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

Nature of Statutory Criteria/Case Summary: The parent of a 10-year-old female enrollee has requested authorization and coverage for relationship development intervention therapy. The requested service, relationship development intervention therapy, is not medically necessary for this patient. As noted in the medical literature by, Relationship Development Intervention (RDI) is a family-based, behavioral treatment designed to address autisms core symptoms. The author noted that dynamic intelligence is key to improving quality of life for individuals with autism. However, there currently is a paucity of clinical studies demonstrating the effectiveness of RDI therapy. By contrast, there have been numerous case controlled studies demonstrating the effectiveness of ABA therapy in patients with autism spectrum disorder. All told, the requested relationship development intervention therapy is not supported as medically necessary for treatment of this 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 and neurology with special qualification in child 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Crinone 8%. The submitted documentation fails to demonstrate the medical necessity of the medication at issue. Vaginal progesterone has not been shown to prevent miscarriage.  This is not the standard of care for this patient. Vaginal progesterone has not produced statistically significant reduction in pregnancy loss in the population that has recurrent miscarriages.  Per the medical evidence, using vaginal progesterone has not improved the live birth rate. There is a lack of support for the medication at issue in this clinical setting. Therefore, Crinone 8% was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret 100-40 mg three tablets daily for eight weeks. The submitted documentation supports the medical necessity of the requested medication regimen. 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. The guidelines recommend that non-cirrhotic, treatment naive, genotype 6 patients should be treated with Mavyret, three tablets daily for eight weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg three tablets daily for eight weeks is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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 center services. The submitted documentation supports the medical necessity of the services at issue. In this particular case, the patients alcohol use was central to her daily routine and contributed to significant impairment across multiple functional domains.  Her daily over-consumption of alcohol strained relationships, and often culminated with belligerence and blackouts. The patient also had co-occurring psychiatric issues. If discharged on the first date of service in dispute, the patient was likely to have promptly relapsed, while community-based treatment would have been inadequate at the time.  Per the records, she feared relapse and craved alcohol. Throughout her stay, the patient was actively engaged in treatment, including mindfulness training, family counseling and education, and aftercare preparation to develop a more empowering environment to sustain sobriety. The services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards for a case of this severity and facilitated transition to service delivery in a less restrictive setting.  Additionally, the services provided were reasonably expected to improve the patients condition and prevent a more serious episode of illness. In sum, residential treatment center services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for residential treatment services and partial hospitalization program after treatment from the residential treatment facility. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health condition.Findings: There is lack of support in the documentation for the medical necessity for the requested services in this clinical setting. The requested residential treatment center (RTC) level of care to treat psychosis is not considered within the standard of care. The note did not state that the patient had any suicidal or homicidal ideation or that she had command auditory hallucinations or that the patient required inpatient hospitalization. Although psychotherapy has been determined to be helpful for psychosis in schizophrenia, the standard of care treatment for psychosis is medication therapy. The patient was taking two medications at high doses but it is unclear how long the patient has been compliant with these medications. Per the documentation submitted, the patient had previously discontinued her medication. The records do not demonstrate that the patient is in imminent danger to herself or to others, or exhibits grave passive neglect to support inpatient psychiatric hospitalization. If the patient is in imminent danger to herself or others or exhibited grave passive neglect, then the patient would require inpatient psychiatric hospitalization. However, the documentation does not suggest that the patient requires inpatient psychiatric hospitalization. The patient would meet criteria for an intensive outpatient program to receive enhanced support during the week through psychotherapy as well as more frequent contact with a psychiatrist to adjust her medications to treat her medical condition. For these reasons, the requested residential treatment services and partial hospitalization program after treatment from the residential treatment facility have not been established as medically necessary for treating this 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 50-year-old male enrollee has requested authorization and coverage for Opana 45 mg daily. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. In this case, the patient was recently taking 270 MME per day. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. Moreover, there is no mention that behavior therapy has been completed despite much research to support its use. Moreover, not all non-opioid medications classes have been optimized or tried. All told, the requested Opana 45 mg per day is not supported as medically necessary for treatment of this patients chronic pain. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for posterior cervical fusion stabilization surgery. The records indicate that this patient presents with chronic neck pain. She has a neurological examination that has been within normal limits. She has no localizing features to her pain to implicate any level of her cervical spine as her pain generator. She has no dermatomal/myotomal symptoms or findings of a cervical radiculopathy. Moreover, the patient has no symptoms of spasticity, increased tone, or pathologic reflexes. There is no evidence of cervical instability. The patients symptoms of increased pain with use of arms above her head and with subclavian bruits suggest that subclavian steal and other vascular problems need to be ruled out. Moreover, there is no documentation of failed conservative management or that the patients pain affects her ability to perform activities of daily living. Overall, the criteria for posterior spinal fusion from the North American Spine Society have not been met in this patients case. The patients symptoms and findings are not consistent with cervical radiculopathy/myelopathy and there is inadequate documentation of failure of conservative management. Thus, the requested posterior cervical fusion stabilization surgery is not supported as medically necessary for treatment of this 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 neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Claravis. The submitted documentation does not support the medical necessity of the requested medication. The patient has requested coverage for Claravis as treatment for recalcitrant nodulocystic acne. The medical evidence supports evaluation by a dermatologist in order to determine other appropriate treatment options. In this patients case, the medical records do not indicate that other systemic approaches to her acne were discussed. Specifically, spironolactone may be an appropriate choice for this patient. There is a lack of support for Claravis in this clinical setting. Therefore, Claravis is not medically necessary for this patient at this time.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 dermatology 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 cervical total disc arthroplasty. The submitted documentation fails to demonstrate the medical necessity of the requested services. Hybrid surgery provides equivalent outcomes and functional recovery for cervical disc diseases, and significantly better preservation of cervical range of motion compared with anterior cervical discectomy and fusion in two-year follow-up. However, more well-designed studies with large groups of patients are required to provide further evidence for the benefit and reliability of hybrid surgery for the treatment of cervical disc diseases. This patient presents with persistent neck pain radiating into the right upper extremity with numbness and tingling. She is reporting moderate functional difficulty in activities of daily living, including dropping things. Clinical examination findings have demonstrated motor and sensory deficits consistent with imaging evidence of C5/6 disc protrusion with central canal stenosis and mild cord compression. She is status post prior C6/7 anterior cervical discectomy and fusion in 2003. Under consideration is a request for an artificial disc replacement at C5/6 adjacent to the fused segment. The current medical literature indicates that large, randomized controlled trials are warranted to validate the initial findings that cervical hybrid surgery is safe and effective. There is no compelling rationale presented to support the medical necessity of total disc replacement at C5/6 over anterior cervical discectomy and fusion. Therefore, the requested cervical total disc arthroplasty is not medically necessary for the 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Zofran. The submitted documentation fails to demonstrate the medical necessity of the requested medication regimen. There is a lack of documentation indicating the patient was treated by a physical health provider. This patient has chronic nausea associated with her medical condition. Although the patient has a diagnosis of irritable bowel syndrome and gallstones, there is a lack of documentation to support that these conditions are the cause of the patients chronic nausea. The treatment for a patient with chronic and prolonged symptoms associated with her medical condition includes medication and cognitive behavioral therapy. Medication choice typically includes a serotonergic reuptake inhibitor antidepressant. There is no indication for the medication Zofran in the treatment of her medical condition. Zofran (ondansetron) is an antiemetic, which has been approved for the treatment of chemotherapy-induced nausea and vomiting, radiotherapy-associated nausea and vomiting and postoperative nausea and/or vomiting. It has an off-label use for nausea and vomiting of pregnancy that is severe or refractory. In this case, the patient does not have a condition that is U.S. Food and Drug Administration approved for the use of this medication. Per the records, the patient has not completed formal cognitive-behavioral therapy, which is indicated for the treatment of the patients medical condition. Furthermore, the daily/chronic use of this medication has the potential to interfere with the patients psychiatric medications. Therefore, Zofran is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 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 hematopoietic stem cell transplantation (bone marrow transplant).  Findings:  Two of the three physician reviewers found: Overall, the accepted role for stem cell transplant (either autologous or allogeneic) in the treatment of diffuse large B-cell lymphoma is when treating relapsed or refractory disease that is still chemotherapy sensitive. CAR-T cell treatment is a relatively new treatment for this disease. Even in heavily pretreated patients, this treatment results in an approximately 50% rate of complete remission, many of which are sustained. Although transplant has been used in patients prior to CAR-T cell therapy, there is a lack of studies exploring its use after CAR-T cell complete remission. There is concern for combining toxicities. The current medical evidence does not support the services at issue in this setting of complete remission with CAR-T cell therapy. Therefore, the requested hematopoietic stem cell transplantation (bone marrow transplant) is not likely to be more effective than other treatment options. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Saizenprep 8.8 mg cartridge. The submitted documentation does not support the medical necessity of the requested medication. There is a lack of evidence in the literature that one brand of growth hormone is more effective than another for the treatment of idiopathic short stature. Furthermore, there is a lack of evidence that one brand of growth hormone carries a higher risk of adverse effects than another. The documentation submitted does not indicate that the patient has tried the preferred brand of growth hormone and has had an adverse effect or was unable to adhere to therapy due to needle-phobia. Therefore, Saizenprep 8.8 mg cartridge is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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.