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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rinvoq (upadacitinib) extended 24-hour release 15 mg. Findings:  The physician reviewer found that In this case, the patient has rheumatoid arthritis and reported good response to Rinvoq. Given that the documentation shows that the patient has tried and failed multiple TNF inhibitors, a trial of another TNF inhibitor when she has had good response to another class of medications is not medically indicated. Therefore, Rinvoq (upadacitinib) extended 24-hour release 15 mg 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for IOP level of care. Findings:  The physician reviewer found that American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, 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) medical, addictive 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. With regard to risk of harm, the records support a score of 3. The patient has a risk of harm, due to a history of suicidal ideation. In terms of functional status, the records support a score of 3. The documentation noted functional impairment due to significant deficits in the patients ability to fulfill obligations and engage in socially constructive activities.With regard to comorbidity, the records support a score of 3. The patient had comorbidity due to a relapse and significant struggles with alcohol and cannabis use that had a negative impact on mental health. In terms of level of stress of the recovery environment, the records support a score of 3.  The patient had a moderately stressful environment related to a stressful employment situation and the need to return to work. With regard to level of support of the recovery environment, the records support a score of 2, as the patient appeared to have some supportive friendships. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment, as her need to return to treatment indicated that past treatment had not enabled her to maintain recovery.With regard to treatment acceptance an engagement, the records support a score of 2. The patient was well engaged in treatment, but had some ambivalence or difficulty connecting to ongoing care. Thus, the patient has a total score of 19. In this case, the recommended level of care is high intensity community-based services. Therefore, IOP level of care that was 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 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 lumbar/sacral facet joint block injection (CPT 64493). Findings:  The physician reviewer found that Manchikanti and colleagues noted that, the evidence for lumbar facet joint nerve blocks using local anesthetics with or without steroid for managing chronic low back pain of facet joint origin is fair to good for short- and long-term improvement. The best evidence for the use of medial branch blocks is for diagnostic purposes leading to a radiofrequency ablation procedure. Cohen and colleagues evaluated the effectiveness of lumbar medial branch blocks and facet joint injections. The authors found that facet blocks might provide prognostic value before radiofrequency ablation. This patients records document the presence of chronic low back pain, which is not radiating into the lower extremities. The patient does not complain of signs or symptoms suggestive of neurogenic claudication. The most recent MRI performed in August 2020 shows significant degenerative disc disease involving L4-L5 with a pars defect at L4 along with severe facet arthropathy involving the L4-5 level. There is evidence of moderate canal stenosis, but this is not symptomatic as there are no reports of neurogenic claudication. The patient has not previously been treated with diagnostic injections of the facet joints/medial branches to help establish the source of her chronic back pain. The current peer-reviewed medical literature supports the use of diagnostic injections to establish whether the pain is facet joint related and whether the patient would be a candidate for radiofrequency ablation procedure in the future. Based on the medical records reviewed and the current evidence-based medical literature, the requested lumbar/sacral facet joint block injection (CPT 64493) is medically necessary for 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 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 authorization and coverage for a compound prescription Biest/progesterone TD cream, composed of: Estriol micropowder 0.24 grams, Estradiol micro-powder 0.06 grams, progesterone micro-powder 7.5 grams, propylene glycol 7.5 mL liquid, and Vanicream 59.7 grams. Researchers note that menopausal hormone therapy (also called hormone therapy or hormone replacement therapy) may treat menopausal symptoms including hot flashes, sleep disturbances, mood lability and depression, and joint aches and pains. The authors noted a lack of evidence supporting the safety or efficacy of custom compounded bioidentical hormone therapy when compared with approved and commercially available products for menopausal hormone treatment. Researchers state that there is no rationale for routine prescribing of unregulated, untested, and potentially harmful custom-compounded bioidentical hormone therapies. Given that there are multiple formulations that are approved by the U.S. Food and Drug Administration (FDA) for menopausal hormone therapy (MHT), the requested medication is not medically indicated. Therefore, a compound prescription Biest/progesterone TD cream, composed of: Estriol micropowder 0.24 grams, Estradiol micro-powder 0.06 grams, progesterone micro-powder 7.5 grams, propylene glycol 7.5 mL liquid, and Vanicream 59.7 grams is not medically necessary for the 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 obstetrics and gynecology 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 IOP level of care. 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 3. The patient had a significant risk of harm, due to suicidal ideation in the past three months, and a recent impulsive departure from his home for several hours late at night. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to social withdrawal and isolation. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of regular cannabis use and depression. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to the social isolation related to the pandemic. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents involvement in treatment planning. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate resiliency and/or equivocal response to treatment as demonstrated by his recent decline in mood and functioning, struggles adjusting to the changes brought on by the pandemic, and continued cannabis use. With regard to treatment acceptance and engagement, the records support a score of 2. The patient participated in treatment and expressed motivation to achieve sobriety, but continued cannabis use while in IOP.Thus, the patient has a total score of 18. In this case, the recommended level of care is high-intensity community-based services. This is consistent with the level of care the patient received and is receiving at IOP. Therefore, IOP level of care was and is medically necessary for the 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam therapy. Findings:  The physician reviewer found that There is no data to suggest that proton therapy would be beneficial in this case or that it would be associated with less side effects than standard treatment with photons. The standard treatment in this case would be with chemotherapy, followed by surgery, followed by radiation with photons. Furthermore, consensus group guidelines do not support the use of proton therapy in this setting (NCCN Clinical Practice Guidelines). In the vast majority of cases, intensity modulated radiation or 3D conformal techniques with photons is able to achieve an acceptable cardiac and lung dose. There is also no level I evidence to support the use of proton therapy for the treatment of breast cancer. Therefore, the requested proton beam therapy is not likely to be more beneficial than any other available standard treatment for the patients condition.Final Result: The reviewer determined that the requested services are not likely to be more beneficial than any other available standard treatment for the patients condition. Therefore, the Health Plans denial should be upheld.Findings: Three out of three physician reviewers found that the requested proton beam therapy is not likely to be more beneficial than any other available standard treatment for the patients condition.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology 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: An enrollee has requested authorization and coverage for Synvisc-One injection for both knees.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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 patients options are limited. The patient has tried and failed other conservative treatments, including corticosteroid injections, with the alternative being total knee arthroplasties for `moderate` degenerative changes. Under these circumstances, the requested Synvisc-One injection for both knees is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's 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 patients parent has requested reimbursement for all or any of the mental health 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 3. The patient had a significant risk of harm, due to a history of hospitalization for suicidality, multiple past impulsive suicide attempts, and incidents of self-harm.In terms of functional status, the records support a score of 4. The documentation noted significant functional impairment due to withdrawal and avoidance of almost all social interaction. The patient rarely left her room, isolated from friends, and missed half to 80% of her school year. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of dyslexia, attention deficit disorder, and Tourettes syndrome.In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to disruptions caused by the pandemic, and her mothers recent marriage. With regard to level of support of the recovery environment, the records support a score of 3 due to her mothers inconsistent attendance at family therapy sessions. 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. With regard to treatment acceptance and engagement of the parent, the records support a score of 3. The patients mother was incompletely engaged, due to her inconsistent attendance of family therapy sessions and lack of response to phone calls and emails from the residential treatment center staff. Thus, the patient has a total score of 21. The records support a score of 4 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care that the patient received at the residential treatment center. Therefore, mental health 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ Nuspin 20 mg/mL. A study notes that under the U.S. Food and Drug Administration (FDA), idiopathic short stature (ISS) is defined by height of -2.25 standard deviations, corresponding to 63 inches for adult men. In this case, the records documented that the patient had normal growth pattern prior to the initiation of somatropin. Given that the patients Z-score does not meet the generally accepted diagnostic criteria for ISS of -2.25 standard deviations, the requested medication is not medically indicated. Therefore, Nutropin AQ Nuspin 20 mg/mL is not medically necessary for the 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 computerized dynamic posturography, quantitative electroencephalogram, Cambridge Brain Sciences Cognitive Test, and/or videonystagmography. Based on the available documentation, this patient presented to his provider with complaints of vertigo, headache, difficulty falling asleep and tiredness after sustaining head trauma from a water bottle. The patient underwent evaluation with computed tomography (CT) of the head and magnetic resonance imaging (MRI) of the brain, which were interpreted as normal. The patient has symptoms suggestive of post-concussion syndrome. The use of the above the quantitative electroencephalogram and Cambridge Brain Sciences Cognitive Test would not alter the treatment of post-concussion syndrome. The treatment of post-concussion syndrome is supportive, and patients may take years to recover depending on the severity of the injury. As this patient complains of vertigo, computerized dynamic posturography and videonystagmography will be helpful in localizing the cause and likely affect treatment. However, the records do not support an indication for the requested quantitative electroencephalogram and Cambridge Brain Sciences Cognitive Test. Therefore, the requested computerized dynamic posturography and videonystagmography are medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services is 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 neurology 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 reimbursement for FoundationOne CDx assay. In patients with metastatic and recurrent cancer from many types of solid tumors, next generation DNA sequencing can help guide treatment. In 2017, the U.S. Food and Drug Administration (FDA) approved the FoundationOne CDx technology for analyzing pathogenic variants in solid tumors. FoundationOne CDx technology detects variations in the coding regions of over 300 genes and provide information about differences between tumor and adjacent noncancerous tissue. The FoundationOne CDx reveals genomic signatures such as microsatellite instability and tumor mutational burden. Per current recommendations, indications for FoundationOne CDx include metastatic and recurrent cancer for a number of solid tumor types as well as tumors of unknown primary, for which genomic information would inform patient management. The records reviewed demonstrate that this patient underwent this testing to guide treatment decisions for her mixed endocervical adenocarcinoma with high-grade neuroendocrine carcinoma. The utility of the FoundationOne CDx has been demonstrated to yield data that is not available with other standard testing in this clinical setting. Therefore, the FoundationOne CDx assay was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the FoundationOne CDx assay was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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.