Persius/hicric huggingface dataset:
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 continued residential treatment center (RTC) services for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that 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). On evaluation, the patient was at some risk of harm (score 2). The patient demonstrated moderate functional impairment (score 3). The patient has significant co-morbidity (score 3). The patient is noted to have a mildly stressful environment (score 2) with supportive parents (score 2). The patient has demonstrated equivocal resiliency and response to treatment (score 3) with a limited history of prior treatment. The patient has been obstructive to treatment (score 3) and is noted to make comments about wanting to change her behavior but remains ambivalent about stopping her substance use. This composite score of 18 meets the criteria for an intensive outpatient program (IOP) treatment. The patient continues to need treatment for her cannabis use disorder, major depressive disorder, generalized anxiety disorder, and ADHD, but this can be safely and adequately provided in a less restrictive environment. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the heart scan coronary computed tomography angiography (CCTA) provided. Findings:  The physician reviewer found that based on the records provided, the patient presents with some coronary risk but no documented coronary disease. In this circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary CT scanning . Treatment change or addition based on the results of screening with CCTA has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. All told, the CCTA provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the diagnostic procedure at issue was 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 reviewer 1, 2 & 3 are board certified in 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:  An enrollee has requested authorization and coverage for oral/facial myofunctional therapy and myofascial release via the stecco fascial manipulation technique for treatment of the enrollee, who has a history of neck pain and tongue pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has been diagnosed with atypical facial pain/myofascial pain. The mainstay for patients with myofascial pain and a history of temporomandibular joint disorder includes oral appliance therapy. Physical medicine techniques, such as massage, ultrasound and iontophoresis have been used in the past with some success. However, studies are lacking to support fascial manipulation for myofascial pain dysfunction. All told, the requested for oral/facial myofunctional therapy and myofascial release via the stecco fascial manipulation technique are not medically necessary 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 oral and maxillofacial 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 authorization and coverage for facial feminization surgeries. Findings:  The physician reviewer found that based on the entirety of the medical documentation provided for review, including review of the photographs, the requested services are not medically necessary in this clinical setting. The midface and submental areas of this patient appear within the range of normal and not gender specific. Although this patient has documented gender dysphoria, the submitted photographs appear to support structures which are in the range of normal for her age and gender appearance as a female. Overall, the clinical documentation is insufficient to support the medical necessity of requested services. Therefore, facial feminization surgeries  are not medically necessary for the treatment of this patients gender dysphoria. With regards to whether the requested services are reconstructive in nature, the patient has an appearance that is within the range of normal and not necessarily gender specific. The patients condition does not constitute an abnormal structure of the body. The patients appearance is within the spectrum of female appearances with respect to the midface and submental areas. As such, the requested services appear consistent with aesthetic improvement, addressing appearance concerns and not specific gender related abnormalities. There is a wide spectrum of facial appearances that can be consistent with possible typical female appearances. Thus, this patients facial presentation is not considered an abnormal structure and the requested services are not expected to provide a more than minimal improvement in the patients appearance. For these reasons, facial feminization surgeries are not reconstructive in nature. 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 plastic 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 authorization and coverage for risedronate for treatment of the enrollees osteoporosis. Findings:  The physician reviewer found that the request for risedronate is not medically necessary for treatment of the patients medical condition. The Health Plans recommendation of failure of the preferred drugs that include Fosamax and Boniva is medically reasonable and appropriate. The medical records provided for review fails to demonstrate that the patient has tried and failed treatment with Boniva. All told, the request for risedronate 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 internal medicine with sub-specialty certification in rheumatology 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 a bone growth stimulator for treatment of the enrollees delayed union of fracture. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device. Current evidence-based guidelines recommend ultrasound bone growth stimulation as an option for delayed or non-union of fractures, especially with significant associated risk factors. Specific indications include at least three months have elapsed since the date of fracture and the initiation of conventional fracture treatments, serial x-rays have confirmed that no progressive signs of healing have occurred, the fracture gap is one centimeter or less, and the fracture is adequately immobilized. Risk factors include diabetes, osteoporosis, steroid therapy, current smoking, or fractures with extensive soft tissue or vascular damage. This patient presents with complaints of diffuse left foot and ankle pain. She reportedly sustained a left fifth metatarsal fracture in late September 2016. Pain was reported in weight-bearing activities. There is reported x-ray evidence of delayed union of her left foot fifth metatarsal fracture. However, there is no documentation of serial x-rays showing no progressive signs of healing or current fracture gap. There is no documentation of adequate immobilization or discussion of conventional fracture treatments. Therefore, the requested bone growth stimulator is not medically necessary for the treatment of this patient. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx Melanoma Gene assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the treatment of the patients melanoma. Moreover, its usage is not expected to impact the treatment or outcome of the patients melanoma. As such, the genetic testing (gene expression profiling) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was 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 physician reviewers are  board certified in dermatology 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: The patient has requested authorization and coverage for Sovaldi with RibaPak for 12 weeks. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa and Vosevi are recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials which showed the superiority of Epclusa to Sovaldi with ribavirin. Therefore, the use of Sovaldi and ribavirin is no longer supported by the guidelines for genotype 2. Delay in treatment may result in decreased survival. For these reasons, although treatment of hepatitis C is needed, the request for Sovaldi and Ribasphere is not supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested regimen 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Prometheus Anser IFX diagnostic testing. Findings:  The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Monitoring patients on infliximab with measurement of infliximab levels and antibodies to infliximab continues to be an area of intense investigation. In general, infliximab levels correlate inversely with disease activity. However, there are a lack of controlled data which have identified the optimal drug level and the issue remains speculative. In addition, the American Gastroenterological Association indicates that there is low quality of evidence in support of reactive measurement of infliximab drug levels. For the reasons provided, the Prometheus Anser IFX diagnostic testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was 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 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 reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. To objectively determine if the patient meets criteria for the appealed level of stay, the Level of Care Utilization System (LOCUS) criteria is used. This is an accepted, national standard for determining the appropriate level of care for adults. The patients risk of harm based on the LOCUS criteria is a 2 which correlates to low risk of harm. The patients functional status is a 3, moderate impairment.  The patients medical/addictive/psychiatric comorbidity is a 3 which correlates to significant comorbidity.  The patients recovery environment is a 3, moderately stressful environment. The patients level of support is also scored a 3, limited support.   The patients treatment history is scored a 3 which correlates to equivocal response to treatment and recovery. The patient was in an intensive outpatient program previously but relapsed. The documentation submitted did not mention other prior treatments. The patients engagement and recovery status is scored a 3, limited engagement and recovery. The patient is attentive and engaged during treatment. However, the patient does not feel that she is an addict and will not commit to complete sobriety. It appears that she remains ambivalent about her desires to stop using alcohol. The patients total scored is 20. Based on the LOCUS criteria, the patient would meet criteria for a partial hospitalization program (PHP) and not RTC. The patient requires treatment for her alcohol use disorder, but the treatment can be performed at a PHP level of care. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia during colonoscopy for evaluation of the enrollees colon screening. Findings:  The physician reviewer found that the patient does not meet the criteria for anesthesia services performed during the colonoscopy. Specifically, the patient does not have any medical issues that necessitate the use of monitored anesthesia care for routine, screening colonoscopy. There is no documented history of high dose chronic opioid or benzodiazepine use that would render the patient intolerant to standard sedatives. Final Result: The reviewer determined that the service at issue was 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 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 authorization and coverage for one-on-one counseling services once per week, or at any frequency for treatment of the enrollees post-traumatic stress disorder (PTSD) and mood disorder. Findings:  The physician reviewer found that the records provided for review document that this patient has been diagnosed with post-traumatic stress disorder (PTSD) and mood disorder. He has been experiencing psychological distress and psychotherapy treatment would be helpful in this case. However, there is a lack of rationale for individual one-on-one counseling services at least once per week. The Health Plan has authorized an out-of-Plan referral, which is appropriate for this patients current behavioral health needs. Thus, the requested one-on-one counseling services once per week, or at any frequency are not supported as medically necessary for treatment of this patients PTSD and mood disorder. 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly chiropractic services for treatment of severe chronic neck, shoulder, and back pain. Findings:  The physician reviewer found that chiropractic maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong or enhance the quality of life or to maintain or prevent deterioration of a chronic condition. As defined by the Centers for Medicare and Medicaid Services (CMS), when further clinical improvement cannot reasonably be expected from continuous ongoing care, the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is considered maintenance therapy and not considered medically necessary. The records indicate that this patient is receiving chiropractic care but is no longer making active improvement. Given these findings, the requested weekly chiropractic services are not supported as 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 board certified in chiropractic 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.