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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Endometrin inserts. The Health Plan has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees high-risk pregnancy. The submitted documentation does not support the medical necessity of the medication at issue. In this enrollees case, the provider has recommended the use of vaginal progesterone suppositories to help prevent preterm labor. This recommendation occurred when a growth scan of the fetus at 33 weeks two days noted a shortened cervical length of 1.4 cm. The enrollees cervix had previously been measured in mid-trimester during a routine fetal anatomy scan. The cervix was found to be normal in length of greater than 3 cm. After the shortened cervix was noted, the enrollee underwent a preterm labor evaluation and started on vaginal progesterone. Vaginal progesterone has been found to be helpful to prevent preterm labor in select sub groups of enrollees. The American College of Obstetricians and Gynecologists (ACOG) recommends the use of vaginal progesterone as an option to reduce risk of preterm labor include the following criteria; asymptomatic women; singleton gestation, no prior preterm birth; and an incidentally identified short cervical length that is less than 20 mm before 24 weeks. Although vaginal progesterone has been found to be helpful in prolonging gestation in asymptomatic enrollees who happen to have a shortened cervix, this enrollee differs from the ACOG criterion in that the length of the cervix was normal in the mid-trimester and only after the mid-trimester did the cervical length change. In addition, the end-point in several major studies was 33-33.6 weeks, and this enrollee was 33 weeks two days. Since this enrollee was 33 weeks two days and had a normal cervix in the second trimester, the enrollee falls outside of the criteria created by these studies. Therefore, Endometrin inserts were not medically necessary for the treatment of this enrollee.Final Result: The reviewer determined that the medication at issue was not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for partial hospitalization services received on the basis that the services at issue were emergent in nature. Findings:  The physician reviewer found during their review of the submitted documentation that the patient was experiencing a psychiatric emergency upon admission to PHP. However, the records demonstrate the patient subsequently improved with treatment and was no longer experiencing a psychiatric emergency. The psychiatrist reported that the patient was improving. He denied any suicidal or homicidal ideation. Although the patient remained anxious and sad, he was cooperative and did not have psychosis. The patient was no longer at imminent harm to himself or others. He was not gravely disabled. The patient had stabilized to the point that he was able to attend to activities of daily living. While the patient continued to require treatment for his major depressive disorder with psychotic features, he had experienced sufficient improvement to be discharged from his current facility. Therefore, the services at issue were not necessary for treatment of a psychiatric emergency medical condition. Final Result: The reviewer determined the patient did not receive psychiatric emergency medical services on the dates of service at issue. 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: An enrollee has requested authorization and coverage for lumbar spinal fusion surgery. The submitted documentation supports the medical necessity of the requested services. He has failed nonoperative measures. The provider has deemed him to be a good candidate for spinal fusion. Spinal decompression for spinal stenosis is associated with a good outcome.  Translumbar interbody fusion is associated with a high fusion rate, and when combined with decompression, it increases the probability of a good outcome, particularly if iatrogenic instability is created. There is moderate evidence that for lumbar degenerative disc disease without instability, a standalone lumbar interbody fusion has good clinical outcomes. There is sufficient support for the requested services in this clinical setting. Therefore, the requested lumbar spinal fusion 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan injections. The submitted documentation supports the medical necessity of the requested services. The current literature supports the use of viscosupplementation for osteoarthritis of the knees. Intraarticular hyaluronic acid provides a significant benefit in knee osteoarthritis. As noted by researchers, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Per the research, the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. There is sufficient support for the requested services in this clinical setting. Therefore, hyaluronan injections are 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 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: A patient has requested authorization and coverage for Tymlos. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients osteoporosis. The submitted documentation does not support the medical necessity of the requested medication. Fractures are the most dangerous aspect of osteoporosis. Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates. Newer treatment agents have become available over the past few years, including Tymlos (abaloparatide), a synthetic analog of parathyroid hormone-related peptide. Anabolic agents, such as this have been shown to improve bone mass and decrease fracture risk in osteoporosis patients by directly stimulating osteoblasts to produce new bone. Other relatively new agents are also currently available for treatment of osteoporosis, such as Prolia and Forteo.  Forteo is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bone. Recent data also demonstrates that Forteo may aid in the healing of fractures and non-unions in osteoporotic patients.  As such, this may be an ideal agent for this patient. The Health Plans requirement that the patient try a formulary agent prior to Tymlos is medically appropriate. Therefore, the requested Tymlos is not medically necessary for this patient.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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 reimbursement for partial hospitalization services. The submitted documentation supports the medical necessity of the services at issue. This patient reported an early age of first use. His alcohol use was complicated by a history of cancer and co-occurring depression and anxiety.  This is of particular relevance since it has been well-established that anxiety-ridden mood disorders, without the complication of addictive illness, are difficult to treat and in general have poorer outcomes.  Notwithstanding, the patients alcohol use and psychiatric symptoms were impairing his daily routine and contributing to significant impairment across multiple domains of functionality. He was drinking a 12-pack or more on a daily basis. He had history of withdrawal symptoms.  He did not have a living environment conducive to recovery as he was living with his son who used cannabis regularly, which was a trigger for the patient.  On the first disputed date, the patient had no aftercare in place at the time. That day, the patient was anxious and not sleeping well. The next day, the patient still had trouble sleeping. On the following day, the nursing staff reported that the patient was agitated and worried, with craving and mild withdrawal symptoms. The psychiatrist noted anxiety and mild withdrawal and elected to add a new medication, gabapentin, to his therapy.  The record reflects that the treatment during the dates of service at issue focused on aftercare planning and treatment consolidation with the application of complex pharmacotherapy and core elements of recovery-oriented interventions and therapies. Considering the severity of this patients illness, the services at issue were medically appropriate. In sum, the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards and facilitated transition to a less restrictive setting. Additionally, the services provided at the time were reasonably expected to improve his condition and prevent a more serious episode of illness. All told, partial hospitalization services were medically necessary for the 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 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 residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.In the provided documentation, the patient was noted to have improvement of symptoms. The entry of the course of treatment section of the discharge summary, noted that the patient slept well and was doing better in school.  The patient was noted to have no panic symptoms.  Progress notes indicated that the patients anxiety was improved, mood stable, and she was cooperative and participating in activities.  During the time period in dispute, there was no documentation of suicidal or homicidal ideation, aggression, self-injurious behavior, abnormal vital signs, non-response or adverse response to medications, frequent medication changes, or difficulty with attending to activities of daily living. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP, 2014). The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services.  Based on the patients clinical status and documentation as outlined above, at the time of the denial, the patient met CASII criteria for intensive outpatient services and not residential treatment level of care. Therefore, treatment at the residential level of care was not medically necessary for this patient.Findings:The reviewer has 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 sub-specialty 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the manipulation under anesthesia of the shoulder for treatment of the enrollee who has a history of shoulder pain. Findings:  The physician reviewer found that There is support in the medical literature for the efficacy of the services at issue in this patients case. The patient has a healed fracture of the clavicle. He was also found to have adhesive capsulitis of the shoulder with limited range of motion. At the time of hardware removal, the provider checked the range of motion of the shoulder, found the presence of adhesive capsulitis, and performed manipulation under anesthesia to improve the range of motion of the shoulder. Manipulation under anesthesia is commonly performed for treatment of adhesive capsulitis and in this patients case was appropriate. The medical literature with regards to the manipulation under anesthesia for adhesive capsulitis support the efficacy of this technique in this clinical setting. As such, manipulation under anesthesia of the shoulder was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined 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:  All three reviewers are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (Anser IFX, Anser IFX-measurement of serum infliximab (IFX) and antibodies to infliximab). The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees  Crohns disease.Findings While there has been debate around the optimal monitoring and management of children with inflammatory bowel disease treated with infliximab, current treatment guidelines published by the American Gastroenterological Association Institute in 2017 recommend monitoring of infliximab levels. In some published studies, these levels and the presence of drug antibodies have been cited as a factor associated with loss or lack of response to infliximab treatment. In this patient, the presence of antibodies and an undetectable drug level led to modifications in his management and he remains in remission. Given that drug level and antibody monitoring are recommended and that they have led to changes in patient management, these factors may be contributing to this patients remission. All told, the genetic testing (Anser IFX, Anser IFX-measurement of serum infliximab (IFX) and antibodies to infliximab) performed were likely to have been of greater benefit than the available standard methods of evaluating this patients medical condition.Final Result: All three reviewers determined the services at issue were 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:  All three reviewers are board certified in pediatrics with sub-specialty certification in pediatric gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a nine-year-old female enrollee has requested authorization and coverage for speech therapy and occupational therapy once per week for treatment of the enrollees intellectual disability and chromosomal anomaly. Findings:  The physician reviewer found that the patient in this case demonstrates significant delays in fine motor, visual-motor, expressive and receptive skills as measured on standardized testing. Direct occupational and speech therapy services were recommended. Direct one-to-one intervention with a speech language therapist can be effective for all areas of language for older children with developmental language disorders, regardless of their gender, receptive language or autism status, or age. Thus, direct speech language therapy services should be available for school-aged children with developmental language disorders, including older children and adolescents with pervasive difficulties.  Consequently, there is a growing demand for rehabilitation services, beginning early, which encompass strategies of prevention, remediation and compensation to maximize a childs function in all activities. For these reasons, the requested speech therapy and occupational therapy services are medically necessary 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 pediatrics with sub-specialty certification in neurodevelopmental 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a water circulating cold pad with pump (HCPCS E0218). The Health Plan has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees symptoms related to his spine surgery. Findings The submitted documentation fails to demonstrate the superior efficacy of the device at issue in this clinical setting. There is a lack of recognized evidence based medical guidelines to support the use of water circulating cold pad with pump as an option for treatment of acute low back pain over the standard ice/cold packs. This patient underwent lumbar spinal surgery on 3/13/18 and was prescribed a cold compression unit for a three week post-operative use. The device at issue was prescribed pre-operatively. As of 3/19/18, the pain had no swelling and was managing his residual back pain without narcotics. The patient stated that plain ice packs were not enough, but there is no clear indication from the submitted records that he had tried standard cold packs in the post-operative period at issue or that they had failed to provide pain reduction. There is no compelling rationale presented or extenuating circumstances noted to support the superiority of a water circulating cold pad with pump over standard cold/ice packs for treatment of this patient, post-operatively. Therefore, the requested water circulating cold pad with pump for dates of service 3/15/18 through 3/28/18 was not likely to have been of greater benefit for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined the device at issue was 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:  All three reviewers are board certified in certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.