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

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested authorization and coverage for cognitive behavioral therapy (CBT), one hour per week for 16 weeks.  Findings: The physician reviewer found that there is sufficient peer-reviewed literatures supporting CBT as effective for the treatment of anxiety disorder in patients with ASD. The results showed that CBT was slightly more effective for children without ASD, but children with ASD still improved with CBT. A meta-analysis team compared eight randomized controlled studies for CBT for the treatment of anxiety of children and adolescents with ASD. The results showed a significant decrease in anxiety with the CBT groups relative to the non-CBT groups. The authors state that Cognitive-behavioral therapy (CBT) is a first-line of treatment for anxiety in typically developing children, and there is emerging evidence that CBT can be helpful for anxiety in children with ASD. Based on the support in the peer-reviewed literature, the patient is likely to benefit from CBT therapy for treatment of his ASD and anxiety disorder. As such, the request for CBT, one hour per week for 16 weeks is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. The patient has a history of attempting suicide on five different occasions. The patient did not have any suicidal ideation, and it was noted that he was not a safety concern at that time. Due to the patients substance use, he has had a significant deterioration in his ability to fulfill his responsibilities. He owned a business but had not participated in the business in months due to his substance use. He had lost 20 pounds due to his methamphetamine use.  The patient has a significant co-morbidity of opioid use disorder, and methamphetamine use disorder. He has no current medical problems that would require 24-hour monitoring. The patient continues to use substances despite negative consequences.  The patient has ongoing interpersonal conflicts with family and girlfriend. Since the relapse, the girlfriend is unsure if she would like to continue the relationship because it might affect her sobriety.  The patient has few supportive resources. His relationship may be ending.  The patient was sober for 22 months prior to his relapse.  The patient has a positive attitude toward recovery and treatment and is cooperative with staff and treatment recommendations. Based on these criteria, the patient would meet criteria for an intensive outpatient program. Therefore, the patient could have been treated in a less restrictive environment. Thus, the residential treatment center services provided from residential treatment center services provided were not medically necessary. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 acupuncture for treatment of the enrollees shoulder pain. Findings:  The physician reviewer found that there are adequate published studies showing the efficacy of acupuncture for shoulder pain. The records provided for review document that this patient has failed prior surgery and physical therapy. A trial of acupuncture is reasonable since the patient has already tried other available treatments. Therefore, the requested acupuncture is medically necessary for this patient. 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 oriental 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a four (4) wheeled power scooter for treatment of the enrollees obesity, leg edema, and difficulty with ambulation.  Findings:  The physician reviewer found that a recent physical therapy mobility evaluation indicated that the patient is able to transfer and ambulate short distances independently without a cane. He also has a cane which he uses. The evaluation noted good upper limb strength and functional upper limb range of motion. The patients home was noted to be inaccessible to entry or egress using a power mobility device. The available records do not indicate that the patient has neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude him from using a properly fitted manual wheelchair to accomplish the mobility-related activities of daily living that he would otherwise be unable to address with a cane or walker. Physical activity and the exercise afforded by these self-powered modalities of mobility, moreover, are recommended in the setting of obesity and for musculoskeletal health. All told, the requested a four (4) wheeled power scooter is not medically necessary for this patient.  Final Result: The reviewer determined that the requested equipment 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 for the IgG food sensitivity testing for evaluation of the enrollees allergies. Findings:  The 3 physician reviewers found that the medical records do not document any diagnosis consistent with a food allergy. The current National Institutes of Health National Institute of Allergy and Infectious Disease expert panel states that IgG food testing is not validated. In addition, the Joint Task Force on Practice Parameters for Allergy and Immunology also state that IgG food testing is not recommended for use in this clinical setting. As such, IgG food testing is not within the current standard of care. Accordingly, the IgG food sensitivity testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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 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 two is board certified in internal medicine with sub-specialty certification in 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 internal medicine with sub-specialty certification in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment care for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. To objectively determine if the patient meets criteria for length of stay, the Level of Care Utilization System (LOCUS) criteria was used. This is an accepted, national standard for determining the appropriate level of care for adults.  In terms of risk of harm, the patient scored a 3. The patient had a moderate risk of harm. He had no history of suicidal ideation or suicide attempts. He was consuming two to four bottles of wine per day and had driven under the influence. The patient was admitted due this increased risk and detoxified. The patient was motivated for treatment and was participating in groups and other treatment. In terms of functional status, the records support a score of 3. The patient demonstrated moderate impairment.  He was employed, although his drinking disturbed his ability to fulfill his responsibilities and obligations. With regards to medical/addictive/psychiatric comorbidity, the records support a score of 3.  The patient had a significant comorbidity of alcohol use disorder, attention deficit/hyperactivity disorder, sedative hypnotic use disorder, stimulant use disorder, depression and generalized anxiety disorder. The patient continued to use substances despite negative consequences.  In terms of recovery environment, the patient scored a 2.  The records indicate a mildly stressful environment. The patient lived with his parents. Per documentation, it is a sober environment. With regards to the level of support, the records support a score of 2. The patient had a supportive environment. His parents were supportive. With records to treatment history, the records support a score of 2. The patient has had prior treatment and was sober for 13 years.  In terms of engagement and recovery status, the records support a score of 2.  The patient was motivated for recovery and was compliant with treatment recommendations.  Thus, the records support a total score of 17. Based on these criteria, the patient would meet criteria for an intensive outpatient program. Therefore, residential treatment care provided was not medically necessary for the treatment of this patient. 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 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 Remicade for treatment of the enrollees ulcerative colitis. Findings:  The physician reviewer found that per the U.S. Food and Drug Administration prescribing information for Inflectra, it is biosimilar to Remicade. Specifically, there are no clinically meaningful differences between the biosimilar product and the reference product per the package insert.  Clinical studies have concluded that switching patients with inflammatory bowel disease from Remicade to Inflectra is not inferior to continued treatment with Remicade.  Additionally, two randomized, double-blinded trials (PLANETAS and PLANETRA) demonstrated no difference between Remicade and Inflectra in pharmacokinetic parameters, safety, and efficacy.  Data from extensions of these studies, and real world data in patients with inflammatory bowel disease, suggest that switching from Remicade to Inflectra is not associated with adverse outcomes.  For these reasons, Remicade is not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition.  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 authorization and coverage for custom lateral unloader knee orthosis for the left knee for treatment of the enrollee who has a history of sarcoma soft tissue and bilateral knee pain. Findings:  The physician reviewer found that evidence based medical guidelines and peer reviewed literature supports the requested device in this clinical setting. This patient is currently not an appropriate candidate for knee surgery to address her knee pain. The use of orthotics as a method of providing pain relief for this patients left knee is medically indicated and appropriate. Custom fabricated orthotic is a reasonable part of nonsurgical management of degenerative osteoarthritis of the knee. The patient has general health considerations which does not allow her to undergo knee surgery at this time, make temporizing measures appropriate and necessary. Orthotics may be combined with the use of a cane, walker and external support. The device will also allow the patient to have appropriate physical and occupational therapies to provide pain relief and to temporize before any surgical interventions. For these reasons, coverage for custom lateral unloader knee orthosis for the left knee is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device 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 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: An enrollee has requested reimbursement for anesthesia services for evaluation of the enrollees ulcerative colitis. Findings:  The physician reviewer found that The American Gastroenterological Association Institute (AGAI) noted that 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. The AGAI also noted endoscopic procedures that may require an anesthesia specialist include endoscopic retrograde cholangiopancreatography (ERCP), stent placement in the upper gastrointestinal tract, and complex therapeutic procedures. In this case, the patient presented without comorbidities or complex endoscopic procedures that would necessitate the use of a monitored anesthesia care. As such, the anesthesia received was 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: 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 continued orthoptic training for treatment of her binocular vision disorder.  Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested services in this clinical setting. The goal of orthoptic therapy is to stimulate and normalize accommodative, oculomotor and vergence abilities. The endpoint of orthoptic therapy for these conditions is when the patient is able to maintain clear, single binocular vision with a series of orthoptic tasks. Eye conditions such as convergence insufficiency, accommodative insufficiency, and ocular motor dysfunction are successfully treated with orthoptic therapy. Each of these eye conditions often presents with symptoms of blurred vision at near, discomfort, strain and headaches and fatigue associated with near tasks.  The literature provides a solid base of research supporting vision therapy as an effective treatment mode for oculomotor, accommodative and convergence deficiencies. However, the standard treatment time for these conditions is between 12 to 24 sessions.  For this patient, 30 sessions were completed over a 12 month time period. As such, in this patients case, her sessions have exceeded the typical treatment times. The medical literature does not support additional orthoptic therapy sessions in this clinical setting. The likelihood that additional orthoptic therapy sessions will improve this patients condition is low. Accordingly, continued orthoptic training is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in optometry with expertise in pediatric optometry 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 Zepatier 50/100 mg for treatment of the enrollees hepatitis C infection. Findings:  The physician reviewer found that According to the 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). This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including or Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50/100 mg is 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 and prospective authorization and coverage for 30 hours per week of one-to-one applied behavioral analysis (ABA) therapy, three hours per week of social skills group therapy, and 2.5 hours per week of consultation and supervision. Findings:  The physician reviewer found that ABA is a medically necessary intervention for the treatment of autism spectrum disorders, and remains one of the most evidence based interventions available. In this case, the patients family is requesting continued coverage of ABA therapy to address the patients delays in adaptive, social, behavioral and communication skill sets. There is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. The patient appears to have made progress in many areas as evidenced by the data from the progress reports. However, she continues to demonstrate significant delays in social skills and adaptive skillsets as measured across multiple domains. The patient continues to require a high level of behavioral support. The Behavior Analyst Certification Board indicates that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week.  Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore the Health Plan's denial should be overturned. 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.