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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for lidocaine patches, 5%. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients chronic back pain with severe sciatica. The submitted documentation does not support the medical necessity of the requested medication quantity. In a prospective randomized double blind trial, the Lidoderm patch was no better than placebo in treating low back pain. According to researchers, this lack of effect was studied by using functional magnetic resonance imaging. The results showed that there was not a significant benefit as compared to placebo. The requested medication has not been proven effective for chronic back pain and is not medically reasonable or necessary in this clinical setting. Therefore, lidocaine patches, 5% are 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 anesthesiology with sub-specialty certification in pain management 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prometheus Anser IFX testing. Patients with low infliximab concentrations and high titers of antibodies to infliximab will most likely require treatment with a different agent. Some providers advocate for the use of monitoring infliximab trough levels at week 14, permitting dose escalation before the development of clinical or laboratory evidence of disease activity. In randomized trials comparing therapeutic drug monitoring with routine management, therapeutic monitoring was associated with fewer relapses. All told, the Prometheus Anser IFX testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the Prometheus Anser IFX testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the Prometheus Anser IFX testing performed was 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 pediatrics with sub-specialty certification in pediatric 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

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for the services rendered. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation does not support the medical necessity of the services at issue. Although the patient had a history of increasing emotional and behavioral disturbance, prior to the acute hospitalization, there was evidence of serious family dysfunction precipitating the events three days prior to the patients  hospitalization. The American Psychiatric Publishing Textbook of Psychiatry states that parent-child dysfunction, resulting in depression, oppositional behavior, and self-injury is best treated by thorough psychiatric, psychological, family assessment, and family therapy. This therapy typically takes place in a dialectic behavioral therapy environment that involves all family members and provides a common reference and set of coping mechanisms. The patients admission to a treatment program thousands of miles away precluded meaningful family intervention and may have increased the patients alienation, anger, and depression. Studies in child and adolescent psychiatry state that adolescents with depression respond to cognitive-behavioral therapy and to antidepressant medications. All appropriate interventions could have been made in a less restrictive environment than in an intermediate outdoor behavioral health program. In summary, the services rendered were not medically necessary for 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 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 authorization and coverage for mastopexy and abdominal body contouring. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The requested surgeries appeared to be for the purpose of removal of excess skin and tissues of the subcutaneous nature per the progress notes. The surgeries were performed in the abdomen, buttocks and breast tissue area along with a surgery for breast prosthesis. The progress notes and photographs indicate that the patient had breast tissue prior to surgery. The surgeries did not appear to be for the purpose of creation of breasts, but rather cosmetic alteration of current breast tissue as well as cosmetic alteration of excess skin tissue due to weight loss. The progress notes indicate that the patient presented for elective cosmetic-type surgery. The submitted documentation does not indicate that the patient specifically reported that her body size and shape was contributing to her gender dysphoria. It is also noted that the patient is continuing to receive hormone therapy which will contribute to redistribution of tissue as well.  Therefore, mastopex and abdominal body contouring were 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 with expertise in the treatment of gender dysphoria 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 intravenous immunoglobulin (IVIG). Central to the idea of PANDAS is the concept that after Group A beta-hemolytic streptococcal (GABHS) infection, antibodies are generated that cross-react with antigens present in the basal ganglia and related structures. This in turn causes pathologic derangement of poly-synaptic pathways that subserve both cognitive, emotional and motor functions frequently associated with obsessive compulsive disorder and other neuropsychiatric disorders. In the medical literature, researchers reported on a clinical trial that showed no difference between IVIG and placebo in the blinded phase for pediatric patients with a purported diagnosis of PANDAS. All told, the current medical literature does not support the requested IVIG as medically necessary for 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. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency neurolysis/ablation. Review of the literature with comprehensive analysis of the published data pertaining to the effectiveness and risks of fluoroscopically guided cervical medial branch thermal radiofrequency neurotomy for treating chronic neck pain of zygoapophyseal joint origin. The authors concluded that if performed as described in the International Spine Intervention Society guidelines, fluoroscopically guided cervical medial branch thermal radiofrequency neurotomy is effective for cervical zygoapophyseal joint pain and carries only minor risks. This patient complains primarily of severe left-sided neck pain with radiation to the shoulders and head. The provider does not document any evidence of radiculopathy. Based on the guidelines, the patient is a good candidate for radiofrequency neurotomy. For these reasons, the radiofrequency neurolysis/ablation performed and prospective authorization and coverage for radiofrequency neurolysis/ablation were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is actively practicing.  All three 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: A enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Findings:  The physician reviewer found that the patient had a remote history of stroke and remote history of left lower extremity fractures. He had been hospitalized with aspiration pneumonia and enterocolitis. He had a limited prior level of function. The patient required oversight of his medical conditions and medication management. There were skilled therapy needs in terms of progressing his mobility and ability to perform essential activities of daily living such as bed mobility without assistance. However, he had received SNF level care for approximately six weeks and his medical conditions were stable. In addition, there were no complex wound care needs. Based on the patients progress, there was little expectation that achieving further gains would impact the burden of care at discharge. Daily skilled services were not medically necessary and the patients condition would not be expected to have deteriorated with services provided on a less than daily basis. The patient had reached a functional plateau consistent his current neurological status and co-morbid medical conditions. The patient was receiving care that could have been provided by his non skilled caregivers with periodic skilled oversight and modification of the care plan if needed. Given these findings, the SNF services provided were not and are not medically necessary for treatment of this patients medical condition. 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 physical medicine and rehabilitation 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: A patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus, genotype 1a. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret for eight weeks. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 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: A 43-year-old female enrollee has requested authorization and coverage for reduction mammoplasty for their back pain.  Findings:  The physician reviewer found that Her symptoms include upper back and shoulder pain, as well as shoulder grooving seen on photographs. The photographs are supportive that her clinical condition and functional deficit of pain are likely directly related to her macromastia. The amount of resection planned by the provider is significant at 500 grams. The American Society of Plastic Surgeons (ASPS) state that based on the results of Level I and II Evidence, reduction mammoplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. The ASPS noted that the patient should have documentation of the severity of symptoms of breast hypertrophy and the impact on health related quality of life. This patients symptoms include chronic breast pain due to the weight of breasts, shoulder grooving, and upper back and shoulder pain, which satisfies these criteria. Moreover, the patient has shoulder grooving in the photographs provided for review. Based on this, the patient has functional problems that are directly related to her significant macromastia. Breast reduction is a well-known procedure that directly addresses this functional deficit and is appropriate in this clinical setting. Accordingly, the requested reduction mammoplasty is supported as medically necessary for treatment of this patients mammary hypertrophy and ptosis. 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 plastic 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 residential treatment center services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient was admitted to the treatment center due to some oppositional behaviors as well as some depressive symptoms. His mood and depression symptoms appeared mild in nature. On his intake evaluation, he and his family reported symptoms of autistic spectrum disorder. He was not noted to have aggressive behaviors during his stay.  He appeared to have some level of rigid thought process which is typical of patients with autistic spectrum disorder. The patient denied serious depression or anhedonia during his stay. There was no documentation of debilitating anxiety or psychosis. The documentation does not support failure of intensive outpatient therapy, partial hospital program therapy or cognitive behavioral therapy. The progress notes indicate that the patient had relational issues with his family as documented in his initial psychiatric evaluation. Initial psychiatric recommendations included working on parental communication in psychotherapy.  It is not clear what type of family therapy the family had engaged in on outpatient basis. Functional family therapy appeared to be indicated in this case and has proven highly successful in decreasing violence, drug abuse, conduct disorder and family conflict. Functional family therapy is typically administered on an outpatient basis. The submitted records indicate that this type of treatment would have been appropriate for the patient and his family on an outpatient basis. The evidence base regarding childrens mental health treatment has shown that treatment outside of a residential setting is effective and appropriate and is as beneficial as residential treatment center programs. Due to his lack of severe symptoms and dangerous behaviors, less restrictive care was medically appropriate. Therefore, residential treatment center services were 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation supports the medical necessity of a portion of the services at issue. This patient had an acute episode of illness that initially warranted inpatient psychiatric services. The hospital-based care provided was reasonably expected to improve the patients condition and prevent a more serious episode of illness. However, based on the medical records submitted for review, treatment at the acute level of care was no longer medically necessary after the first disputed date of service. On the first disputed date of service, the patient continued to endorse passive suicidal ideation. The patients family system was negotiating cultural and stigma issues related to mental illness and psychiatric treatment. Nonetheless, they were supportive and involved. The patient was engaged in active treatment. The patients new medications were both increased. Thus, discharge would have been premature at the time. On the second disputed date of service, the patient was anxious about returning home and consolidating the experience of the fathers care. The patient was looking forward to continuing treatment in a partial hospital program and believed it would begin the following day. The patient had an enjoyable visit with friends and played a board game.  The patient was sleeping well at night. There was no report of inappropriate or concerning behaviors on the unit. Neither the patients thought processing nor cognition were compromised. The record noted that the patients mood was normal and was negative for active or passive suicidal ideations. The patient did not require any rescue medication and there were no changes made to the daily regimen, which appeared to be well tolerated with no adverse drug reaction. On-going care was clearly necessary. However, after the first disputed date of service, there was no evidence of an acute psychiatric syndrome that service delivery in a less restrictive setting would have been unsafe or inadequate. As such, a portion of the residential treatment center services were medically necessary. Final Result: The reviewer determined that a portion of the services at issue were 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 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.