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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested residential treatment services for treatment of his schizophrenia.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patients longitudinal history and symptom inventory, along with his complex pharmacotherapy that includes high-dose clozapine which is a medication typically reserved for the most refractory cases of schizophrenia, is consistent with severe impairment and grave disability.  The current medical evidence supports residential treatment in this clinical setting.  In the absence of the disputed service, the patient would experience unnecessary morbidity, and require frequent treatment at the acute level of care.  The requested services are reasonably expected to optimize his functionality and prevent a more serious episode of illness.  Further, the services are safe, appropriate and consistent with good medical practice.  Based on the data provided and considering the relevant peer-reviewed literature and community practice standards, the requested residential treatment services are medically necessary 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 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:  The parent of an enrollee has requested 12 hours of direct applied behavioral analysis (ABA) therapy per week, 5 hours per week of assessment, and 5 hours per week of treatment planning for treatment of the enrollees autism spectrum disorder.  Three physician reviewers found that according to Myers and Johnson, Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. In this case, the Health Plan states that a reduction in hours is clinically justified to be in line with having a 40 hour per week program. However, the documentation submitted does not show that he receives interventions at school. Therefore, ABA is medically necessary and should be provided for this patient at a minimum of 12 hours per week with 5 hours per week of assessment, and 5 hours per week of treatment planning.  Final Result: Three reviewers determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing.  One reviewer is board certified in neurology with special competence in child neurology 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:  An enrollee requested magnetic resonance imaging (MRI) of the bilateral knees for evaluation of her phlebitis, difficulty walking, and osteoarthritis.   Findings:  The physician reviewer found that the medical literature reported that most cases of knee pain can be effectively evaluated through physical examination and judicious use of radiography.  Despite this, an increasing number of magnetic resonance images (MRIs) of the knee are being ordered for patients with incomplete work-ups or for inappropriate indications. The medical literature concluded that MRI utilization by orthopaedic surgeons results in more appropriate interventions for patients with symptoms and findings most amenable to surgical intervention. The medical literature urged caution in ordering knee MRI in patients with radiographic evidence of degenerative changes. Thus, the literature supports obtaining plain film radiographs of the knees as more helpful than ordering MRI of bilateral knee at this time. Therefore, the requested MRI of the bilateral knees is not supported as medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that the requested services are 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 diagnostic radiology 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 requested residential treatment program services for medical treatment of the enrollees post-traumatic stress disorder (PTSD), trichotillomania, and mood disorder.   Findings:  The physician reviewer found that although well-developed clinical guidelines and patient placement criteria provide assistance, determination of the appropriate length of stay for complicated patients negotiating the developmental stage of identity formation poses a significant challenge for treatment providers. With that said, the records support the medical necessity of initial residential treatment services.  However, subsequent residential treatment services were not medically necessary for treatment of the patients medical condition.  Specifically, the documentation lacks daily progress notes, nursing entries and a psychiatric assessment detailing the longitudinal history, impact of the illness burden and past treatments tried and failed. The patient was hopeful, developing better insight and grasping the second-order effects of dishonesty. She had an unremarkable family session a week prior in which her father was very positive, and her mother continued to be supportive. There were no reports of behavioral dysregulation or psychiatric impairment. She was stable on her psychotropic medication. In sum, there was no evidence to suggest that the patient would have a recrudescence of the symptoms that prompted the admission if she was transitioned to a less restrictive treatment setting. Considering the documentation provided coupled with community practice standards, the records support the medical necessity of residential treatment services initially provided. However, the subsequent residential treatment services provided onward were not and are not medically necessary patients medical condition. 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 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:  An enrollee has requested Cosentyx for treatment of the enrollees psoriasis.  The physician reviewer found that this patient has tried and failed numerous therapies, including UVB phototherapy, cyclosporine, Raptiva, Enbrel, and Stelara.  He did not tolerate anti-TNF agents due to neutropenia which lead to hospitalization.  The requirement that the patient first fail Humira prior to authorization for Cosentyx is not reasonable given the severe side effects in response to Enbrel.  In addition, he has been treated with multiple other systemic agents without sufficient control of his disease.  Recent studies have shown a superior control of psoriasis with Cosentyx over Stelara.  Given the number of systemic agents which have been tried and failed and the adverse effect of neutropenia in response to prior anti-TNF therapy, the requested medication Cosentyx is medically indicated for the treatment of this patient.  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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intravitreal Avastin injections for treatment of her medical condition.  Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Avastin has a proven role in treating other exudative retinal diseases, and there are case studies of beneficial treatment in the setting of non-exudative macular disease such as macular telangiectasia.  There is no standard treatment for macular telangiectasia, and the disease often does not respond to medical or surgical treatment.  In this case, the patient has cystoid macular edema and pigment epithelial detachment likely related to macular telangiectasia. All told, intravitreal Avastin injections and future intravitreal Avastin injections were and are likely to be of greater benefit than other treatment alternatives.  Final Result: 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: All three reviewers are board certified in ophthalmology and are 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:  An enrollee has requested radiofrequency ablation for treatment of his venous insufficiency.    The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical records do not document compression stocking use.  A three-month course of conservative treatment is widely recognized by physicians treating this type of venous disease as appropriate prior to ablation.  The records do not document urgent issues such as bleeding or ulcer.  The Health Plans requirement that the patient complete a three-month course of conservative measures, including graded compression stockings, is medically appropriate.  All told, radiofrequency ablation was not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that 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 vascular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the breasts for evaluation of her medical condition.  The physician reviewer found that the submitted documentation supports the requested diagnostic procedure in this clinical setting.  This patient has a very strong family history of breast cancer, and her most recent mammogram noted extremely dense breast tissue.  The extremely dense tissue described on her mammogram markedly limits the utility of standard mammography.  While the risk in this patient has not been calculated in the records provided, the family history and extremely dense breast tissue are factors which are suspicious for increased lifetime susceptibility to breast cancer.  Due to the limited use of mammography as an adequate screen in this patient and the marked increased sensitivity of MRI for cancer detection in the breast, the requested MRI of the breasts is medically necessary for the evaluation of this patient.  Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 growth hormone (GH) Saizen for treatment of the enrollees idiopathic short stature.  The physician reviewer found that this patient has short stature but normal growth velocity given the presence of very early puberty, normal growth factors, a normal GH response on provocative GH testing, and no morphological abnormalities of the pituitary gland or midline brain structures. Thus, he does not have classic GH deficiency. Based on the bone age and height, the estimated final adult height is shorter than expected based on the genetic potential, but not short enough to meet the U.S. Food and Drug Administration (FDA) criteria for a trial of GH therapy for idiopathic short stature. According to  the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient does not meet most of these criteria. Therefore, the requested Saizen is not supported 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested triamterene hydrochlorothiazide (HCTZ) 37.5 mg, three times a day, for treatment of her medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  Menieres disease is considered a chronic condition.  Treatment may successfully relieve symptoms, but does not address the underlying abnormal pathophysiology.  The goals of treatment are to reduce the frequency and severity of vertigo attacks, reduce or eliminate hearing loss and tinnitus associated with attacks, alleviate chronic symptoms, and prevent disease progression, particularly hearing loss and imbalance.  Treatment consists of lifestyle modifications, medications, rehabilitation and surgical intervention.  Medications include diuretic medications.  Triamterene is used for the treatment of hypertension or edema when hypokalemia has developed on hydrochlorothiazide alone or when the development of hypokalemia must be avoided.  The U.S. Food and Drug Administration (FDA) approved dose is triamterene 37.5 mg, one to two doses daily.  In this case, the documentation does not support that the patient requires doses of triamterene in excess to the FDA recommendation.  All told, triamterene HCTZ 37.5 mg, three times a day is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication quantity 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus. Three physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, the highest priority patients include those who are at highest risk of substantial morbidity and mortality from untreated hepatitis C infection, namely those with advanced fibrosis or compensated fibrosis, transplant recipients, and those with severe extrahepatic manifestations of HCV infection. High priority patients include those at high risk of fibrosis progression, such as patients with substantial fibrosis (Metavir stage of F2), human immunodeficiency virus (HIV) coinfection, coexisting liver disease, and diabetes mellitus. This patient does not meet criteria for highest or high priority. As such, the patients request for Harvoni is not medically necessary.  Final Result: Three reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for evaluation of her risk for breast cancer.  Three physician reviewers found that the addition of digital breast tomosynthesis to the standard digital screening mammographic images has gained wide popularity in the past few years. Despite the absence of long-term studies showing increased survival rates using the additional technique, there is data demonstrating that its addition has decreased the need for repeat imaging and increased the detection of small cancers, especially in patients with dense breast tissue. Given these findings, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Three reviewers are board certified in diagnostic radiology and are 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested wireless capsule endoscopy for evaluation of her constipation.  Two physician reviewers found that the wireless capsule endoscopy measures pressure, pH, and temperature throughout the gastrointestinal tract.  It is used for identifying patients with gastroparesis and delayed transit of the small bowel or colon.  There is a lack of support for the services at issue in this clinical setting.  This patient meets criteria for irritable bowel syndrome.  She has evidence of dysynnergic defecation.  The standard of care would be to optimize laxative therapy and provide a trial of biofeedback.  All told, wireless capsule endoscopy was not likely to have been more effective than other options for evaluating this patient.  Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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.