XR. Findings:  The physician reviewer found the submitted documentation does not support that the requested medication is medically necessary. The patient had tried generic Adderall XR and found that the medication did not last as long as the brand name formulation. However, generic Adderall XR is considered by the U.S. Food and Drug Administration (FDA) to be equivalent to, and as effective as, the brand name Adderall XR. Moreover, there is currently a paucity of medical literature demonstrating that brand name Adderall XR is more effective than the generic formulation. Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the patients medical condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has chronic low back pain, sciatica, chronic neck pain and cervical radiculopathy. The patient was treated with acupuncture for his conditions. He was diagnosed with chronic spondylosis and stenosis of the entire spine. He has degenerative disc disease through the cervical spine and the lower lumbar spine. He underwent three epidural injections, utilized opioid pain medications, tried physical therapy, and started acupuncture. He had 18 treatments of acupuncture for the cervical radiculopathy and left shoulder pain, which helped his left shoulder pain and somewhat improved his chronic upper back pain. He also had eight treatments of acupuncture for his thoracic spine pain and leg myalgia, which helped his leg pain somewhat but not his buttocks and mid back. Per a report, the patient has worsening neck and left upper extremity pain of seven to eight out of 10, and acupuncture only helps temporarily. The patient has received sufficient acupuncture treatment to his neck and low back. He has not reportedly made any sustained and significant improvement after 26 total treatments with two different providers. He indicates that he experienced temporary relief with treatments. However, he is not reasonably expected to make further sustained improvement through more treatment. Acupuncture is an effective short-term treatment for patients with chronic neck pain. However, there is only limited evidence for long-term effects. Also, studies show that acupuncture is not clinically more effective than sham-acupuncture or placebo for neck or back pain. The patient has been referred for surgical management due to the lack of relief of conservative measures. Acupuncture is not supported as medically necessary for his 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 a board certified chiropractor licensed in oriental 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 reimbursement for an additional three hours of weekly direct one-to-one ABA therapy services (eight hours per week total) and reimbursement and prospective authorization and coverage for eight hours of weekly direct one-on-one ABA services going forward.  Findings:  The physician reviewer found that given this patients diagnosis of autism, ABA services are medically necessary to treat his identified deficits. Although the patient has received years of ABA therapy, significant gains have been made, and further goals are still being addressed. The Behavior Analytic Certification Boards (BACB) autism treatment guidelines highlight that continued treatment is dependent upon an individual patients needs. Moreover, there is no identified duration of treatment that has been shown to be the maximum, as ABA is individualized treatment based on each patients unique manifestations within their natural environments. Further supporting ABA in this clinical setting, the National Autism Centers National Standards Project (NSP) has identified that behavioral interventions are the only evidence based treatment backed in the medical literature as effective for patients with autism over 22 years of age. Specifically, the NSP reported that ABA can target the skill areas of communication, self-regulation, personal responsibility, and problem behaviors. As reported in the records provided for review, these areas have been the focus in this patients treatment plan. Overall, the patient has not met all of his treatment goals, as the treatment plan lists several ongoing and new goals. However, the patient continues to make progress on treatment goals as evidenced by the multiple graphs throughout the treatment plan. The additional three hours of weekly direct one-on-one ABA therapy will enable the patient and provider to continue to address the patients behavioral areas of concern. Based on these findings, an additional three hours of weekly direct one-to-one ABA therapy services (eight hours per week total) in the past, and eight hours of weekly direct one-on-one ABA services going forward were and are 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 a board certified psychologist and a board certified behavior 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly psychotherapy sessions. 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) 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. The patient presents with some risk of harm (score 2) due to recent suicidal ideation. The patient has mild functional issues (score 2) with deterioration in his expected level of functioning and inability to regularly attend school. The patient has no reported co-morbidity (score 1) such as active serious medical problems or substance use. The patients recovery environment is minimally stressful (score 1) and his recovery environment is supportive (score 1) as his family is actively involved in treatment. The patient has demonstrated limited response to previous treatment (score 3) with continued symptoms. The patient has been constructive in treatment (score 2) and his parents work actively with providers (score 2). This gives the patients presentation a composite score of 14, which correlates with outpatient services. Given this support, the requested weekly psychotherapy sessions are medically necessary for treatment of this patients behavioral health issues.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.