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

Nature of Statutory Criteria/Case Summary: An enrollee has requested chiropractic services. The submitted documentation does not support that the requested services are medically necessary. Chiropractic maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong or enhance the quality of life. Chiropractic maintenance therapy is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, chiropractic treatment becomes supportive rather than a corrective in nature. Researchers have indicated that chiropractic treatment was greatest in short-term pain reduction. In this case, there is no documentation that the patient had tried any other therapies or that she was in an active rehabilitation program. There is no indication in the records that the patient was receiving care for acute pain. The patient was reported as having chronic pain and receiving chiropractic care as maintenance therapy. Under these circumstances, chiropractic services are not medically necessary for treatment of the 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 chiropractic and oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services. The submitted documentation does not support the medical necessity of the requested services. A large randomized controlled trial examining the effect of adding acupuncture or Alexander Technique exercises to usual care (medication and physical therapy) for chronic neck pain found significant improvements in pain reduction and associated disability and self-efficacy. Regarding the complaints of vertigo-dizziness, acupuncture demonstrates a significant immediate effect in reducing discomforts and visual analog scale of both dizziness and vertigo.Although an acupuncture trial for pain management would have been reasonable and supported by the peer review literature, additional treatments should only occur based on progressively greater, incremental objective gains. In reviewing the submitted records, it appears that the patient underwent an unknown number of acupuncture sessions for the treatment of vertigo and cervical myofasciitis. The provider failed to document the number of sessions completed and/or any specific, measurable, sustained, significant, objective functional improvement (quantifiable response to treatment) obtained with previous acupuncture. Based on the records, the patient is not presenting with a flare-up of the condition or a re-injury. Under these circumstances, additional acupuncture treatment is not medically necessary to treat the 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 licensed in oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested vision therapy services. The submitted documentation does not support that the requested services are medically necessary. The field of vision therapy includes many treatments and diagnoses, most of which have not been proven scientifically. This is the conclusion that multiple academic organizations, including the American Academy of Ophthalmology, have reached. In this case, the evaluation of the patient by vision therapy providers has identified numerous ocular abnormalities, but there is little scientific evidence to indicate that these abnormalities are related to the patient's reading problem. The only condition in which vision therapy has been shown to be effective is convergence insufficiency, in which a patient has trouble bringing the eyes close together when they look at near. The submitted documentation in this case includes patient NPC measurements that have not been consistent, and it is unclear whether the patient truly has convergence insufficiency. In the event that it was clearly established that the patient truly had convergence insufficiency, the first step in treatment would be home exercises, such as pencil push-ups, and vision therapy would only be considered if home exercises had not been effective. While the precise nature of the vision therapy being offered is not clear, it may have some benefit for convergence insufficiency only. Under these circumstances, the requested vision therapy is not medically necessary for the treatment of the 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 ophthalmology 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

An enrollee has requested authorization and coverage for prostatic arterial embolization. The American Urological Association (AUA) guidelines state that prostatic arterial embolization is not recommended for the treatment of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH) outside the context of a clinical trial. The first-line therapy for management of BPH includes medical therapy with alpha blockers, 5 alpha reductase inhibitors, phosphodiesterase inhibitors, and anticholinergic medications. For patients who fail to respond to medical therapy, a transurethral resection of prostate (TURP) procedure is indicated. In patients with large glands measuring 100 cc or more, Holep and simple prostatectomy are considered the standard of care. This patient is noted to have a prostate gland measuring over 100 cc. Moreover, randomized trials do not demonstrate improved efficacy of prostate artery embolization over TURP, Holep, or simple prostatectomy. All told, the requested prostatic arterial embolization is not likely to be more beneficial for treatment of this patients medical condition than standard therapies.Findings:  Three physician reviewers found the requested prostatic arterial embolization is not likely to be more beneficial for treatment of this patients medical condition than standard therapies.Final Result: The reviewers determined that the requested prostatic arterial embolization is not likely to be more beneficial for treatment of this patients medical condition than standard therapies.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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: An enrollee has requested authorization and coverage for Orthovisc injections to both knees. Researchers found that intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. A study recommends hyaluronan acid for appropriate patients with knee osteoarthritis, based on a very large network. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement and is more effective. There is no detailed evidence of recent failed conservative treatment. Additionally, there is no current pain or functional assessment. Under these circumstances, Orthovisc injections to both knees are not medically necessary for the treatment of the 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 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.Findings:  The physician reviewer found that
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 and reimbursement and prospective authorization and coverage for intensive outpatient program services. The American Psychiatric Association treatment guidelines for substance use disorders recommend that residential treatment or similar care higher than outpatient is indicated for patients who Do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance useand wholack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In this case the patient required a safe and stable living environment in order to develop recovery skills thus qualifying for ASAM American Society of Addition Medicine Level 3.1 treatment at least. This level of care is similar to what the patient received. While detoxification is provided to make a patient physically stable and safe rehabilitation is the essential component that should follow detoxification to help a patient maintain sobriety and reduce risk of relapse. Given the severity of this patients illness and his high risk of relapse residential treatment center services were in accordance with generally accepted standards of medical practice as evidenced by the American Psychiatric Association guidelines and American Society of Addiction Medicine criteria. Residential treatment was also clinically appropriate for the patients illness and was therefore medically necessary. The American Psychiatric Association treatment guidelines for substance use disorders also note that IOP can be used as step-down programs for individuals leaving hospital or residential settings who are at a high risk of relapsing or to stabilize patients by retaining them in treatment and providing more extended intensive outpatient monitoring of relapse potential and co-occurring disorders. IOP services are classified as ASAM Level 2.1 treatment which encompasses services that are capable of meeting the complex needs of people with addiction and co-occurring conditions like this patient with opioid use disorder MDD and PTSD. In this case IOP treatment was and is in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. Therefore the IOP services provided to the patient were and are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue and requested services were and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has chronic low back pain and myofascial pain, and has requested authorization and coverage for the medication Belbuca. The Health Plan indicated that it had not been determined that all covered formulary drugs on any tier would be ineffective. Or would not be as effective as the requested non-formulary drug, or would have more adverse effects than the requested non-formulary drug. There are other alternative drugs available which the patient has not tried and failed.At issue in this case is if the medication Belbuca is medically necessary to treat the patients medical condition.The Center for Disease Control (CDC) guideline does not support chronic opiate maintenance for non-malignant low back pain. The assertion that transdermal Buprenorphine is safer is not evidence-based. Studies have demonstrated that opiates were not superior to treatment with non-opioid medications for improving pain related function over a 12-month period. The patient does not have a documented source of low back pain, and the evidence does not support chronic opiate use in this clinical setting. Therefore, the requested Belbuca is not medically necessary. 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 subspecialty 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 reimbursement for Supartz injections. Findings:  The physician reviewer found that the medical literature and submitted documentation support the medical necessity of the services at issue. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As noted by a medical study, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. The authors performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. In this case, the submitted medical records document subjective, objective, and radiographic imaging findings consistent with osteoarthritis of the knee. The patient has failed conservative treatment, including cortisone injections. Under these circumstances, the Supartz injections provided to the patient were medically necessary for the treatment of the patients medical condition.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 39-year-old male requesting reimbursement and prospective authorization and coverage for the residential treatment center (RTC) level of care.  Findings:  The physician reviewer found that The American Psychiatric Association treatment guidelines for substance use disorders recommend that residential treatment services or similar care higher than outpatient services are indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.Patients require safe and stable living environments in order to develop their recovery skills thus qualifying for ASAM Level III treatment at least, similar to what this patient received at the facility.Although the patient makes statements at times minimizing his condition, his doctors feel strongly that he remains at high risk for relapse and self-harm. Given the severity of the patients illness, the RTC services were and are in accordance with generally accepted standards of medical practice and clinically appropriate for the patient's behavioral health condition. Therefore, the RTC services were and are medically necessary, and the Health Plans denial should be overturned.Final Result: The reviewer determined that the requested services were and 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

An enrollees parent has requested authorization and coverage for 40 hours per week of direct ABA services. The National Standards Project identifies ample data indicating that ABA is the most effective treatment for children and adults on the autism spectrum. The Behavior Analyst Certification Board (BACB) indicates that the duration of ABA treatment is effectively managed by evaluating the patients response to treatment. The BACB noted that some patients will continue to demonstrate medical necessity and require continued treatment across multiple authorization periods. This definition of treatment does not include an average length of treatment, as there is no one size fits all approach to ABA treatment. Each individual patients treatment is tailored to their specific needs, with some needing treatment for short periods of time, while others will need treatment across the lifespan. In this patients case, although she has made gains in the reduction of problem behaviors, she continues to engage in elevated rates of severe self-injury in the form of head banging. In addition, she has not yet mastered many adaptive and functional goals. Further, her results on testing indicate that she is performing several years below her age level. Given these findings, the requested 40 hours per week of direct ABA services are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychology and is a board certified behavior analyst 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: The patient has requested authorization and coverage for proton beam radiotherapy. Integral treatment options for patients with meningiomas include surgery, conventionally fractionated radiation, and stereotactic radiosurgery. Radiation techniques can be delivered with protons or photons. The primary difference between proton and photon irradiation is that protons stop abruptly in the tissue, so there is less exit dose through normal tissue. The use of proton therapy is an accepted radiation technology that has proven efficacy and tolerability in certain conditions including base of skull chordomas or chondrosarcomas. In the medical literature, researchers concluded that proton therapy is a safe and effective treatment for patients with untreated, recurrent, or incompletely resected intracranial meningiomas. According to the current data, proton beam radiotherapy can improve normal tissue sparing in this clinical setting. Given this support, the requested proton beam radiotherapy is likely to be more beneficial for treatment of this patients medical condition than standard alternative therapies including photon beam radiotherapy. One reviewer found that the proton beam radiotherapy is not likely to be more beneficial for treatment of this patients medical condition than standard alternative therapies including photon beam radiotherapy.Final Result: Two of the three reviewers determined that the requested services 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 radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology 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.