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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 24 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), no data are available for retreatment of Sovaldi and Daklinza failures in genotype 3 patients; Epclusa and ribavirin for 24 weeks may be considered for those who require immediate re-treatment, such as patients with cirrhosis, as in this case. Per the guidelines, patients with diabetes mellitus are at risk for faster disease progression. The guidelines state that available data comes from patients who have failed Epclusa. 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: The parent of an enrollee has requested authorization and coverage for occupational and physical therapy at a frequency of once per week.  Findings:  The physician reviewer found that the medical records support the medical necessity of the requested services.  A child with attention deficit/hyperactivity disorder may experience difficulties in many aspects of life, including processing of sensory information, motor planning, executive functions, and fine motor coordination. This patient been diagnosed with attention deficit/hyperactivity disorder, seizures, and cerebral palsy.  He has a number of functional deficits which are negatively impacting his ability to perform and participate in activities of daily living.  Further, he has difficulty with ambulation and balance because of asymmetric increased lower extremity tone and frequent falling.  Occupational therapy, with its focus on fine motor skills, self-regulation, visual perceptual skills, and self-help skills, is ideally suited to help this patient optimize his functional capacity and ability to care for himself.  Physical therapy is ideally suited to facilitate improvement in lower extremity tone and gait, optimizing his independence.  Both of these rehabilitative interventions are medically necessary for this patient to maximize his functional abilities.  Thus, the requested occupational and physical therapy at a frequency of once per week is medically indicated 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 physician 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.
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 hospital bed with rails. Findings:  The physician reviewer found that a review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested equipment. In patients with dementia and agitation, the use of bedrails is not recommended as it has been shown that more severe injuries occur in beds with rails than beds without rails. Patients with dementia attempt to climb over the rails and sustain more severe head, back and hip injuries. Therefore, the request for a hospital bed with rails is not medically advisable or necessary as it may result in more severe injuries. 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 physician 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 bi-level positive airway pressure (BPAP) machine. Findings:  The physician reviewer found that based on the current medical literature and the presented clinical records, the BPAP machine to be provided is medically necessary for evaluation of the patients medical condition. The patient presents with mild obstructive sleep apnea and development of central apneas while undergoing standard CPAP titration. The patient was switched to BPAP to complete titration with no further central apneas and AHI reduced to 0. The patient was initially having problems with BPAP compliance due to face mask issues, but she was appropriately treated with nasal pillows with chin strap. In this case, continued use of the BPAP machine is medically necessary based on polysomnogram findings with central apneas and compliance greater than 4 hours per night. For the reasons provided, the requested device is medically necessary for treatment of the 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 physician reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease and critical care 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 reimbursement for residential level of care services. Findings:  The physician reviewer found that due to the lengthy history of drinking and increased reports of consumption, a residentially based detoxification and preliminary introduction to chemical dependency treatment was safe, appropriate and consistent with good medical practice.  Although addiction specialty services remained indicated, the clinical documentation does not demonstrate the medical necessity of treatment in a 24-hour supervised setting.  First, the absence of significant comorbidity supported a less restrictive setting.  There was no evidence of the emergence of late alcohol withdrawal symptomatologies.  Despite the diagnoses of hypothyroidism and transaminitis, the patient was medically stable and completed the detoxification treatment uneventfully.   Upon admission for detoxification, her depression and anxiety were untreated.  However, the patient responded well to the introduction of a pro-serotonergic medication while her symptoms were not generating a psychiatric syndrome that warranted treatment in a residential setting. Second, the patient embraced recovery principles and was motivated in her quest for sobriety.  She had a safe and sober environment at home.  She had no other addictions besides alcohol.  She had no prior history of chemical dependency treatment in a less restrictive setting, such as anti-craving medication, community programming, outpatient specialty care, intensive outpatient services or partial hospitalization.  Modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. There was no evidence to suggest that comprehensive, evidence-based services provided in a less restrictive treatment setting would have been insufficient or inadequate at the time.  All told, residential level of care services during the dates of service in question were not medically indicated 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 physician 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 Nucynta ER 100 mg twice daily for treatment of the enrollees fibromyalgia and myofascial pain syndrome. Findings:  The physician reviewer found that the Centers for Disease and Control and Prevention (CDC) indicate that epidemiologic studies suggest that concurrent use of benzodiazepines and opioids may put patients at greater risk for potentially fatal overdose. The CDC also indicates that clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. The CDC states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, clinicians should prescribe the lowest effective dosage. In this case, the patient is taking 7.5 morphine milligram equivalents (MME)/day. The provider proposes to increase this to 87.5 MME/day. There is no rationale provided for this considerable increase in the MME/day. Also, the record demonstrates that tolerance has taken place. In this clinical setting, adding more pure mu agonists for a short while will treat the symptoms of mu agonist saturation. However, down regulation will transpire and then the patient is back to where they started in terms of perception in pain. In addition, the patient will likely be worse off since the patient now has a much higher opioid tolerance level and it would take much longer to wean off the pure mu agonist with even greater pain in order to reset their mu agonist receptors. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for dental surgery and anesthesia procedure for treatment of the enrollees dental caries and chronic periodontitis. Findings: The physician reviewer found that Patients with special needs often present a challenge for the dental care team. The exacting and surgical nature of dental procedures requires significant patient cooperation to ensure the safe delivery of care. Some individuals who have special care needs have difficulty cooperating during treatment, thus creating a potentially harmful situation. The medical literature demonstrates that the safety of the patient and treating staff may be compromised when treating a patient with disabilities due to the patients inability to cooperate. In this case, the records demonstrate that the patient has a history of developmental delays and autism and is unable to sit in a dentist chair due to her disabilities. Final Result: The reviewers 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 dentistry 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 the resumption of care at a skilled nursing facility (SNF) with physical therapy for treatment of the enrollee, who has a history of chronic hypercapnic respiratory failure. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested services in this clinical setting. In this case, the patients medical condition appears stable. There are no complex wound care needs. She does not require medical oversight of her condition at a hospital level of care. She had shown some progress but the gains had been very minimal. There were no medication concerns and discharge home was being recommended. Her burden of care was unchanged since the start of care. The patient made no functional improvement as of the date in question and there was no reasonable expectation of achieving gains that would impact the burden of care at discharge. The patients care can be provided at a lower level of care including through custodial care. 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 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: 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 150.5 hours per month of applied behavioral analysis (ABA) therapy necessary for treatment of the enrollees autism spectrum disorder. Findings: The physician reviewer found that the Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, the patient has made progress with ABA therapy, but he continues to demonstrate dangerous behaviors of aggression and elopement. Given the medical necessity of ABA therapy for children with autism, coupled with the patients maladaptive behaviors that include elopement, aggression and stereotyped/repetitive behaviors, the request for 150.5 hours per month of ABA is medically necessary for treatment of the patients autism. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for eight hours per day of in-home skilled nursing services provided and forward. Findings:  The physician reviewer found that The request for eight hours per day of in-home skilled nursing services provided and  forward is medically necessary for treatment of the patients medical condition. According to the American Academy of Pediatrics (AAP) guidelines for home care of infants, children, and adolescents with chronic disease, comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens. AAP guidelines further state that the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities. Treacher-Collins syndrome, also known as mandibulofacial dysostosis, is an autosomal dominant syndrome characterized by facial abnormalities, including lower eyelid colobomas, sunken cheekbones, blind fistulas at the corners of the mouth and by the ears, deformed external ears, receding chin, large mouth, and abnormal hair growth pattern. Facial clefts and deafness may occur. The mandible and other facial bones may be hypoplastic. Dental abnormalities are common. In infancy, airway and feeding are of greatest concern, requiring tracheostomy and gastrostomy placement. Over time, surgical reconstruction may be performed to approximate normal facial structure. In this case, the patient has a number of medical issues as a result of and in addition to his prematurity and congenital abnormalities. Given the severity of the patients defects and potential for complications with increased morbidity, it is not reasonable or safe for the parents to care for the patient round-the-clock. The patients needs must be addressed 24 hours a day. Skilled nursing provides the level of proficiency needed to maintain the patients health and well-being, preventing morbidity and maximizing development, and allowing the layperson caregivers time to maintain the household, and address personal needs. As such, the request for in-home skilled nursing services is medically necessary eight hours daily from date of denial and forward.  Final Result: The reviewers 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: Physician reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care 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 reimbursement and prospective authorization and coverage for intensive outpatient (IOP) treatment.  Findings:  The physician reviewer found that  the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. A review of the patients IOP records indicate that the patient was not suffering from suicidal or homicidal ideation or psychosis. The patient has long-standing anxiety issues and appeared to have recent suicidal ideation due to uncontrolled anxiety. the patient has completed successful inpatient and PHP treatment recently. The patient continues to have anxiety symptoms. The patient's target anxiety symptoms are typical of children with anxiety disorders. Due to the fact that it may take a significant amount of time for these behaviors to show significant improvement, it appears that they are more approved appropriately treated with continued outpatient therapy, in a setting that allows generalization to home and school type environments. Outpatient treatment and least restrictive options are considered first lines of care as referenced by The American Academy of Child and Adolescent Psychiatry which recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports.  The records indicated that this patient has separation anxiety disorder. As such, it is critical that the patient is treated in the patient's home so that the  patient is not further separated from the patient's family.  Cognitive behavioral therapy is a mainstay for anxiety treatment and is effective on an outpatient basis. As noted by Brady and colleagues, The cognitive-behavioral treatment program was similarly effective in anxious children with and without comorbid disorders; both groups showed clinically significant reductions in pretreatment diagnoses and symptoms.  In summary, the patient has stabilized and this patient's current behavioral issues are secondary to the chronic nature of the patient's anxiety and can be treated on an outpatient basis. According to the submitted documentation, the patient is not displaying symptoms that would warrant the intensity of an IOP level of care. Therefore, IOP services forward were not and are not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry 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.