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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Exome Sequence Analysis. The requested whole exome sequencing is supported as medically necessary for evaluation of this patient given the personal and family history. The medical literature identified causative diagnosis in 25% of 250 probands studied with whole exome sequencing, which is better than genetic technologies previously considered standard, such as karyotype analysis or chromosomal microarray. This patient has multi-system disease with learning disabilities as well as a family history of intellectual disability and dysmorphic features, with normal chromosomal microarray results. These multi-system findings increase the likelihood of an underlying single gene disorder which can be identified by whole exome sequencing, especially in the setting of a normal chromosomal microarray. A unifying diagnosis may provide insight into helpful treatments for developmental manifestations. All told, the requested Exome Sequence Analysis is medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are 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 pediatrics with a sub-specialty certification in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for methadone HCL 10 mg tablets. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. In addition, there is no mention that behavior therapy has been completed despite much research to support its use. Moreover, not all non-opioid medications classes have been optimized or tried. All told, the requested methadone HCL 10 mg tablets is not supported as medically necessary for treatment of this patients chronic pain. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for genetic tests for Ashkenazi Jewish associated disorders that were performed on 11/03/17. Findings: The physician reviewer found that the services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. The patient is of Ashkenazi Jewish descent and should be offered certain screening tests. Some experts have advocated for a more comprehensive screening panel for those of Ashkenazi descent, including tests for several diseases that are less common. The following is a list of autosomal recessive conditions for which screening should be considered in individuals of Ashkenazi descent: Bloom, familial hyperinsulinism, Fanconi anemia, Gaucher disease, glycogen storage disease type I, Joubert syndrome, maple syrup urine disease, mucolipidosis type IV, NiemannPick disease, and Usher syndrome. Therefore, the genetic tests for Ashkenazi Jewish associated disorders that were performed on 11/03/17 were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation 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 obstetrics and gynecology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A patient has requested reimbursement for the methylenetetrahydrofolate reductase (MTHFR) gene test, and the two common MTHFR variants, polymorphisms provided. Findings:  The physician reviewer found that the services at issue were not likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Although there is a reported association between hyper-homocysteinemia and thromboembolic disease, studies involving testing for mutations or polymorphisms of the MTHFR gene have not yielded conclusive evidence that the findings will impact treatment decisions. The clinical utility of this test has not been established in any randomized clinical trial. Further, it is unlikely that MTHFR mutation testing would alter the management or therapy resulting in improved clinical outcomes. Long-term systemic anticoagulation would be indicated for the patient in any case. Therefore, the methylenetetrahydrofolate reductase (MTHFR) gene test, and the two common MTHFR variants, polymorphisms provided were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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 internal medicine with sub-specialty certification in cardiovascular disease 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: A enrollee has requested authorization and coverage for neurotherapy. Papatola and Lustig defined the medical necessity of healthcare as services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. This patients records document the patient is already receiving services to meet his essential health needs in the form of case management, social skills groups, and CBT therapy. In the peer-reviewed medical literature, there is limited evidence of the effectiveness of neurotherapy on treating autism symptoms. Moreover, neurotherapy does not meet the current medical guidelines for effective treatment of patients with autism. Based on the current information, the requested neurotherapy is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is a licensed psychologist and a board certified 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 77-year-old male enrollee has requested reimbursement and prospective authorization and coverage for continued skilled nursing facility (SNF) care including physical therapy, occupational therapy, and speech therapy services. Medical literature noted that, the process of cerebral re-organization are slow and may need many months to complete; there is a large heterogeneity of recovery over the first 3 months after stroke; the recovery of activities of daily living develop within 26 weeks after the stroke insult. This patients functional status is significantly lower than his baseline. He has shown progress after review of physical therapy, occupational therapy, and speech therapy notes. He has undergone skilled rehabilitation for six weeks, and is within the ideal treatment period at which stroke recovery is observed. Given these findings, the patient will likely benefit from continued skilled therapy to improve his functional status. Accordingly, the continued SNF care including physical therapy, occupational therapy, and speech therapy was and is medically necessary for treatment of this patients medical condition. 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 internal medicine with sub-specialty certification in geriatric 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 topical compound cream Keto/Keta/Cyclo/Lido/Gaba. In the documentation available for review, not all the standard treatment options for fibromyalgia have reportedly been tried and failed. In addition, topical anti-inflammatory agents have not been demonstrated to be more efficacious than oral anti anti-inflammatory agents in the treatment of fibromyalgia. Researchers concluded that more studies are needed for elucidation of the role of topical analgesics and their effects, especially when combined with other treatments. Finally, not all of the components of the requested compound medication have significantly better concentrations in topical form when compared with oral alternatives. For these reasons, the requested topical compound cream Keto/Keta/Cyclo/Lido/Gaba is not medically necessary for treatment of the 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 54-year-old male enrollee has requested reimbursement for the specialized laboratory testing, called genomic analysis. In the peer-reviewed medical literature, FoundationOne testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as FoundationOne, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is insufficient to support the use of FoundationOne in lieu of standard testing. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the specialized laboratory testing, called genomic analysis, was not likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for Norco 10-325 mg, for six (6) pills per day. Findings: the reviewer found that The Centers for Disease Control and Prevention states that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting opioids. when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage per day. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. Moreover, not all non-opioid medications classes have been optimized or tried. For all these reasons, the requested authorization and coverage for Norco 10-325 mg, for six (6) pills per day, is not 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Findings:  The physician reviewer found that Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for cyclosporine 2% compounded with ophthalmic drops. The Health Plan has denied this request indicating that the requested compounded medication is considered investigational for treatment of the patients chronic bilateral Thygeson's superficial punctate keratitis (TSPK). Findings:  The requested compounded medication is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. In this patients case, the treatment of Thygesons SPK with cyclosporine is not more beneficial than any available standard therapy, based on the efficacy and availability of topical steroids, (the standard of care), and the lack of evidence that cyclosporine 1% is safe and effective for this patients condition. There are no controlled studies in the medical literature with sufficient numbers of treated patients to show that cyclosporine is a viable alternative to steroid treatment for patients with Thygesons. Therefore, cyclosporine 2% compounded with ophthalmic drops are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested compounded medication is 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/QualificationsAll three reviewers are board certified in ophthalmology 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: A patient requested reimbursement for the residential treatment services provided. 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. The patients medical records indicate that there were post-acute withdrawal symptoms were mild to moderate in nature, and the patient was not a danger to oneself or others. The patient was medically and psychiatrically stable. The patients medication regimen did not require a structured setting and could have been managed in an ambulatory setting. There were no emotional, cognitive, or behavioral issues at play to warrant medical and nursing monitoring. Records reflect that the patient had been in treatment multiple times in the past and was not naive to the treatment and recovery process. The patient was cooperative, appeared motivated, and was engaged in the relapse prevention process. In patients such as this, with severe opiate use disorders, the standard of practice is medication-assisted treatment; however, it appears that this subject was not broached. The patient was seeking a sponsor. The patient had a solid stable marriage of 30 years. The psychiatric symptoms of depression, anxiety, grief and loss could have continued to be therapeutically treated in a lower level of care. Examination of group notes also reflects that there was no further progress documented, as the notes are almost exactly the same up to the date of discharge. The patient's recovery could have been effectively continued in an ambulatory setting with the community support of the 12-step groups and a sponsor, as well as counseling and/or individual psychotherapy. Therefore, the residential treatment 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: A 64-year-old male enrollee has requested authorization and coverage for Stat-A-Dyne WHFO splint. The requested Stat-A-Dyne WHFO splint is supported as medically necessary to improve and maintain this patients wrist, hand, and finger motion as his radial nerve recovers. The device has not been recommended for treatment of the patients fracture. The patients provider recommended the device for treatment of motion deficits related to radial nerve injury and paralysis. This is an appropriate indication for the requested device. Therefore, the Stat-A-Dyne WHFO splint is medically necessary for this patient with complete radial nerve palsy following open humerus fracture and radial nerve disruption. Final Result: The reviewer determined that the requested device 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 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.