Persius/hicric huggingface dataset:
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 genetic testing (cytogenomic SNP microarray). The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees congenital cytomegalovirus and developmental delay. At issue in this case is whether the requested genetic testing (cytogenomic SNP microarray) is medically necessary for treatment of the patients medical condition.Per researchers, the clinical utility of chromosomal microarray (CMA) is well established. CMA is now considered first-line genetic testing for individuals with developmental delays and autism spectrum disorders. It is important to note that CMA technology has been shown to provide clinically actionable information. In a study, a retrospective chart review of CMA testing was performed on individuals with developmental delay; intellectual disability; autism spectrum disorders and congenital anomalies in order to determine the proportion of cases where abnormal CMA results impacted recommendations for clinical action. Among the 1792 patients that were reviewed, 13.1 percent had clinically relevant results. When an abnormal result was identified, a recommendation for clinical action was made 54 percent of the time. Findings in this study clearly demonstrated that CMA results influenced medical care in the majority of patients by precipitating medical referrals; diagnostic imaging; or specific laboratory testing, supporting the use of CMA as a clinically useful diagnostic test. Per researchers, recent evidence-based international guidelines promote the use of CMA as a first-tier investigation for global developmental delay. This is if no etiological indicators from history and examination are found. The higher sensitivity that it has for identifying submicroscopic deletions and duplications (than standard karyotyping methods) and better definition of the breakpoints and size of imbalances all make CMA a suitable first-line test. This patients clinic picture is significant for hypotonia, severe microcephaly and global developmental delay in the context of congenital CMV. In this clinical setting, CMA testing is supported as an important diagnostic tool for this patient. Therefore, the genetic testing (cytogenomic SNP microarray) is medically necessary.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 clinical genetics and genomics, and pediatrics with subspecialty certification in developmental-behavioral 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Abilify Maintena 400 mg injections. Abilify Maintena has been US Food and Drug Administration (FDA) approved for the treatment of schizophrenia and for the maintenance treatment of Bipolar I disorder in adults. However, Abilify Maintena has not been FDA approved for treatment of patients with OCD or depression. This patients diagnoses includes OCD and moderate to severe depression. Based on the documentation, the patient does not meet the criteria for schizoaffective disorder. As this patient does not meet the criteria for diagnosis of schizophrenia or Bipolar I disorder, there is no clinically recognized indication for the requested medication. Thus, the requested Abilify Maintena 400 mg injections are not supported as medically necessary for treatment of this patients OCD and depression. 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 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 intravenous immunoglobulin (IVIG) treatment September 2017 to August 2018 and going forward; and requested reimbursement and authorization and coverage for Rituxan February 2018 to May 2018 and going forward. The Health Plan has denied this request indicating that the requested services at issue were and are not medically necessary for treatment of autoimmune limbic encephalitis, autism, and Aspergers syndrome.Researchers noted that autoimmune proven encephalitis is associated with antibodies that respond to therapy for antibodies with IVIG as primary therapy treatment.  IVIG is supported as reducing antibodies and improving inflammatory response. Researchers noted that IVIG is beneficial for treatment of immune response causing inflammation related to immune response encephalitis. Autoimmune limbic encephalitis is a relatively rare condition for which treatment is directed at immune modulation. Scientists reported Rituximab is effective and safe as a second-line immunotherapy for autoimmune limbic encephalitis (ALE), regardless of autoantibody status. Researchers noted treatment included first-line immunotherapy, second-line immunotherapy, and tumor removal if found.The records documented support for the diagnosis of antibody proven autoimmune encephalitis.  The condition was reported to have not responded to IV steroids.  IVIG was and is medically necessary to improve medical condition.  The reports indicate some improvement with IVIG such that Rituxan was added.  The patient has shown improvement since Rituxan was added.  Peer reviewed literature reflects many patients with this disease require IVIG as a treatment but also up to 50% of patients have less than adequate response and require other therapy with Rituxan being most common secondary treatment.  As such, both IVIG and Rituxan were and are medically necessary for the patients 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 neurology with a 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for balloon ostial dilation. Findings:  Two of the three physician reviewers found Sinus ostial dilation is a therapeutic option for selected patients with chronic rhinosinusitis and recurrent acute rhinosinusitis who have failed appropriate medical therapy. Clinical diagnosis of chronic rhinosinusitis and recurrent acute rhinosinusitis should be based on symptoms of sinusitis and supported by nasal endoscopy documenting sinonasal abnormality or mucosal thickening on CT of the paranasal sinuses. Recurrent acute sinusitis was documented in this patients case. There was evidence of acute and chronic disease on CT scan. Additionally, there was evidence of sinus disease on endoscopy. Researchers noted that balloon dilation produces faster recovery, less postoperative pain and fewer debridements than functional endoscopic sinus surgery. In sum, balloon ostial dilation was likely to have been of greater benefit than other treatment options.  Final Result: The reviewers determined that the services at issue were 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 otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Myoelectric elbow-wrist-hand orthosis. The Health Plan has denied this request, indicating that the requested device is not medically necessary for treatment of the enrollees left middle cerebral artery (MCA); and posterior cerebral artery (PCA) stroke.At issue in this case is whether the requested Myoelectric elbow-wrist-hand orthosis is medically necessary for treatment of the enrollees medical condition.The medical literature regarding this type of device is limited to preclinical work, developmental work and small anecdotal reports reporting potential for benefit (Ren et al; Maciejasz et al; Proietti et al.), some of which is industry-sponsored work. While the device can provide some functional benefits theoretically, it is not known whether users will adopt the device for regular functional use in the long-term; beyond the short-term as a novelty device. Also not known is if the device itself causes injuries with long-term use at the shoulder due to the devices significant weight. Current commercially available iterations of this type of device remain heavy; bulky; difficult to don; and difficult to use on a practical basis.Further study of an unbiased nature is required in order better understand the adoption of the device into actual functional use outside of research settings, and to establish safety. Although the enrollee in the current case has severe impairments that are not expected to improve with any further conventional management; the device in question is not reasonably expected to favorably affect the enrollee's long-term clinical or functional outcomes in a practical manner while worn. It is not reasonably expected to stimulate or promote any underlying neurological recovery beyond the limited recovery that has occurred to date. Therefore, the Myoelectric elbow-wrist-hand orthosis is not medically necessary.Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for occipital nerve block therapy. As noted in the peer-reviewed medical literature, occipital nerve blocks have not been demonstrated to be safe and effective for the treatment of migraine or other types of headache. Researchers found that there was no evidence of long-term improvement of chronic migraine type headache with occipital nerve blocks. Similarly, other researchers also reported that greater occipital nerve blocks do not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. Given these findings, the occipital nerve block therapy was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the occipital nerve block therapy was not and is 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 occipital nerve block therapy was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 1 is board certified in neurology with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in neurology with subspecialty certification in sleep medicine and is actively practicing. Physician reviewer 3 is board certified in neurology 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 parent of a male enrollee has requested authorization and coverage for Norditropin Flexpro.  The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Idiopathic short stature (ISS). This is a boy with short stature. He also had a normal biochemical evaluation and was negative short stature homeobox (SHOX) gene. He has a family history of delayed puberty. There is insufficient evidence of whether this patient has ISS since no GH stimulation test was done. This patient has a growth velocity of 4.9cm/year (based on June 2017 and April 2018), which is a normal growth velocity and makes the diagnosis of growth hormone deficiency or ISS requiring growth hormone unlikely. No growth hormone (GH) stimulation test was done. The current height of the patient is not -2.25 SD below the mean. The estimated predicted adult height is not below 53 and is not 4 inches or more below the mid-parental height. The subjective and objective findings suggest the diagnosis of idiopathic delay of growth, and puberty, which does not require treatment with growth hormone.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 pediatrics, with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing. The American College of Cardiology (ACC) guidelines do not support use of the advanced lipid testing in this clinical setting. Rather, the guidelines recommend application of standard risk factors and lipid profiling to direct decisions regarding lipid management. The guidelines have shifted away from specific target values and emphasize use of the pooled risk score analysis for treatment decisions. Moreover, there is a lack of scientific data supporting a role for prothrombin factor II and MTHFR mutations. For these reasons, the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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: An enrollee has requested authorization and coverage for intensive outpatient program services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health condition. At issue in this case is whether the requested intensive outpatient program services are medically necessary for treatment of the patients behavioral health condition. The American Psychiatric Association (APA) treatment guidelines for eating disorders defines intensive outpatient program services as level two treatment. Intensive outpatient program services are for those medically stable to the extent that more extensive medical monitoring is not required. Intensive outpatient program services are for those where some degree of external structure would be required. The APA guideline for major depressive disorder notes that admission to an intensive day program may also be indicated for severely ill patients. Those who lack adequate social support outside of a hospital setting; who have complicating psychiatric or general behavioral health conditions, or who have not responded adequately to outpatient treatment. In this case, the patient has comorbid conditions of depression. She also has difficulty persisting with treatment and a recurrence of symptoms and behavior since stepping down from intensive outpatient program services to the next level of treatment. Therefore, the intensive outpatient program services are medically necessary. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for laboratory services provided by Prometheus Laboratories (CPT code 84999 Prometheus Anser IFX test) and prospective authorization and coverage for laboratory services to be provided by Prometheus Laboratories every four to eight weeks (CPT code 84999 Prometheus Anser IFX test).Findings:  Two of the three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. This test can potentially prevent patients from having a flare and may allow patients to avoid unnecessary medications. This test provides information regarding the drug level as well as antibody formation. If the drug level is low, it can be increased potentially before a patient starts to have increased symptoms. If there are symptoms, this test can help decide if the patient needs an increased dose or needs to change medications. Therefore, laboratory services provided by Prometheus Laboratories (CPT code 84999 Prometheus Anser IFX test) and future laboratory services to be provided by Prometheus Laboratories every four to eight weeks (CPT code 84999 Prometheus Anser IFX test) were and are likely to be superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were and 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, 2 and 3 are board certified in pediatrics with sub-specialty certification in pediatric gastroenterology 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 SummaryAn enrollee has requested authorization and coverage for an epidural steroid shot #2 (a second epidural steroid injection). Findings:  The physician reviewer found that The submitted documentation does not support the medical necessity of the requested service. Vorobeychik and colleagues have noted that epidural steroid injection (ESI) has shown short term improvement for radicular pain, but for no other types of low back pain. Rivera has also noted that there was moderate evidence of short term benefit of radiculopathy by ESI. ESI is supported when radiculopathy is documented with objective findings on examination. Repeat ESI injection is supported when there is at least 50% reduction in pain for a duration of 2-4weeks. In this case, the medical records provided for review do not document physical exam findings consistent with radiculopathy. Furthermore, while the records quantify the duration or degree of relief from a previous ESI, they note only one day of reduction in pain. Under these circumstances, an epidural steroid shot #2 (a second epidural steroid injection) is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 neurology, 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.