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

Nature of Statutory Criteria/Case Summary: The guardian of an enrollee has requested reimbursement for residential treatment center services. To objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 2. The patient does not have a history of any suicide attempts. Prior to admission, the patient had passive suicidal ideation, with no plan or intent. By 10/26/17, the patient did not have any suicidal ideation. The patient superficially cut herself prior to admission. With regards to functional status, the records support a score of 3. The documentation stated that the patient had interpersonal deficits with her peers which she would like to improve. She is described as mature. In terms of comorbidity, the records support a score of 2. She has no medical problems that would require frequent monitoring. With regards to environmental stress of the recovery environment, the records support a score of 3. The patient had a serious disruption in her family milieu after her adoptive mother passed away. She was living with her guardians who struggle to care for her. In terms of environmental support, the records support a score of 3. The guardians are supportive, but they admit that they are too advanced in years to give the support that the patient requires. However, another family relative is supportive. With regards to resiliency, the records support a score of 3. The records indicate moderate response to treatment.  In terms of acceptance and engagement, the records support a score of 2. The patient had a positive relationship with clinicians and other care providers. She actively participated in treatment planning and cooperated with treatment. Thus, the records support a composite score of 18. Based on these criteria, the patient met criteria for an intensive outpatient program (IOP). Therefore, residential treatment center services provided from 10/26/17 through 11/20/17 were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for brand name Qualitest Norco instead of brand name Mallinckrodt Norco for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that There is a lack of support in the medical literature for the requested brand name medication in this patients case. In the documentation available for review, the patient reported that Norco manufactured from Mallinckrodt causes her chest and arm pain. The record notes that this patient is taking the 5/325 mg of Mallinckrodt Norco and is exposed to two substances that the Qualitest brand does not have in its 5/325 mg formula, namely crospovidone and colloidal silicon dioxide. While the literature suggests that Norco from Mallinckrodt contains less inactive ingredients than Norco from Qualitest, this only applies to Norco 10/325 mg dosage. It is also noted that povidone is found in both brands, making crospovidone less likely the problem. In addition, while both of these substances are known in the medical literature to cause allergies, it is only in rare cases. In this patients case, it is unclear from the records if she has an allergy to these substances. There is a current recommendation to perform allergy skin testing to see which substances she may be allergic. In addition, the medical literature recommends that skin testing should be completed due to the possible concern of a hypersensitive state to crospovidone and/or colloidal silicon dioxide, as they are found in the Norco from Mallinckrodt. Only upon confirmation of immediate reading skin tests and/or delayed reading skin testing that is positive for an allergy to crospovidone and/or colloidal silicon dioxide would Qualitest 5/325 mg of Norco be medically necessary. Therefore, at this time the requested authorization and coverage for brand name Qualitest Norco instead of brand name Mallinckrodt Norco has not been demonstrated as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that requested medication brand 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: An enrollee has requested reimbursement for FoundationOne test. Findings:  Two of the three physician reviewers found understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. Although next generation sequencing holds promise, it is not yet ready for routine clinical use. At this time, there is a lack of data demonstrating that this information can guide treatment decisions for patients with metastatic breast cancer. The use of next generation sequencing, such as with FoundationOne testing, continues to be the subject of ongoing clinical trials. As a standard of care, biopsies confirming metastatic breast cancer should be tested for estrogen, progesterone, and HER2. It is not documented that this was done on the liver biopsy. All told, FoundationOne test was not likely to have been superior over other available modalities for evaluating this patient.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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test (CPT 81479 x 2). Findings:  Three physician reviewers found that The American College of Obstetricians and Gynecologists (ACOG) recommends cell free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultra-sonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. Since this patient is under 35 years old, the aneuploidy risk for this patient in this pregnancy does not warrant cell free DNA testing for aneuploidy. Testing for microdeletion syndromes is also not recommended by the medical literature. Given the rarity of these conditions, the detection rate is significantly lower than for trisomy 21 and 18. ACOG specifically states, Routine cell-free DNA screening for microdeletion syndromes should not be performed. In view of all of these considerations, the gene test (CPT 81479 x 2) provided was not likely to have been more effective than the standard options of evaluating this patient. Final Result: 2 of 3 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 obstetrics and gynecology 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 the Orthovisc injections. Hyaluronic acid injection for osteoarthritic knee pain is an established part of osteoarthritic knee pain treatment algorithms and generally considered a second-line treatment after independent exercise, weight loss and simple medications such as nonsteroidal anti-inflammatory medications or acetaminophen. With long-term data supporting widespread use, the injections have been confirmed to be safe with no severe or systemic side effects. In contrast, nonsteroidal anti-inflammatory pain medications, acetaminophen, opioids and oral or intra-articular corticosteroids can have serious systemic side effects and are not reasonable treatment options for some patients. This patient had adequate relief of severe osteoarthritic symptoms with prior hyaluronic acid injection. For these reasons, the requested Orthovisc injections are supported as medically necessary for treatment of this patients bilateral knee osteoarthritis.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 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 parent of an enrollee has requested authorization and coverage for weekly occupational therapy for six months. The submitted documentation supports the medical necessity of the requested services. This patient has difficulty performing age-appropriate activities of daily living, is unable to keep up with family and peers due to deficits in strength and coordination, and is at risk of significant injury because of recurrent falling. With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills, processing information, and regulating the response to incoming information, occupational therapy is well suited to affect positive change in this patient. Without appropriate occupational therapy intervention, he is likely to continue to lag behind peers and fail to achieve his functional maximum. All told, weekly occupational therapy for six months is 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 pediatrics 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 authorization and coverage for continuous treatment at a tertiary care center. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who has a history of cutaneous mastocytosis.There is support in the documentation provided for the requested services in this clinical setting. This patient was diagnosed with a form of cutaneous mastocytosis. At this time, there is no evidence of systemic involvement but the patients medical condition is a persistent concern requiring careful examination and staging of the patient. Based on the documentation provided, it appears the etiology of the patients condition was initially unknown. The patient sought a second opinion from a hematologist/oncologist and has been receiving treatment from the same provider for approximately three years. At this time, the patient has requested that her care be continued with the same provider. In this patients case, the documentation provided supports that this patient should continue to receive treatment at a tertiary care center capable of proper staging work up. The records demonstrate the medical necessity for continuous therapy at a tertiary care center for the 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 internal medicine with sub-specialty certification in medical oncology and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lorazepam and Norco. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications. Before prescribing opiates, a risk assessment should be performed as well as setting goals for pain management. Chronic use of opiates for non-malignant pain is not recommended. The patient is also on a benzodiazepine, which would put her at increased risk of overdose. It is the standard of care to see a patient with enough frequency to detect aberrant behavior, note changes in medical history or physical status. There is a lack of support for the requested medications in this clinical setting. Therefore, lorazepam and Norco are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 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: An enrollee has requested reimbursement for the ThyGenX Oncogene Panel and ThyraMIR microRNA tests. Findings:  Three physician reviewers found while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. The relatively new development of molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. The testing performed in this case may allow patients to avoid unnecessary surgeries. Therefore, the ThyGenX Oncogene Panel and ThyraMIR microRNA tests were likely to have been superior over other methods of evaluating this patient. 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX Reflux Management System. Findings:  The physician reviewer found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. Evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration approval. Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention. The currently available peer reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial than standard treatment, surgical fundoplication. For these reasons, LINX Reflux Management System is not likely to be of greater benefit than the available standard treatment options for the treatment of this patients medical condition. Final Result: Two of the reviewers determined requested services are 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:  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 reimbursement for gene testing. Findings:  The three physician reviewers found this patient was suspected to have Muir-Torre syndrome based on her skin biopsy and family history. Muir-Torre syndrome is a rare autosomal dominant condition characterized by the association of at least one sebaceous skin tumor and at least one visceral malignancy. Muir-Torre syndrome is caused by germline mutations in the DNA mismatch repair genes and is considered a phenotypic variant of hereditary nonpolyposis colorectal carcinoma syndrome. Internal malignancies most frequently associated with Muir-Torre syndrome include colorectal, endometrial, ovarian, and urothelial cancers. The patient meets criteria for testing. Therefore, gene testing was likely to have been superior over other methods of evaluating this patient. 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier tablets for 12 weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.