Persius/hicric huggingface dataset:
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 an additional ten (10) hours per week of applied behavioral analysis (ABA) therapy (a total of 25 hours per week for treatment of the autism spectrum disorder.   Findings:  The physician reviewer found that the efficacy of ABA therapy in improving maladaptive behaviors in patients with autism is well supported in the peer-reviewed literature. Granpeesheh and colleagues assessed the effects of age and treatment intensity in behavioral outcomes for children with autism. The authors concluded that Our data indicated that the number of treatment hours and the childs age showed a linear relationship with the number of mastered behavioral objectives. The highest age group (7-12 yrs) did not show significant relationship between treatment hours and number of behavioral objectives mastered. Participant in this age group showed a relatively flat line in that approximately 17 behavioral objectives were mastered each month regardless of if the child was receiving high or low treatment hours. In this case, the patient started ABA therapy at 13 years of age. Although the primary goals of treatment in the areas of aggression and compliance were not met, the patients overall performance has remained steady. In addition, aggression occurred at a range of 0 to 1.0 per hour over a three month period. The Health Plans authorization of 15 hours per week is medically reasonable in this clinical setting. All told, the request for an additional ten (10) hours per week of ABA therapy (a total of 25 hours per week) are not medically necessary for treatment of the patients 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 board certified in pediatrics with sub-specialty 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 129 hours per month of applied behavioral analysis (ABA) therapy (CPT H2019) provided for treatment of the autism spectrum disorder.  Findings:  The physician reviewer found that The services at issue were not and are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient is making progress with ABA therapy, and there is not medical indication for an additional 17 hours per month of direct ABA services. According to the records provided, the patient has had a decrease in her tantrums from 2.5 per hour lasting 30 minutes, to one per day lasting 1-30 minutes. Elopement has decreased from five per hour to 2.5 per hour. Aggression has decreased from 2.1 per hour to 0.5 per hour. Non-compliance has decreased from baseline of eight episodes per session to 4.5 per session. Property destruction has also decreased from three episodes per session to one per session. The records demonstrate that the patient has made improvement from baseline in skill deficits and problematic behaviors targeted in the treatment plan using validated assessments of adaptive functioning. For the reasons provided, the request for 129 hours per month of ABA therapy (CPT H2019) provided have not been established as medically necessary.  Final Result: The reviewer determined that the services at issue 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 pediatrics with sub-specialty 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 reimbursement for monitored anesthesia care (MAC) services (CPT codes 00740 and 00810) for evaluation of the enrollees colonoscopy and endoscopy. Findings:  The physician reviewer found that In regards to the use of sedation for gastrointestinal tract endoscopy, the American Gastroenterological Association Institute (AGAI) recommend that use of an anesthesia professional should be strongly considered for American Society of Anesthesiologists (ASA) physical status P3 through P5 patients. Reviewers noted that other possible indications for an anesthesia specialist include patients with pregnancy, morbid obesity, neurologic or neuromuscular disorders, a history of alcohol or substance abuse, and patients who are uncooperative or delirious. In this case, this patient presented with ASA grade II without comorbidities that would support the use of MAC services. As such, the MAC services (CPT codes 00740 and 00810) provided were not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty 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: The patient has requested reimbursement for the gene test (Foundation One) for evaluation of the enrollees head and neck squamous cell carcinoma. Findings:  The physician reviewer found that Foundation One is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the Foundation One assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment (Von Hoff, et al). A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the Foundation One test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing at issue 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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 authorization and coverage for Harvoni for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage or substance use. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. In addition, the use of Zepatier is not appropriate for this patient due to concurrent use of atorvastatin. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication 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 sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment for treatment of the enrollees behavioral health conditions. Fulfills requirements of (1374.33) (h)(1)(A), (B), and (C).Findings:  The physician reviewer found that The physician reviewer found the submitted documentation supports the services at issue in this clinical setting. In this case, the patients alcohol use was impairing his daily routine and contributed to significant impairment across multiple domains of functionality. His drinking was straining his marriage and undermined the recovery environment at home.  His excessive consumption was jeopardizing his employment. Although he was not diagnosed with a psychiatric illness, the patient was negotiating emotional dysregulation stemming from intrapsychic stress and substance use. Finally, despite completion of a residential treatment program during the episode of illness, the patient was unable to maintain sobriety in his environment.  Based on the records, this patient had not consolidated the treatment gains necessary to succeed in the outpatient setting during the dates of service in dispute and was likely to have relapsed in a community-based setting if discharged during this timeframe. In this patients case, 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.  In sum, residential treatment was medically necessary for the treatment of this patient. Fulfills requirements of (1374.33)(h)(1)(H) and (K)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. Fulfills requirement of 1374.33(h)(1)(I)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. Fulfills requirement of (1374.33)(h)(1)(G)
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oral immunotherapy (OIT) for treatment of the enrollees peanut allergy. Findings:  The physician reviewer found that there is a lack of evidence to support the benefits of OIT for the treatment of peanut allergy. There is conflicting data as to OITs safety and efficacy published in recent literature. Recent studies show promising data for the use of immunotherapy in food allergic patients. However, therapies such as OIT are not recommended for routine clinical practice. The current standard of care in the treatment of food allergies is allergen avoidance and ready access to self-injectable epinephrine. Food allergy is a potentially life threatening condition. There is a lack of U.S. Food and Drug Administration approved therapies, apart from avoidance, patient education, and injectable epinephrine for acute allergic reactions. As such, OIT is an experimental treatment in which food allergic patients consume gradually increasing quantities of the food to increase their threshold for an allergic reaction. This therapy carries a significant risk for allergic reactions. The ability of OIT to desensitize patients to particular foods is well documented, although the ability to induce tolerance has not been established. In sum, OIT will not likely be more beneficial than the standard options for the treatment of this patient. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in allergy and immunology with expertise in pediatric allergy 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.Physician reviewer number two is board certified in pediatrics and allergy and immunology 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.Physician reviewer number three is board certified in pediatrics and allergy and immunology 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 authorization and coverage for lumbar medical branch blocks for treatment of the enrollees lower back pain. Findings:  The three physician reviewers found that the documentation available for review, the provider does not document an examination that is consistent with facet mediated spine pain. In addition, the medical literature does not recommend medial branch blocks and subsequent radiofrequency ablation when a patient has active radicular pain, as in this patients case. Moreover, it is likely the patient would get the same relief from a steroid injection alone without also having the increased risk from a radiofrequency ablation procedure. The records do not demonstrate a prior failure from facet injections or an epidural injection. There is a lack of support in the medical literature for the recommended services. As such, lumbar medial branch blocks are not likely to be of greater benefit than the standard options available for the treatment of this patients medical condition.  Final Result: All three reviewers determined that the requested services are 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. Qualifications of Physician reviewer number one is board certified in anesthesiology with sub-specialty 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.Physician reviewer number two is board certified in anesthesiology with sub-specialty 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.Physician reviewer number three is board certified in anesthesiology with sub-specialty 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: An enrollee has requested reimbursement for endoluminal ablation of varicose veins provided for treatment of the enrollees varicose veins.Findings:  Two physician reviewers found that current Society for Vascular Surgery (SVS) and American Venous Forum (AVF) guidelines state that We recommend compression therapy as the primary treatment to aid healing of venous ulcerationand [t]o decrease the recurrence of venous ulcers, we recommend ablation of the incompetent superficial veins in addition to compression therapy. The guidelines recommend against selective treatment of perforating vein incompetence in patients with simple varicose veins (CEAP class C(2) and recommend treatment for pathologic perforating veins located underneath healed or active ulcers. The patient had palpable pulses and was diagnosed as CEAP class 2. Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in surgery with sub-specialty certification in vascular surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center level of care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patient had no post acute withdrawal symptoms.  The patient was not a danger to the patient or to others. The patient was not gravely disabled.  The records show that the patients activities of daily living were intact. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  The patient was medically and psychiatrically stable.  The patient was motivated and appeared to be working the program. The patient showed good progress in recognizing relapse triggers and improving impulse control.  The patient was compliant and was on medication-assisted treatment. The patient participated in individual, group, and family therapies.  The patient partook of other activities that the facility offered.  The patient had support systems in place.  The patient could have safely continued treatment at an ambulatory lower level of care in conjunction with a 12-step program and ongoing substance abuse counseling.  The patient no longer required 24-hour supervision at residential level of care. Therefore, the residential treatment center level of care services were not medically necessary for the treatment of this 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 psychiatry with sub-specialty certification in addiction 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.