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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. In this case, the patient was at minimal risk of harm (score 1) due to a lack of current suicidal ideation, homicidal ideation or signs of psychosis. The patients functional status was minimally impaired (score 1) due to apparent transient impairment functioning following an identified stressor of substance use. He was employed and his activities of daily living were intact. The patient had minor comorbidities (score 2) due to no medical problems. He had anxiety and depression that were under control. He did not have serious medical issues that affected his treatment. The patients recovery environment was mildly stressful (score 1) with no major losses of interpersonal relationships and his living environment posed no significant threat or risk. The patients recovery environment was supportive (score 2), as some elements of his support system were willing and able to participate in treatment. The patient has demonstrated significant improvement with treatment (score 2) with moderate ability to refrain from substance use. The patients s mental health symptoms were under good control and the records suggest that he responded well to the IOP program. The patient was motivated and engaged in treatment (score 2). The provider described the patient as collaborative, cooperative, and insightful into his need of treatment. This gives the patients presentation a composite score of 11, which correlates with recovery maintenance health management. The records suggest the patient was a candidate for treatment in a less restrictive setting. Therefore, the IOP services provided 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 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 enrollee requested authorization and coverage for the medication, Trulance (plecanatide) for chronic idiopathic constipation. She was started on a different medication but she reported she did not have a great response. Her gastroenterologist has now prescribed Trulance. According to the medical literature, the FDA has approved Trulance for chronic idiopathic constipation.  Its safety and efficacy were established in a trial study.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for neurofeedback treatment. Biofeedback is a technique that enables a patient to learn how to change physiological activity to improve health and performance. Neurofeedback is the type of biofeedback most often discussed in research. Current medical literature categorizes neurofeedback as a complementary and alternative medical treatment for autism spectrum disorder. Evidence from well-controlled trials do not support neurofeedback as an effective treatment for autism. According to a recent study, the available studies do not support the use of neurofeedback in the treatment of autism spectrum disorder. This patient is currently receiving ABA therapy, which remains the gold standard to manage the behavioral issues specifically associated with autism. Therefore, the requested neurofeedback treatment is not medically necessary for 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 pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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: The patient has requested reimbursement for nerve block injection. There is adequate data to support a role for occipital nerve blocks for the treatment of this patients headache with occipital neuralgia. However, this patients records do not document that less invasive treatment options were exhausted prior treatment with nerve block injections. Specifically, there is no mention of the completion of behavior therapy, despite much research to support its use. In addition, not all medications in the various classes have been optimized. Moreover, there is a lack of support for treatment with steroid injections while the patient is taking oral steroids. For these reasons, the nerve block injection was not 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 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:  Reviewer 1, 2, and 3 are board certified in anesthesiology with subspecialty certification in pain management 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The parent of the enrollee requested reimbursement for  partial hospitalization program (PHP) services.  The enrollee has a history of autism, anxiety, depression, attention deficit hyperactivity disorder, and Tourettes disorder. He entered the partial hospitalization program (PHP) for suicidal ideation and depression. His psychiatrist documented he required a highly structured PHP with frequent physician oversight that could be not provided by less intensive outpatient programs due to his suicidal ideation, severe family conflict, and inability to engage appropriately in social interactions. The treatment plan was for continued PHP level of care with continued psychotherapy to augment medication management.  He was at a moderate risk of eventual self-harm or harm to others. The enrollee could control unsafe behavior while in a highly structured program with supervision. The patient met criteria for partial hospitalization.Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested Ciclopirox 8% solution for onychomycosis. The enrollee saw his primary care physician and got a prescription for Ciclopirox 8% solution, presumably during this visit, although there is no mention of this in the plan.  Lab tests were ordered, but no hepatic panel was done to see if the enrollee would be able to take oral antifungal medication.  In addition, there is no mention of onychomycosis as a diagnosis in the enrollees note from his visit.  There is insufficient evidence in the medical record showing the enrollee has onychomycosis.  The medical literature has shown that Ciclopirox is significantly more effective in the treatment of onychomycosis caused by Trichophyton rubrum, but without a documented culture, it would be difficult to know if this medication would even be beneficial for this enrollee.  Another study done with Ciclopirox 8% showed a lack of penetration of the nail plate in sufficient concentrations to prevent the growth of Trichophyton rubrum and thereby showed that it lacked any antifungal efficacy. Other studies have shown that the cure rate achieved with Ciclopirox 8% during clinical trials has proven less than impressive. Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in podiatry 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for radiofrequency ablation (RFA) of bilateral sacroiliac (SI) joint.  According to the medical record, the enrollee has a history of lumbar stenosis, lumbar radiculopathy, lumbar facet arthropathy, and sacroiliitis causing low back pain that radiates down both legs. He was referred to a pain management physician and was treated with radiofrequency ablation (RFA) that helped with his pain and provided relief for 12 to 18 months. The medical literature has limited support for this approach with mostly case series and case reports confounded with multiple techniques and short term follow-up. There is minimal clinical benefit from radiofrequency ablation of the sacroiliac joint in randomized trials.  Studies are limited by small numbers of enrollees, varying techniques and prominent placebo effects.  Final Result: Three of the three reviewers determined the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in pain management 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous iron infusions (INFeD).The current medical evidence supports the requested services in this clinical setting. Some individuals with reduced or absent iron stores who have not yet developed anemia may have symptoms, such as fatigue or reduced exercise tolerance, especially premenopausal women. Gastric bypass and other gastric surgeries, such as partial resection for ulcer disease or gastrectomy for gastric cancer, increase the risk of iron deficiency, as well as numerous other vitamin and mineral deficiencies. Intravenous iron is preferred over oral iron due to poor absorption and tolerability and is considered a standard of care in most gastric bypass patients. Therefore, intravenous iron infusions (INFeD) 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 internal medicine with sub-specialty certification in hematology 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 enrollee has requested authorization and coverage for Stelara. Psoriasis is an inflammatory skin disease that typically presents with sharply demarcated erythematous plaques.Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.  The condition has a negative impact on the quality of life of enrollee, especially in those with moderate or severe disease.  Researchers found that Stelara has demonstrated efficacy, short-term safety, and convenience of use in the treatment of plaque psoriasis and psoriatic arthritis. In support of long-term efficacy, researchers reported that a regimen of subcutaneous Stelara provided durable improvement in psoriasis relief through up to three years. Researchers cautioned that methotrexate, cyclosporine and mycophenolate mofetil may be associated with an increased risk of lymphproliferative disorders. Further, the researchers noted that tumor necrosis factor (TNF) alpha inhibitors may cause a slightly increased risk of cancer. This enrollee has severe plaque psoriasis with involvement of 75% of enrollee's BSA. The provider reports that Stelara has controlled the enrollees psoriasis during recent years. The provider has recommended against treatment with methotrexate or anti-TNF agents due to the associated risks. Therefore, treatment with Stelara is medically necessary for treatment of this enrollees severe plaque psoriasis. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: The enrollee has requested reimbursement for residential treatment center services. The enrollee has a history of bulimia nervosa, body dysmorphia, depression, and anxiety. She denied suicidal/homicidal ideations or psychotic symptoms. She remained in RTC when she stepped down to a partial hospitalization program.  Findings:  The physician reviewer found that the necessity for residential treatment is based upon an evaluation of specific criteria. These criteria include: medical status, suicidality, weight as percentage of health body weight, motivation, co-occurring disorders, structure needed for eating/gaining weight, ability to control compulsive exercising, purging behavior and environmental stress. The enrollees laboratory values and vital signs were normal. Her admission weight was over ideal body weight. She would qualify for this level of care if her weight were <85% of ideal body weight. She had no suicidal ideations or co-occurring mental disorder. Final Result: The reviewer determined that the requested therapy was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for applied behavioral analysis (ABA) services provided, and 40 hours per week of ABA therapy going forward. The presenting information supports the ABA services already provided, and 40 hours per week of ABA therapy going forward, as medically necessary for treatment of this patient. Specifically, the records document interfering behaviors, low Vineland-3 scores, and a large scope of goals identified in the treatment plan. The patients rate of interfering behavior highlights that while the patient has made significant improvements, the patient has yet to meet the final goal. These behaviors are socially unacceptable, making access to other treatment areas, such as social interaction, difficult to achieve. Findings: the physician reviewer found that the patients overall composite and daily living scores are more than two standard deviations from the mean, while her communication and social scores are two standard deviations from the mean. Her motor scores are a relative strength, but still over one standard deviation from the mean. In age equivalents, the patient is more than two years behind in some areas, but almost four or more years in all other areas. According to the Behavior Analyst Certification Board (BACB), dosage is dependent upon goals of treatment, specific patient needs, and response to treatment. The goals listed in this patients treatment plan highlight 27 goals and seven interfering behaviors. The number of goals listed is appropriate for the requested service intensity. The BACB highlights a reduction in service intensity should align with discharge and transition planning. As the patient has not acquired the skills to meet the criteria for discharge, a step down in services is not warranted. Therefore, ABA services provided, and 40 hours per week of ABA therapy going forward, were and are medically necessary for the treatment of this patient. Final Result: The reviewer 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: The reviewer is board certified in psychology, a licensed behavioral 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) level of care with daily sessions with a therapist, psychologist and psychiatrist. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Based on the available documentation, this patient presents with some risk of harm (score 2) The patient has demonstrated challenges in performing activities of daily living (ADLs), but he has been able to adequately perform ADLs (score 2). The patient has been able to share in individual and group therapy. The patient has no reported medical, substance use, or developmental issues (score 1). The patients recovery environment is described as stressful and tense (score 3). The provider noted that the patients family has a history of unresolved conflicts leading to an inability to solve family problems. The patient has few other relationships for support. The patients recovery environment lacks support (score 3) as the patient has parents and a home to return to, but his parents have not actively reached out for family sessions. The patients treatment has resulted in moderate response (score 3) due to the patients improvement with medications, and participation in treatment with fewer suicidal statements. The provider noted that the patient was reluctant to take medication and participate in therapy (score 3), but eventually complied. The patients parents have not been actively involved with family therapy with the patient (score 3). This CALOCUS scoring gives the patient a score of 20, which is consistent with partial hospitalization program (PHP) level of care. Therefore, the requested RTC level of care with daily sessions with a therapist, psychologist and psychiatrist are not supported as medically necessary for 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 psychiatry with subspecialty 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.