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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entresto 24-26 mg tablets two times daily. Based on the records provided for review, this patient has severe coronary disease and a reduced left ventricle ejection fraction (LVEF) of 25% in the setting of acute coronary syndrome prior to coronary revascularization with coronary artery bypass graft (CABG) surgery. There is no documentation that the patient continued to experience heart failure with a severely reduced LVEF of 40% or less postoperatively. Entresto is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with chronic heart failure and reduced LVEF. In this patients clinical circumstance, the medical records do not support an indication for Entresto in the absence of documentation of either congestive heart failure or reduced LVEF of 40% or less post coronary revascularization. For these reasons, the requested Entresto 24-26 mg tablets two times daily are not medically necessary for treatment of this patient. 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 subspecialty certification in cardiovascular disease 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

The patient has requested authorization and coverage for continuous passive motion (CPM). Researchers concluded that both CPM and conventional physical therapy are beneficial for the treatment of adhesive capsulitis in diabetic patients. However, the authors found that CPM provided distinctive improvements in the function and pain levels of adhesive capsulitis patients. This patient was diagnosed with left shoulder adhesive capsulitis. Clinical examination findings documented significant preoperative loss of left shoulder range of motion that has failed to respond to medications, injections, physical therapy, and home exercise. She underwent left shoulder manipulation under anesthesia and capsular release. The provider has recommended use of a postoperative CPM unit, which is consistent with the current evidence-based medical literature and guidelines for the treatment of moderate to severe adhesive capsulitis to restore shoulder functional mobility. Given this support, the requested CPM is medically necessary for treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for an open osteochondral allograft of the left knee. The enrollee suffered a knee injury while playing basketball. He was unable to ambulate. The enrollee underwent arthroscopic medial meniscus repair and partial lateral meniscectomy, and medial and lateral femoral condyle chondroplasty. A post-surgical re-evaluation reported the enrollee will need a second surgery to the medial femoral condyle and a chondral allograft. As noted by literature, osteochondral allograft transplantation to treat cartilaginous defects of the knee may be considered medically necessary when both the size of the cartilage defect is greater than or equal to 2 square centimeters in total area, as documented by magnetic resonance imaging or arthroscopy, and the condition involves a focal, full thickness, (grade III or IV) isolated defect of the weight-bearing surface of the medial or lateral femoral condyles or trochlear region. This enrollee has a reported cartilage lesion of 1 centimeter. The medical record documentation noted that the enrollee has full mobility with walking mobility. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery and orthopedic sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Stelara 45 mg/0.5 mL subcutaneous solution. According to the American Academy of Dermatology (AAD), Stelara is the preferred agent for pediatric patients with psoriasis who are 12 years of age and older. This patient has severe scalp and ear psoriasis with involvement of 5% of her BSA. The patient reports pain and self-consciousness related to her skin condition. The records provided for review document that the patient has failed treatment with multiple topical steroids over the course of more than one year. Treatment has included topical fluocinonide ointment, ketoconazole shampoo, and clobetasol solution. Currently, treatment with methotrexate or cyclosporine is not recommended for long-term use in pediatric patients with psoriasis. Given these findings, the requested Stelara 45 mg/0.5 mL subcutaneous solution is medically necessary for treatment of this patient.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 dermatology 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 patient has requested reimbursement for inpatient psychiatric hospitalization level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 4 criteria for inpatient psychiatric hospitalization level of care services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patients risk for withdrawal was elevated given uncertainty regarding opioid used and when last used. She required several doses of Ativan and Hydroxyzine for anxiety, and multiple doses of Zofran for nausea, thereby further supporting the providers concern for the patients safety and monitoring for suicidality, despite the fact that she had not reported a specific plan. The patients history suggests she was in crisis when she presented to the emergency department after having suicidal ideation for two days, worsening anxiety, depression, and inability to function at home or care for her infant daughter. On evaluation, the provider placed her on observation to ensure her safety given her suicidality. The patients withdrawal management required treatment at Level 4, with 24-hour monitoring every 30-60 minutes until improvement begins, then every two hours. For dimension 2, the patient complained of concomitant abdominal pain, nausea, myalgia and headache, which warranted 24-hour observation and stabilization. At the end of her admission, the patient was deemed stable for transfer and step-down to a residential treatment center (RTC). For dimension 3, the patient reported inability to control her opiate use without 24-hour psychiatric management and support. Overall, her co-occurring anxiety, social stress, and other social stressors made it improbable that she could control her impulses outside this level of care. Per ASAM Level 4 guidelines, this patient met criteria from dimensions 1 through 3, which support treatment at the inpatient psychiatric hospitalization level of care. Given these findings, the inpatient psychiatric hospitalization level of care services were medically necessary for treatment of this patient. 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 with subspecialty certification in addiction 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: The patient has requested authorization and coverage for Flexitouch pneumatic compression device (E0652) and segmental pneumatic appliance for use with pneumatic compressor, full arm (E0668). Lymphedema is a complication associated with treatment for breast neoplastic disease (Doscher, et al.). Treatment options for lymphedema include various physiotherapeutic interventions, skin care, and compression bandaging (Merchant and Chen). Once a patient achieves an initial stage of limb volume reduction, maintenance management can include self-directed exercises, compression garments, and intermittent pneumatic compression devices used in the community. However, there is a paucity of studies demonstrating reduced cellulitis rates and treatment needs with significantly improved outcomes with the addition of intermittent pneumatic compression pump therapy. The addition of trunk appliances on intermittent pneumatic compression pump devices have not been shown to improve patient health outcomes in this clinical setting. Accordingly, the requested Flexitouch pneumatic compression device (E0652) and segmental pneumatic appliance for use with pneumatic compressor, full arm (E0668) are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tymlos pen injector. Osteoporosis is an increasingly widespread condition. Fractures are the most dangerous aspect of osteoporosis and can lead to acute and chronic pain as well as increased mortality. Until recently, pharmacological options for the treatment of osteoporosis have been limited to anti-resorptive agents, including the oral bisphosphonates. Newer treatment agents have become available over the past few years, including Tymlos (abaloparatide), a synthetic analog of parathyroid hormone-related peptide.  Anabolic agents, such as this medication, have been shown to improve bone mass and decrease fracture risk in osteoporosis patients by directly stimulating osteoblasts to produce new bone. Due to the severity of this patients osteoporosis and his inability to tolerate bisphosphonate therapy, Tymlos pen injector is medically appropriate. Therefore, Tymlos pen injector is medically necessary for the treatment of this patient. 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 Repatha Sureclick 140 mg/mL pen injector.The submitted documentation supports that the requested medication is medically necessary. In this case, the patient has multiple risk factors for coronary artery disease (CAD) as well as some calcification on CT scan. The patient failed to reach his LDL goal with conventional statin/ezetimibe therapy. In addition, he has already been maintained on PCSK-9 inhibitor for many years with a very good LDL response and no side effects. Based on this significantly elevated cardiac risk and his failure to adequately respond to conventional two drug lipid lowering therapy, Repatha PCSK-9 inhibitor therapy is both medically necessary and appropriate for treatment of his severe hyperlipidemia. Accordingly, the requested medication Repatha Sureclick 140 mg/mL pen injector is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in cardiovascular disease, 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

The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services four times per week. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework, this patient meets the criteria for IOP services four times a week. The findings give the patient a composite score which is consistent with high intensity community based services, such as IOP. Furthermore, per CALOCUS, minimal oversight should be required for this level of services and reviews should not be required more than every two weeks of persons with acute conditions and every two months for those with more slowly evolving conditions. Given this patients presentation over the past two years, his condition can be considered chronic in nature and slowly evolving. For these reasons, the IOP services four times per week were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla (apremilast) 30 mg.Otezla is an FDA approved oral small molecule (OSM) medication for the treatment of adult patients with moderate to severe plaque psoriasis and active psoriatic arthritis. The efficacy for Otezla for psoriatic arthritis has been supported by multiple studies. In this case, while it is not clear that the patient has evidence of moderate to severe plaque psoriasis, he does have documented active psoriatic arthritis. While Otezla should generally not be used for patients with erosive disease, as the capacity of the drug to prevent joint injury has not been adequately established, there is no radiologic or clinical data provided in this case that established erosive disease. The patient could not tolerate methotrexate due to side effects (though he did actually have some clinical improvement with it), therefore, switching to another OSM medication with a different mechanism of action is a reasonable approach, given a failed prior response to Humira and Taltz. Under these circumstances, the requested medication Otezla (apremilast) 30 mg is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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 authorization and coverage for radiofrequency ablation of right and left first and second perforator veins (CPT 36475 and 36476). The American Venous Forum (AVF) supports ablation of superficial and perforator veins in a patient with a venous leg ulcer (C6) and incompetent superficial veins that have reflux to the ulcer bed in addition to pathologic perforating veins with an outward flow of more than 500 millisecond duration, with a diameter of more than 3.5 mm, located beneath or associated with the ulcer bed. For these patients, the AVF suggests ablation of both the incompetent superficial veins and perforator veins in addition to standard compressive therapy to aid in ulcer healing and to prevent recurrence. This patient has a two-year history of chronic venous stasis disease with symptomatology consisting of lower extremity pain, discomfort, edema and skin changes quite consistent with venous disease. He has failed compression therapy, which was started when duplex scanning of the veins of both lower extremities indicated bilateral greater and lower saphenous vein reflux and Cocketts vein reflux. Measurement and duration of reflux at that time were sufficient to justify vein ablations. The patient returned two years later for evaluation of complaints consisting of bilateral lower extremity edema, discomfort, and non-healing wound at the gaiter area of the right leg. Physical examination revealed a venous ulcer above the ankle on the right and lipodermatosclerosis on the left. Duplex scan in March 2020 documented bilateral greater and lower saphenous vein, and Cocketts vein reflux. CEAP classification makes the right leg a C6 lesion and the left leg C4. Based on these findings, the requested radiofrequency ablation of right first and second perforator veins (CPT 36475 and 36476) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested radiofrequency ablation of right first and second perforator veins (CPT 36475 and 36476) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in surgery with subspecialty certification in vascular surgery 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:  The enrollee is requesting authorization and coverage for Canasa. The enrollee has diagnoses of ulcerative colitis and ulcerative proctitis. The enrollees symptoms include rectal bleeding, left lower quadrant abdominal pain, and bloating. The provider prescribed Canasa (mesalamine) suppositories. A colonoscopy report showed internal hemorrhoids. The enrollees medications include balsalazide, oral and rectal mesalamine, Cortenema, and sulfasalazine. A progress note recommendeded the continuation of Canasa as the primary treatment for the enrollees ulcerative proctitis. A professional guideline strongly recommends Canasa (mesalamine) for ulcerative proctitis based on high-quality evidence.  Furthermore, a governmental body lists ulcerative proctitis as the indication for the use of Canasa. The professional guideline also states that, in those with ulcerative proctitis, rectal 5-aminosalocylate therapies compounds, such as Canasa, should be used for maintenance of remission. Since this enrollee has ulcerative proctitis, treatment with rectal topical mesalamine is consistent with the guidelines.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.