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

An enrollee has requested authorization and coverage for a wheelchair car lift.Weakness in post-polio syndrome, which can develop after many years or decades of stability following an acute poliomyelitis episode, is thought to be the result of ongoing neurological processes, including a reduced number of active motor units and motor unit size diminution, with a failure of reinnervation processes to keep up with and compensate for ongoing denervation processes. This weakness can gradually progress and potentially result in severe functional impairment and poor quality of life. Recommendations in this clinical setting generally include energy conservation techniques, pacing strategies, and generally participating in activities at a judicious level, i.e., avoiding overuse of weak muscles, while also avoiding inappropriate levels of inactivity.In this case, the patient has a weak right leg due to post-polio syndrome. She has been ambulating by compensating with her unaffected leg and upper limbs. This has caused significant strains on the connective tissues of these limbs. She also uses a wheelchair for some mobility. She has requested a wheelchair car lift to transport her wheelchair in her car. Her impairments make it difficult to impossible to get her wheelchair into and out of the vehicle. While travel in a motor vehicle may be desired; however, it is an elective activity, and is not needed to accomplish mobility-related activities of daily living or instrumental activities of daily in a reasonable and timely manner. Accordingly, the requested wheelchair car lift for vehicle transportation is not medically necessary because travel in a motor vehicle is not a medical necessity. Therefore, the requested wheelchair car lift is not medically necessary to treat the patients medical condition.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: The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. 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. Applying CALOCUS guidelines, this patient meets the criteria for IOP services. The patient has demonstrated significant risk of harm (score 3) due to his history of two prior suicide attempts, as well as impulsivity. The patient has shown moderate functional impairment (score 3) considering his recent stabilization achieved while in treatment. The patient has significant comorbidities given his cannabis use and attempt to conceal use during participation in IOP. The patients recovery environment has been mildly stressful (score 2) due to reported anxiety about school performance. The patients recovery environment has been highly supportive (score 1) as his parents have been actively involved his treatment planning and there are adequate family resources to assist the patient is in his recovery. The patient has exhibited moderate response to treatment (score 3). The records report that the patient has been treated in two prior hospitalizations and his improved mood after residential treatment. The patient has been non-collaborative in treatment (score 4) as he has refused to participate in treatment and has been described as disruptive in group therapy. This gives the patient a composite score of 19, which is consistent with high intensity community based services, such as IOP. Per CALOCUS, minimal oversight should be required for this level of service and reviews should not be required more often than every two weeks for persons with acute conditions and every two months for those with more slowly evolving conditions. This patients progress for his condition has been slowly evolving, due to longstanding difficulties and two hospitalizations. The patient started the IOP in December 2019 and he has not completed two months of treatment. Based on these findings, he continues to qualify for the IOP level of care. Accordingly, the IOP services 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: The patient has requested authorization and coverage for buprenorphine (Butrans Patch 5 mcg). Researchers performed a meta-analysis comparing the results of 33 studies evaluating the safety and efficacy of buprenorphine in the treatment of patients with chronic pain. The authors concluded that the current clinical and long-term safety data support the use of buprenorphine over full mu-opioid receptor agonists for the effective and preferential treatment of chronic pain at a critical time when safer and less addictive treatments are needed. In this case, the patient has chronic neck pain with radicular features and cervical canal stenosis at C5-6 and C6-7 confirmed on magnetic resonance imaging (MRI). She has tried and failed multiple conservative treatment options. A recent evaluation by neurosurgery recommended artificial cervical disc replacement at the affected levels. Her pain management provider has recommended a low dose buprenorphine patch for treatment of her chronic neck pain due to previous intolerances to full opioid agonists in the past. Current peer-reviewed medical literature validates the efficacy of buprenorphine for use in chronic pain population and current consensus guidelines support using buprenorphine as first-line treatment over traditional full opioid agonists due to better safety profile, tolerability and non-inferior analgesic effects. Given this support, the requested buprenorphine (Butrans Patch 5 mcg) 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 anesthesiology with subspecialty certification in pain management 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 and prospective authorization and coverage for inpatient medical/surgical treatment. The records provided for review document that this patients wound care has required the use of a wound VAC that is changed every three days. He is also receiving three parental antibiotics that will be ongoing until six to eight weeks after the wound closes. He requires skilled physical and occupational therapy for activities of daily living and a Clinitron bed. He is non-weight bearing on the left lower extremity. Documentation shows an improving wound bed without evidence of acute infection or exposed bone. The providers progress notes indicate that the patient has been afebrile and hemodynamically stable. He is tolerating oral analgesics and oral nutrition without complications. The patient continues to require physical and occupational therapy, wound care every three days and daily parental antibiotics. The records do not support the medical necessity of inpatient medical/surgical treatment for management of this patients medical condition. The patients laboratory values are stable and improving, which suggests that the infection is being appropriately treated. Parental antibiotics and a wound VAC do not require inpatient hospitalization. All told, inpatient medical/surgical treatment was not and is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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 internal 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. 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. Applying CALOCUS, a portion of the IOP services at issue were medically necessary for treatment of this patient. On the first day of the Health Plans denial, the patient has demonstrated significant risk of harm (score 3) due to a past suicide attempt and recent suicidal ideation with plan but without intent. The patient has exhibited moderate functional impairment (score 3) given her conflict with her family and recent gains made in the context of the IOP program. The patient has mild comorbidity (score 2) with a history of substance abuse and recent sobriety. The patients recovery environment has been mildly stressful (score 2) as she recently lost her aunt and has demonstrated distress over her parents performance expectations. The patients recovery environment is highly supportive (score 1) due to the presence of wraparound services as part of the IOP program. The patient has exhibited moderate response to treatment (score 3) with continued distress despite lower levels of care, and some recent progress at the current IOP including sobriety. The patient has been incompletely engaged in treatment (score 3). The records document that she has shown manipulative behaviors, continued conflict with her parents, and difficulty accepting responsibility for her actions. This gives the patient a composite score of 17, which is consistent with high intensity community based services, including IOP treatment. Per CALOCUS, minimal oversight should be required for this level of service and reviews should not be required more often than every two weeks for persons with acute conditions and every two months for those with more slowly evolving conditions. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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 lidocaine 4% nasal spray.Medical literature supports that the requested medication is medically necessary. A 2014 double-blind, randomized clinical trial (RCT) to evaluate the efficacy of intra-nasal lidocaine on different types of headache found that after intervention, patients mean base pain scores were significantly lower in the group given intra-nasal lidocaine than in the group given normal saline (placebo). The trial concluded that intra-nasal lidocaine is an efficient method for pain reduction in patients with headache and recommended this method in patients referred to an emergency department (ED) with headache. A 2019 meta-analysis of intra-nasal lidocaine for acute migraine concluded that intra-nasal lidocaine can be considered a useful option for patients with an acute migraine. It yields a high success rate, a low pain intensity, an infrequent need for rescue medicine, and tolerable adverse events.In this case, the patient has a rare mast cell disorder which limits her ability to use many classes of medications to treat her headaches. She has tried and failed common treatments for idiopathic intracranial hypertension and still suffers from intractable headaches. She has also trialed intra-nasal lidocaine spray with significant relief of her headaches, and there is evidence to support this form of treatment in the recent randomized trials and a meta-analysis study. Under these circumstances, the requested lidocaine 4% nasal spray is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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: The patient has requested authorization and coverage for Lorbrena (lorlatinib) 100 mg. In a recent phase 1/2 study, Lorbrena demonstrated anti-tumor activity for patients with ROS1 positive metastatic lung cancer who have failed treatment with crizotinib, including patients with intracranial metastases. This patients records do not document that she is refractory to crizotinib. Based on the documents provided for review, crizotinib may still be effective for control of this patients disease as she discontinued this medication due to pregnancy. The patient is PD-L1 positive and could be a candidate for checkpoint immunotherapy given the clinical evidence of anti-tumor activity for central nervous system metastases. All told, the requested Lorbrena (lorlatinib) 100 mg is 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 oncology 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 patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. 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. Applying CALOCUS, this patient does not meet the criteria for RTC level of care services. The patient was at some risk of harm (score 2) due to past cutting, recent suicidal ideation without intent or plan, as well as some impulsivity without serious harm to herself or others. The patient has demonstrated moderate functional impairment (score 3) given to conflict with her parents and recent decline in her weight and appetite. The patient has mild comorbidity (score 2) considering her substance use and mental health issues. The patients recovery environment has been mildly stressful (score 2) due to family conflict, and the patients struggles with boundaries and limits. The patients environmental support has been limited (score 3) as the records noted the patient has a lack of access to appropriate care in her area. The patient has shown moderate resiliency to treatment (score 3) with continued symptoms despite long-term outpatient medication management and a recent psychiatric hospitalization. The patient has been incompletely engaged in treatment (score 3) as she has limited insight and minimizes her symptoms and problematic behaviors. This gives the patient a composite score of 18, which is consistent with high intensity community based services, such as intensive outpatient program (IOP) level of care. All told, the RTC services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for radiation therapy to the schwannoma.The submitted documentation does not support that the requested services are medically necessary at this time. An assessment of patient suitability for radiation therapy or referral to radiation therapy for treatment planning, is an important step in the process of care. Patient assessment would typically include, at a minimum, a recent physical examination by a referring provider, and the ordering and evaluation of any appropriate adjunct testing by a referring provider, who would most appropriately be a Neurosurgeon in this case. In this case, the submitted documentation reflects that the patients most recent appointment with her Neurosurgery provider was not recent. In addition, while the patient had MRI of the thoracic spine performed recently, there is no documentation of a recent examination with the Neurosurgery provider. Furthermore, there is no documentation of a recent assessment of the patients suitability for radiation therapy which culminated in a referral for radiation therapy. Records reflect that the patient has effectively self-referred in seeking Health Plan authorization and coverage for radiation therapy. Without the appropriate referral from a neurosurgical specialist, the requested radiation therapy to the patients schwannoma is not medically necessary for their medical condition at this time.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 radiation oncology 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

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for clinically managed high-intensity residential 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. The patients recovery environment was supportive and free from alcohol. Given the findings on the ASAM guideline, the RTC services provided from were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise 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.