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 15 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder.  Three physician reviewers found that according to the American Academy of Pediatrics for the management of children with autistic spectrum disorders, Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. In this case, the request for 15 hours per week of ABA therapy is medically necessary for treatment of the patients autism spectrum disorder. Based on the documentation submitted for review, the patients progress cannot be sustained with the authorized amount of 12 hours of ABA per week. Fifteen hours per week of ABA services are clinically indicated given that his progress has been impacted by the reduction of services. In addition, the best medical practice dictates that if the patient responds best to ABA therapy, then that is what should be implemented. In this case, the patient had been receiving 15 hours per week of ABA services s recommended by his treating therapists and was noted to be progressing as expected. As such, 15 hours per week of ABA was and is medically necessary for treatment of the patients autism spectrum disorder. Final Result: Three reviewers determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in neurology with special competence in child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing.  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 mental health residential treatment services for treatment of his behavioral health condition.  The physician reviewer found that the mental health residential treatment services were medically necessary for treatment of the patients medical condition. In this case, the patient has diagnoses of school avoidance, ODD, autism spectrum disorder, ADHD and depressive disorder with risk to self or others. The patients behavioral conditions continued despite outpatient services which included individual psychotherapy, family therapy and medications. According to Chamberlain a residential treatment center only should be considered for families who are not able to provide therapy at home or at school. In-home services are preferable to residential placement and are often sponsored by state and local child welfare agencies. In addition, the American Academy of Child and Adolescent Psychiatry guidelines state that Day treatment, residential, and hospitalization facilities may need to be considered if the family is unable or unwilling to collaborate with the treatment of a more severe case of ODD. In this case, the patient failed multiple attempts at lower levels of care as well as inpatient admission. Given the patients history including the clinical documentation provided, residential treatment was medically necessary and appropriate in this clinical setting and consistent with standards of good medical practice. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested genetic testing (molecular profiling) for evaluation of his lung cancer with brain metastasis. Two physician reviewers found that molecular profiling is an assay of an individual patients cancer cells to detect specific genomic or molecular abnormalities that might serve as a target for a potential treatment. There are multiple non-randomized clinical trials exploring the value of molecular profiling. However, there is a lack of data from these trials demonstrating improved health outcomes based on the findings in these assays. Currently, there is a paucity of scientific data suggesting that the genetic testing (molecular profiling) was likely to have been more beneficial than standard available testing. Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. Two reviewers are board certified in oncology and hematology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested speech therapy and occupational therapy for treatment of the enrollees autism spectrum disorder.  The physician reviewer found that in this case, the patient is appropriately receiving ABA services for his diagnosis of ASD.  The review by Reichow and colleagues indicated that early intensive behavioral intervention for children with ASD was extremely effective. The requested speech therapy and occupational therapy are not clinically indicated at this time. In this case, ABA is the most effective intervention for a non-verbal child with ASD. Traditional speech therapy requires sitting in a room repeating sounds and naming pictures and at this time, the patient is not yet ready for this type of therapy. However, after a period of of intensive ABA therapy he may be ready. In this setting, play-based interactions with ABA are clinically indicated to work on his speech. In addition, early intensive behavioral intervention can provide some play based interactions to promote the understanding of communication. As such, the request for speech therapy is not medically necessary. In addition, occupational therapy is also not medically necessary at this time. Occupational therapy focuses on teaching the child to learn fine motor and adaptive skills, however this is not appropriate therapy for this patient at this time. In this clinical setting, ABA services are clinically indicated and should be his focus, however speech and occupational therapies are not medically necessary. 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 sub-specialty certification in developmental and behavioral 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the name brand medication Linzess for treatment of her medical condition. The physician reviewer found that review of the submitted additional documentation fails to demonstrate the medical necessity of the requested medication. Linzess is a guanylate cyclase-C agonist that is U.S. Food and Drug Administration (FDA) indicated for treatment of irritable bowel syndrome with constipation and chronic idiopathic constipation. The additional records submitted, which includes endoscopic and radiologic imaging, provides insufficient evidence that the patient has irritable bowel syndrome or has a diagnosis of constipation, such as infrequent bowel movements, difficulty during defecation or the sensation of incomplete bowel evacuation. Therefore, the request for name brand medication Linzess is not supported as 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12 week course of Harvoni for treatment of his chronic hepatitis C virus genotype 1a. Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all hepatitis C virus infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of hepatitis C virus infected persons is to reduce all liver-related health adverse consequences, including end stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. This patient has some advancement of fibrosis. Therefore, as per the FDA recommendation, this patient should be approved for Harvoni for eight weeks, not the requested 12 weeks to prevent further progression of fibrosis due to ongoing hepatitis C virus infection. Thus, an eight week course of Harvoni is supported as medically necessary.  Final result: Two reviewers determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 OxyContin 20 mg tablets, quantity of 120 tablets per month for treatment of the enrollees systemic lupus erythematosus. Findings:  The physician reviewer found that the requested OxyContin 20 mg tablets, quantity of 120 tablets per month is not medically necessary for treatment of this patients medical condition. The current standard of care for chronic pain associated with disc herniation is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anti-convulsants and anti-depressants considered adjunctive to this therapy. Long-term opioids are associated with a high risk of dependence and tolerance. Therefore, long-term administration is not recommended. Researchers reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  Final Result: The reviewer determined that the requested medication quantity is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested lumbar spinal fusion for treatment of his post laminectomy syndrome.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Anatomical studies have documented prior laminectomy, but these studies raise the question as to whether or not there has been an adequate decompression of spinal nerve root impingement.  The records document congenital central spinal stenosis and multiple levels of neural foraminal stenosis.  The medical records do not document lateral flexion extension views with demonstration of instability.  While the documents reviewed are consistent with an L5 spinal nerve root dysfunction, extruded intervertebral disc is stated to be present proximal to the level that typically would affect the L5 nerve root.  There are conflicting statements concerning the efficacy of conservative management to date.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested lumbar spinal fusion is not medically indicated for the 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a biopsy of a lump in her neck and a computed tomography (CT) scan of the chest, neck, abdomen, and groin area for evaluation of her medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has multiple systemic symptoms as well as a lump in her neck that concerns her.  As she has already had extensive imaging studies done, there is no medical indication to repeat them.  Radiologically, she has been found to have two right-sided adnexal cysts, with no other abnormality.  In this patients case, the requested CT scan of the chest, neck, abdomen, and groin is not likely to reveal new information.  With regards to the lump at the right posterior triangle of the neck, there is documentation of multiple physical examinations having been done by various providers, and only two mention this finding.  One provider describes this finding as a small node and the other providers impression was a subcutaneous cyst.  Ultrasound evaluation of this lump describes it as a 2-3 mm short axis normal-appearing lymph node.  This method of evaluation has been shown to be accurate in differentiating benign from malignant nodes in the neck.  The node does not show any malignant characteristic by either structure or size criteria.  Excision of this node is not likely to yield further useful medical information in this case and, as the node appears to be in the posterior triangle, the procedure holds possible risk of damage to the spinal accessory nerve.  All told, the requested biopsy of a lump in her neck and a CT scan of the chest, neck, abdomen, and groin area are not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in otolaryngology with sub-specialty certification in head and neck 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intravenous immune globulin for treatment of his status post kidney transplant.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  The records do not indicate that a recent biopsy has been performed, and a biopsy is recommended in all patients who develop donor specific antigens.  Donor specific antigens in patients with stable renal function and no antibody-mediated rejection by biopsy do not adversely affect long-term graft survival.  In this patients case, donor specific antigens may have developed when immunosuppression was reduced.  Since this patient is not likely to be highly sensitized, the donor specific antigens have developed after the first year, and allograft function is stable, the medical evidence supports a transplant biopsy prior to consideration of intravenous immune globulin.  All told, the requested intravenous immune globulin is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in nephrology 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

A female enrollee requested a small drain placed (CPT 0191T) during eye surgery for medical treatment of her glaucoma.  Findings:  Two physician reviewers found that current peer-reviewed medical literature and this patients records support the use of the small drain placed (CPT 0191T) during eye surgery as likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a female enrollee requested inpatient mental health services for medical treatment of the enrollee's behavioral health condition.  Findings:  The physician reviewer found that the documentation provided for review did not describe an acute psychiatric syndrome, grave disability or medical illness that necessitated services at the acute level of care.   There was no evidence to suggest that treatment in a less restrictive setting would have been unsafe or unreasonable based on the documentation provided. Thus, the inpatient mental health services were not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power wheelchair for treatment of her mild degenerative disease in the bilateral hip joints status post bilateral hip arthroplasty, bilateral knee pain, and back pain.  The physician review found that the Centers for Medicare and Medicaid Services (CMS) guidelines for the use of powered mobility devices states that these devices should be reserved for patients that are unable to use a walker or manual wheelchair safely. This patient has normal strength, well situated knee replacements and no spinal instability. In addition, she is capable of using a walker. The current medical literature also describes the benefit of walking and mobility for patients with chronic low back pain. In the absence of any significant physical findings explaining the need for a powered mobility device, exercise and walking are beneficial to chronic pain patients. Consistent with these findings, the requested power wheelchair is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation 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.