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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for XomeDx (whole exome sequencing) Trio  GeneDx. Findings:  Two of the three physician reviewers found whole exome sequencing is a technology whereby the portion of the genome consisting of coding sequences is analyzed to look for variants that may explain the patients phenotype. Whole exome sequencing may be indicated when there is a suspected genetic disorder based on signs and symptoms, with no known single gene condition fitting the phenotype. Initial studies show a diagnosis is made by exome sequencing in approximately 25% of patients referred for testing. The vast majority of these patients had a neurological phenotype, a category into which the patient may fit given her history of migraines and stroke-like episodes. In this case, the results from the requested services are likely to impact patient management. In sum, XomeDx (whole exome sequencing) Trio  GeneDx is likely to be of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewers 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewers 3 is board certified in cytogenetics and genomics and is 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: The spouse of an enrollee has requested reimbursement for acute psychiatric inpatient treatment services that were provided to the enrollee. Per colleagues, patients with major depressive disorder may be treated outside of a hospital setting with the lack of dangerous behaviors. Per colleagues, ECT is routinely administered on an outpatient basis for patients that are not exhibiting dangerous behaviors and are free from suicidal and homicidal ideation. In this case, the patient was not exhibiting dangerous behaviors towards herself or others and was fully cooperative in treatment. The patient could receive her mental health treatment in a setting that is less restrictive than an inpatient psychiatric setting, due to her overall stable symptoms. She was not noted to have any severe mood swings or other symptoms associated with her mood disorder. Therefore, the acute inpatient psychiatric services that were provided to the patient were not medically necessary.Final Result: The reviewer determined that the services at issue 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 psychiatry with subspecialty 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement, and authorization and coverage for private duty nursing in the home (CPT code S9124). The submitted documentation supports the medical necessity of the requested services. The American Academy of Pediatrics supports home health nursing care for patients with skilled multi-system care needs. In this case, skilled nursing care is required to administer medications and nutrition through the G-tube, and to monitor vitals and lungs in order to prevent aspiration pneumonia and other complications. Care by a skilled nurse is required to administer the medications in a correct dose and frequency. Under these circumstances, private duty nursing in the home (CPT code S9124) was, and is, medically necessary for treatment of the enrollees medical condition.Final Result: The reviewer determined that the requested services 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom shoe orthotics.  plantar heel pain is one of the most common musculoskeletal conditions affecting the foot. Contoured foot orthoses have been found to be effective for plantar heel pain. Collected data shows that among conservative treatments for plantar fasciitis such as prefabricated foot orthoses and heel inserts, the greatest reduction of heel peak pressure is achieved by the prefabricated foot orthosis, which provided a fivefold reduction compared to the next most effective insert. The contoured nature of a prefabricated foot orthosis increases the midfoot contact area, resulting in wide distribution of forces in the heel and midfoot. These findings indicate that of the shoe inserts tested, the contoured prefabricated foot orthosis is the most effective at reducing pressure under the heel in older people with heel pain. In this case, given the patients diagnosed plantar fasciitis with associated heel pain, and the demonstrated effectiveness of custom foot orthotics to treat this condition, custom foot orthotics are medically necessary for treatment of the 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing for factor II (prothrombin) and factor V Leiden mutation. Findings:  Three physician reviewers found that surgery is a known risk factor for deep venous thrombosis. Clinical guidelines for heritable thrombophilia testing and management were published in 2010 based on review of available evidence in the medical literature. The summary recommendation of these guidelines is that testing for heritable thrombophilias is not indicated in unselected patients presenting with venous thromboembolism. The results of testing do not help guide clinical management, nor do they help predict risk of recurrence. There is insufficient evidence to assess whether genetic testing influences patient management or clinical outcomes. The clinical utility of genetic testing in patients with a provoking risk factor, such as surgery or immobilization, would be expected to be even less than in those with an unprovoked venous thromboembolism. In sum, genetic testing for factor II (prothrombin) and factor V Leiden mutation was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were 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 reviewer 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 3 is board certified in clinical cytogenetics and genomics and is 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: An enrollee has requested authorization and coverage for right hip arthroplasty. The submitted documentation supports the medical necessity of the requested procedure. The patient is documented to have sustained multiple traumatic injuries from a motor vehicle collision including a hip dislocation associated with fracture of the acetabulum. Traumatic hip dislocations are high energy injuries that often result in considerable morbidity. In patients with traumatic hip dislocation, many previously published cases show that arthroscopy reveals a broad spectrum of intra-articular damage which can be appropriately treated with arthroscopic intervention. CT is not sensitive in the detection of intra-articular osteochondral loose bodies or capsular interposition in all cases. Historically, open reduction has been the standard of care in hip dislocations that require surgical intervention. However, recent studies have documented the advantages of arthroscopic surgery in these cases. No serious periprocedural adverse events were reported with arthroscopy. Studies have confirmed the safety and efficacy of arthroscopic treatment of traumatic hip dislocations. In this case, there is a known fracture of the acetabulum with bone fragments in the joint. Under these circumstances, right hip arthroscopy is medically necessary for treatment of the patient's 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for residential treatment center 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, treaters 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. Per CALOCUS, residential treatment center level of care requires a composite score of at least 23.Regarding the six CALOCUS dimensions, the patient has some risk of self-harm, given his continuing intent to use substances (score = 2). Regarding functional status, he has minimal impairment (score = 1). There are no comorbidities noted (score = 1). The patient has moderate stress in the home environment for recovery (score = 3); regarding supports, the patients surviving parent is noted to be involved in his treatment (score = 2). The patient is equivocal in his acceptance and commitment to treatment, and he avoids the issues around the death of one parent and will not commit to sobriety (score = 3). The patient is obstructive toward his therapy goals, avoiding issues around the death of one parent and persisting in denial about his use of substances (score = 3); the patients surviving parent generally accepts treatment, but is reluctant to have the patient home again (score = 2). For a CALOCUS composite score of 17, the recommended level of care is high-intensity outpatient therapy. Therefore, residential treatment center services are not medically necessary for this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and specializes 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an implantable cardioverter defibrillator. The submitted documentation supports the medical necessity of the requested service. The patient has been treated with carvedilol and losartan, standard medications for left ventricular dysfunction. The patients ejection fraction has not improved and a left bundle branch block electrocardiogram (EKG) pattern in present. The patient therefore meets standard criteria for prophylactic implantable cardioverter defibrillator implantation. Use of an implantable cardioverter defibrillator under these circumstances is consistent with American College of Cardiology (ACC) guidelines. Furthermore, the fact that the patient is undergoing chemotherapy and radiation, which may worsen her heart function, only strengthens the need for device implantation. Accordingly, an implantable cardioverter defibrillator is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 cardiovascular disease, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement, authorization, and coverage for acute inpatient psychiatric services. Most evidence-based treatment guidelines concur that the deciding factor on whether inpatient psychiatric care is necessary is whether patients appear to be a harm to themselves or others. Milliman guidelines agree on this point and additionally cite factors such as overt psychotic ideation, complex biomedical issues, grave disability impairing daily living function, and/or high levels of impulsivity, aggression or mania. In this case, the patient was not evincing suicidal or homicidal ideation. He was not expressing overt psychosis. There was no issue of self-injurious behavior or complex medical issues.  Although he was still showing some elements of grave disability, he was not functionally impaired in all areas of daily living such that he required inpatient level of care. There was no evidence of gross impulsivity, aggression, or mania. The patient could have been treated at a lower level of care with less restriction, such as residential.Final Result: The reviewer determined that the requested services 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 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 reimbursement and prospective authorization and coverage for a series of three alcohol injections. Findings:  Two of three physician reviewers found that the submitted documentation supports the superior efficacy of the services at issue. The alternative therapy is systemic therapy to control the disease. If palliation is necessary, radiation therapy may be used. There is support for alcohol injections in this setting. Alcohol injection is a less invasive procedure which has been shown to be effective.  Therefore, a series of three alcohol injections were and are likely to be more effective than other treatment options in this patients case.Final Result: The reviewers determined that the services at issue were and 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 internal medicine with sub-specialty certification in medical oncology 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: The parent of an enrollee has requested reimbursement, and authorization and coverage for 16 hours of direct applied behavioral analysis (ABA) services per week. The submitted documentation does not support the request for 16 hours of direct ABA therapy per week. While the National Autism Centers national standards project highlights that ABA is an effective treatment for individuals with autism, this project is not a study that recommends the exact dosage of ABA. BACB autism guidelines divide treatment intensity into comprehensive and focused, highlighting that time away from treatment may result in a client falling further behind their peers. In this case, while the patient is having his hours decreased, the patient will not be spending time away from services. The submitted documentation reflects that the patient has made progress on skill acquisition goals in the areas of language and adaptive behavior, and accomplished significant decreases in non-responsiveness and skin picking. Furthermore, while the provider has indicated that the patient has a history of engaging in aggressive behavior, this is not a behavior that the provider is currently assessing or treating, as there was no mention of this behavior in their most recent progress report. Under these circumstances, the request for 16 hours of direct ABA therapy per week is not supported by the submitted documentation. Accordingly, 16 hours of direct applied behavioral analysis (ABA) services per week is not medically necessary for treatment of the enrollees 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 a board-certified behavioral analyst and 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 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 for the medication tramadol. Pursuant to national guidelines, opioids are recommended at the lowest effective dose for the anticipated time duration of pain that is severe enough to require opioids. A therapeutic trial of opioids should not be employed until the patient has failed a trial of non-opioid analgesics. The recommended time ranges from 3 to 7 days, as indicated in the CDC Guideline for Prescribing Opioids for Chronic Pain. These recommendations are primarily based on emergency department guidelines and related literature. Some conditions may require longer use of opioids, including instances that relate to severe trauma or involve patients requiring major surgery. Most recommendations in this regard are based on consensus, with an upper range of use, of approximately 6 weeks, with weaning ongoing after approximately 7-10 days. The CDC has recommended re-evaluation of patients who continue to have pain for longer durations than expected. This allows for confirmation of diagnosis or adjustments in treatment. The recommended formulation for treatment of acute pain should be immediate-release and not extended release/long-acting. In this case, the cited criteria for prescribing opioids have not been met. The patient was evaluated and treated for an episode of acute low back pain with radiculopathy. The clinical note of the patients first evaluation does not quantify the severity of the enrollee's pain using a validated outcome score or a visual analog scale to establish that his pain was severe enough to warrant an opioid prescription. There is no documentation of a failed trial of non-opioid analgesics and other conservative care (exercise/heat/ice/activity modifications/physical therapy) prior to prescribing opioids. Furthermore, the refills continued beyond the recommended 7 days of treatment for acute pain. Under these circumstances, the medication tramadol that was provided was not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue 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 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.