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

Nature of Statutory Criteria/Case Summary: A 75-year-old female enrollee has requested authorization and coverage for 100 days of physical therapy and occupational therapy. Findings:  The physician reviewer found that This patient sustained a stroke over four months ago and remains in need of 24-hour care. She has made modest improvements in bed transfers during her recent SNF admission. Given her progress thus far, the patient may benefit from an additional five days of physical therapy and occupational therapy. However, the documentation does not support the requested 100 days of additional physical and occupational therapies. The patient required total assistance for bathing and toileting, and maximum to total assistance for transfers. She required moderate assistance for bed transfers, and maximum to total assistance for other transfers. She required maximum to total assistance for toileting and dressing. Given this limited progress, five additional days of physical therapy and occupational therapy are medically necessary. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the pelvis and abdomen, with or without contrast (CPT code 72197 and 74183). The submitted documentation supports that the requested services are medically necessary. Magnetic resonance imaging (MRI) of the abdomen and pelvis is required in order to perform magnetic resonance (MR) enterography. Given that the provider has noted that capsule endoscopy may be performed at the time of endoscopy and colonoscopy, MR enterography has the additional benefit of assessing whether the capsule would be at risk of retention. In this case, the patients previously normal laboratory testing was cited by the Health Plan as a reason not to perform MR enterography. However, in pediatric patients, it is not uncommon for all blood testing to be normal at the time of diagnosis. Recent guidelines for diagnosis and management of Crohns disease in children state that normal blood tests do not exclude a diagnosis of IBD. Accordingly, MRI of the pelvis and abdomen, with or without contrast (CPT code 72197 and 74183), is medically necessary to treat 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 pediatrics, with subspecialty certification in pediatric 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement and prospective authorization and coverage for IOP services. Findings:  The physician reviewer found that 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. In this case, the patients presents a composite score of 15, which correlates with outpatient services. According to the CALOCUS the patients presentation did not and does not meet the criteria for the requested level of care. Thus, the IOP services were not and are not medically necessary for treatment of this patients behavioral health issues. 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Copaxone. Findings:  The physician reviewer found that multiple sclerosis is a progressive immune disease affecting the central nervous system, causing neurological dysfunction. Characteristic of the disease is multifocal inflammation of the central nervous system, which causes impaired nerve conduction, leading to symptoms associated with the disease. There are several therapies that can manage multiple sclerosis. In addition to brand name formulation, there are generic formulations. Overall, there is a paucity of evidence in the medical literature that the brand name formulation of Copaxone is more effective with fewer side effects as compared to the generic formulation. Additionally, there are several available therapies that have proven efficacy and may be more beneficial for this patient than Copaxone. All told, the requested brand name Copaxone is not supported as medically necessary for treatment of this patients multiple sclerosis. Final Result: The reviewer determined that the requested brand name 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 neurology 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 Vemlidy. Findings - The physician reviewer found the submitted documentation supports that the requested medication is medically necessary. Published guidelines for the treatment of Hepatitis B recommend entecavir and tenofovir compared with alternatives for the treatment of chronic Hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient was taking, the Vemlidy formulation of tenofovir is effective for Hepatitis B, and is associated with a lower incidence of side effects such as osteopenia and renal disease. The requested medication is therefore recommended for the patients condition, and associated with a lower incidence of side effects. In addition, because the patients Hepatitis B is chronic and has the possibility of increased disease activity when treatment is discontinued, the present request for 12 months of treatment is appropriate. Under these circumstances, the request for Vemlidy 25 mg, once daily, for one year is medically necessary to treat the patients medical condition.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 subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay.Findings:  Three physician reviewers found that this patient had an early stage melanoma. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous is not recommended outside of a clinical study. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. In sum, DecisionDx-Melanoma assay 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left hip replacement surgery. Findings:  The physician reviewer found that total hip arthroplasty (THA) is a very successful and effective orthopedic operation with very good immediate and long-term results to alleviate pain and improve function and the quality of life. Total hip arthroplasty is indicated in end-stage hip osteoarthritis with a high degree of persistent pain, limitation of motion and associated difficulties with activities of daily living, when conservative treatment has failed and in patients who wish to have surgery. With regard to patients with BMI of 40 or above, it has been documented in literature that the cardiovascular risk is slightly greater, and the operative time is slightly longer. However, it does not constitute a contraindication to total hip arthroplasty.In this case, the patients medical history, clinical examination, and radiographic findings establish that she has severe osteoarthritis of the left hip, severe pain, limited motion, and an altered gait that affects other joints as well. The timing of the requested THA is based on the patient's discomfort. The mid-term survival rate of total hip and knee arthroplasty is not adversely affected by obesity. Review of the literature reveals that obese patients were satisfied with the results of their surgery and have an equivalent mid-term survival rate. Under these circumstances, the requested left hip replacement surgery is medically necessary for 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: 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 Nutropin AQ Nuspin. The reviewer found that Short stature is defined by a height at below the third percentiles, or two standard deviations or more below the mean for children of that sex and chronologic age. The patient is plotted at the 14th percentiles for his height on the growth chart, and is therefore not considered short. The patients reported skeletal age is congruent with his chronological age. Based on this information, his predicted adult final height is going to be around 5 feet 8.2 inches, which is normal in the society (above 5 feet 4 inches) and within 2 inches from genetic target height. Under these circumstances, Nutropin AQ Nuspin is not medically necessary for the patients medical condition.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 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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc intra-articular injections, weekly for three doses. The submitted documentation supports that the requested services are medically necessary. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As noted, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, the requested Orthovisc intra-articular injections, weekly for 3 doses, are medically necessary to treat the patients medical condition at this time.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

An enrollee has requested reimbursement for the laboratory services provided by Prometheus Laboratories. The Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. However, in a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. Moreover, the reasons for therapeutic failures remain unclear. While there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. Accordingly, the laboratory services provided by Prometheus Laboratories were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the laboratory services provided by Prometheus Laboratories were 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 laboratory services provided by Prometheus Laboratories were 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 sub-specialty certification in 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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Amitiza 24mcg capsules. The submitted documentation does not support that the requested medication is medically necessary. The requested Amitiza dose of 24mcg, twice daily, is supported for chronic idiopathic constipation only. The recommended dose for irritable bowel syndrome, with constipation-predominant, is 8mcg, twice daily. Furthermore, research shows that for constipation, the first line of therapy should be an osmotic agent, and then another type of laxative such as a stimulant laxative should be tried before a newer agent such as Amitiza is considered, as the newer agents have more adverse effects. The American College of Gastroenterology guideline for the treatment of irritable bowel syndrome recommends Amitiza among many alternatives for treatment, some of which have not been attempted.In this case, an osmotic laxative, Miralax, has not been successful, and the patient has also failed two advanced agents, Trulance and Linzess; however, a trial of a stimulant laxative has not been documented. Under these circumstances, a stimulant laxative should also be tried before a newer agent such as Amitiza is considered. Therefore, the requested medication, Amitiza 24mcg capsules, is not medically necessary for the treatment of the patients medical condition.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 subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a six-month Dialectical Behavior Therapy (DBT) program. Findings:  The physician reviewer found that The submitted documentation does not support that the requested services are medically necessary. DBT is typically used for individuals with a diagnosis of borderline personality disorder. DBT is used to help individuals with emotion regulation issues, instability of affect, and interpersonal problems. In this case, the most recent progress notes from the patients psychiatrist and her therapist indicated that the patient appeared to be functioning well. These notes do not indicate that the patient was experiencing any suicidal ideation. The patient reported that her mood was stable. Her impulse control was noted to be good. The progress notes did not reflect mood swings or other impulsive behaviors. The progress notes indicated that the patient might have received DBT in the past with equivocal results. The submitted records do not indicate that the patient had been diagnosed with borderline personality disorder. The progress notes do not indicate that the patient was suffering from symptoms that would typically be managed by DBT. Major depressive disorder and generalized anxiety may be treated with therapies other than DBT. Under these circumstances, the requested six-month Dialectical Behavioral Therapy (DBT) program is not medically necessary to treat 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 psychiatry, with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.