Persius/hicric huggingface dataset:
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 residential treatment center (RTC) services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient has a serious risk of harm, due to substance abuse, including a recent overdose requiring hospitalization. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to conflict with parents and social isolation due to substance use. The patient demonstrated recent gains or stabilization in functioning while participating in treatment in a structured, protected, and/or enriched service. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance abuse, hallucinations, and a history of pancreatitis. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to the recent death of his grandmother, and his fathers illness and homelessness. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents participation in treatment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, as he overdosed while participating in a partial hospitalization program (PHP), and his symptoms of depression, anxiety, and cravings continued in residential treatment.With regard to treatment acceptance and engagement, the records support a score of 2. The patient was motived and participated in treatment.Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored residence-based services, due to the serious risk of harm score of 4. This is consistent with the RTC level of care. Therefore, RTC services are 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 overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia (CPT code 00812) that was provided for a lower intestinal endoscopic procedure. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that anesthesia provider assistance should be considered in cases of prolonged or therapeutic endoscopic procedures, anticipated intolerance to standard sedatives, increased risk for adverse events due to severe comorbidity (American Society of Anesthesiologists class IV or V), or increased risk for airway obstruction due to anatomic variant. In this case, the documentation did not show the patient met any of these criteria. Therefore, anesthesia (CPT code 00812) that was  provided for a lower intestinal endoscopic procedure was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Prolia injections. Findings: A study noted that treatment is generally recommended in postmenopausal women who have a bone mineral density T-score of -2.5 or less, a history of spine or hip fracture, or indications of fracture risk. The U.S. Food and Drug Administration (FDA) indicates Prolia as appropriate for the treatment of postmenopausal women with osteoporosis at high risk of fracture. In this case, given the patients diagnosis of osteoporosis and bone mineral density T-score of -2.5, the requested medication is medically indicated. Therefore, Prolia injections are 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Flexitouch programmable pneumatic compression pump. In this patients case, there is a lack of indication for a pneumatic compression pump. The patient was noted to have edema after a knee injury that continued despite mild compression stocking use. However, the patient reported that only her foot was swollen after sleeping, which suggests that the patients edema improved with elevation. Blumberg and colleagues reported favorably on the use of pneumatic compression on 100 patients in all treatment groups with use of the Flexitouch system. The authors cautioned that their study was limited in the lack of standardization of all aspects of lymphedema care and lack of a control group, making it difficult to draw more than general conclusions about the benefit of pneumatic compression. Intermittent pneumatic compression is accepted medical treatment for lymphedema when used in conjunction with limb compression and oftentimes manual lymphatic drainage. However, studies have not demonstrated long-term improved patient health outcomes with use of the Flexitouch system as compared to other sequential compression devices in this clinical setting. For these reasons, the Flexitouch programmable pneumatic compression pump was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Flexitouch programmable pneumatic compression pump was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in plastic surgery and is actively practicing. Physician reviewer 2 is board certified in surgery with subspecialty certification in general vascular surgery and is actively practicing. Physician reviewer 3 is board certified in plastic surgery and is 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 patient has requested authorization and coverage for Actemra infusions. Ringold and colleagues noted that, in patients with JIA and polyarthritis and moderate or high disease activity receiving a first tumor necrosis factor inhibitor (TNFi) (with or without disease-modifying anti-rheumatic drugs), switching to a non-TNFi biologic (tocilizumab or abatacept) is conditionally recommended over switching to a second TNFi. In this case, the patient has active JIA with mild swelling in multiple joints and advanced disease with flexion contractures in both elbows and left leg. Given that she tried and failed treatment with a TNFi, Humira, a non-TNFi biologic, such as Actemra, is medically indicated. Therefore, Actemra infusions are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested authorization and coverage for Ativan. The U.S. Food and Drug Administration (FDA) approved indications for Ativan support short-term use for relief of the symptoms of anxiety or anxiety associated with depressive symptoms. Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic. The recommendations include treatment with Ativan for up to four weeks, with extensions based on reevaluation findings to support continued therapy. Per the FDA, continuous long-term use of Ativan is not recommended. In recent guidelines for the treatment of anxiety disorders, Bandelow and colleagues noted that treatment should include psychological therapy, pharmacotherapy, or a combination of both. Cognitive behavioral therapy can be regarded as the psychotherapy with the highest level of evidence. First-line drugs are the selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. The authors concluded that benzodiazepines are not recommended for routine use. The records provided for review document that this patients provider did not recommend continued treatment with Ativan, noting the patients misuse of medications and complex mental health history. The providers decision to not recommend Ativan, a benzodiazepine, is consistent with the FDA approval as well as the guidelines outlined by Bandelow and colleagues. Due to his history of substance abuse and chronic anxiety symptoms, the patient is at elevated risk of tolerance and dependence with benzodiazepines. Moreover, the patients records do not document that the patient has exhausted first-line therapies for anxiety. For these reasons, the requested Ativan 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 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 1 additional acupuncture session (3 total per month). Researchers noted that the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) found limited evidence on the effectiveness of manual therapies, passive physical modalities, or acupuncture for the management of whiplash-associated disorders or neck pain and associated disorders. In a systematic review and best evidence synthesis of peer reviewed literature, the authors concluded evidence suggested that,  electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, and ultrasound) are not effective and should not be used to manage neck pain. In this case, the documentation did not show pre-acupuncture and post-acupuncture baselines for comparison purposes, the total number of acupuncture sessions completed, and measurable, progressive, significant, or objective functional improvement. The records did not indicate a flare-up of the condition, or a re-injury. There is no indication that the patient is currently undergoing an independent conditioning-aerobic program. Given that the documentation does not demonstrate medication intake reduction, work restrictions reduction, or activities of daily living improvement directly attributable to prior acupuncture, the requested service is not medically indicated. Therefore, 1 additional acupuncture session (3 total per month) is not medically necessary.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed acupuncturist, board certified in oriental 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 for mental health residential treatment center (RTC) services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to recent repeated episodes of self-harm, suicidal ideation with a plan prior to admission, and disordered eating of purging and restricting to 200 calories per day. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to serious deterioration of interpersonal interactions with consistent conflict as demonstrated by a tense home environment and family conflict. The patient reported struggles with hygiene due to low mood, and disordered eating.With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity, due to the presence of occasional cannabis use.In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to struggles with expectations from her parents. With regard to level of support of the recovery environment, the records support a score of 2 due to her parents active participation in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment as multiple medication trials had not prevented her recent decline in mood and functioning. With regard to treatment acceptance and engagement, the records support a score of 2, due to patients active participation in treatment. Thus, the patient had a total score of 20. In this case, the recommended level of care was medically monitored residence-based services due to the risk of harm and functional status scores of 4. This is consistent with the level of care that the patient received at the RTC. Therefore, RTC services were medically necessary for the 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 sub-specialty 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 bilateral Orthovisc injections. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior viscosupplementation injections. Given the patients limited options, with the alternative being a total knee arthroplasty, the requested services are medically indicated. Therefore, bilateral Orthovisc injections are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that daily left prefrontal TMS therapy has substantial evidence of efficacy and safety for treating the acute phase of depression in patients who are treatment resistant or intolerant. In this case, the patient has tried and failed multiple medications and is experiencing an acute episode of depression. Given the current medical literature and that the provider recommends TMS, the requested service is medically indicated. Therefore, TMS is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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 left knee ACL repair surgery. Regarding the management of ACL injuries in adults over age 40 years, Salzler and colleagues noted that multiple structural and biomechanical age-dependent changes exist in the ACL, including fewer mesenchymal stem cells, decreased healing potential, decreased structural organization, decreased stiffness, and a decreased load to failure with age. The authors further noted that ACL insufficiency can predispose an older patient to recurrent instability, meniscal and chondral injury, and osteoarthritis. The authors concluded that role of nonsurgical versus surgical management in these patients remained controversial, and that lower-demand patients may be able to cope with ACL deficiency, while limited studies suggested good functional outcomes with surgical ACL reconstruction in higher-demand patients. Regarding the management of ACL rupture in patients aged 40 and older, Legnani and colleagues noted that while surgery is often the best therapeutic option after an ACL tear in the young and active population, ACL reconstruction in the middle-aged population is more controversial due to concerns about a higher complication rate. The authors noted that high-level studies were limited, and deciding factors included occupation, sex, activity level of the subject, amount of time spent performing highly demanding activities, the presence of associated knee lesions, and physiological age and activity level. Current medical literature indicates that the role of surgical management in patients over the age of 40 with ACL instability remains controversial. At this time, it appears that the patient has not exhausted recommended conservative treatment prior to proceeding with surgery. Therefore, left knee ACL repair surgery is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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.