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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for twice a week one and one half hour psychotherapy sessions.In this case, the patient has a history of trauma, depression, anxiety, dissociative identity disorder, and autism spectrum disorder spanning decades. The submitted documentation reflects that the patient has made progress over almost 30 years of treatment which has included inpatient stays, outpatient therapy, and medication management. Treatment is likely to be an ongoing necessity for the patient, however, based on her presenting concerns. Based on the provider's treatment plan, there is evidence that progress has been made since treatment began, and there are clearly outlined goals describing what will be addressed during the requested one and one half hour sessions twice a week. Given the expertise of the treating provider, it would be in the patient's best interest to continue to receive psychotherapy, as there is a dearth of expertise on dissociative identity disorder. The requested intensity of services is in line with what is recommended in treatment guidelines, and it does not appear that the requested services or intensity are at the convenience of either the patient or the provider, and outpatient psychotherapy is one of the least intensive settings in which service can be provided. Accordingly, the requested twice a week one and one half hour psychotherapy sessions are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is a licensed psychologist who is a board certified behavior analyst 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 Cosentyx. The records provided for review document that this patient has coped with his diagnosis of psoriasis for many years. Treatment has included multiple medication trials including topical steroids, which are first-line therapies. Cyclosporine, Otezla, triamcinolone and clobetasol have failed to provide the patient with adequate symptomatic relief from his psoriasis. Most recently, the patient was treated with Enbrel for two years with some improvement, but the provider noted that the patient still has psoriatic plaques on about 20% of his body surface area (BSA). Enbrel is a tumor necrosis factor alpha (TNF-a) inhibitor. Given that the patient is biologic experienced, treatment with Cosentyx is appropriate. Cosentyx has a different pathway than Enbrel and the patient has experienced excellent results with use of Cosentyx. For these reasons, the requested Cosentyx 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

The patient has requested reimbursement and prospective authorization and coverage for subacute residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for RTC 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. Given the findings, this patient meets the six ASAM dimensions to support treatment at the RTC level of care. All told, subacute RTC services provided 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 * 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 enrollees parent has requested authorization and coverage for a leadless pacemaker (single chamber implantable transcatheter pacing system). Patients who require a pacemaker at a young age have an increased risk of complications with their pacemaker leads since they will likely require pacing for their entire lives. Data has demonstrated that pacemaker lead complications increase with longer implant times. Moreover, young patients oftentimes damage or dislodge pacemaker leads with physical activity, which supports an indication for a leadless pacemaker. As this young patient requires a pacemaker for her diagnosis of Mobitz type 2 AV block and AV block Mobitz type 1, Wenckebach, the requested implantable leadless pacemaker is supported over standard pacemakers with leads. Given these findings, the requested a leadless pacemaker (single chamber implantable transcatheter pacing system) 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 a leadless pacemaker (single chamber implantable transcatheter pacing system) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology 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

An enrollee has requested authorization and coverage for Stelara 90 mg every four (4) weeks. American College of Gastroenterology (ACG) clinical guidelines state that ustekinumab (Stelara) should be given for moderate-to-severe Crohns disease patients who failed previous treatment with corticosteroids, thiopurines, methotrexate, or anti-TNF inhibitors or who have had no prior exposure to anti-TNF inhibitors (strong recommendation, high level of evidence). The guidelines explain that among patients who are initial anti-TNF therapy responders, approximately one-third subsequently lose their response to therapy or become intolerant to therapy (secondary nonresponders). These secondary nonresponders can either escalate dose of their current medication, switch to another anti-TNF agent, or switch out of class (to an anti-integrin (natalizumab or vedolizumab), anti-IL-12 / 23 (ustekinumab), or to a novel mechanism. In this case, the patient has a history of active Crohns disease, primary sclerosing cholangitis, and diffuse large B cell lymphoma (DLBCL). His DLBCL makes a TNFi contraindicated. Furthermore, the submitted records demonstrate extenuating circumstances given the patients recent DLBCL, the need to avoid certain medications, the patients partial response to Stelara at standard dosing, the COVID-19 pandemic, and the minimal cancer risk with this medication. Under these circumstances, the requested medication, Stelara 90 mg every four (4) weeks, 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 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

The patient has requested authorization and coverage for weekly biofeedback therapy, weekly eye movement desensitization and reprocessing therapy (EMDR), weekly internal family systems (IFS) for trauma, weekly PTSD acceptance and commitment therapy (ACT), and weekly cognitive hypnosis, somatic experiencing, positive psychology and resilience therapy. The 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. Applying the LOCUS framework, this patient meets the criteria for the requested services. This gives the patient a composite score which is consistent with medically monitored community based services. Thus, a lower level of care is indicated to attenuate her risk factors and minimize further compromise of her mental health. 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 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 exome sequence analysis (CPT 81415 and 81416). Genetic sequencing is helpful in the evaluation of genetic and congenital abnormalities including autism, epilepsy, brain malformations, congenital heart disease, and neurodevelopmental disorders. However, genetic sequencing is not considered within the standard of care for evaluation of cryptococcal central nervous system (CSF) infections. This patient has a history of cryptococcal meningitis, which caused a stroke and significant disability. The medical literature recommends treatment with fluconazole and CSF analysis reduction of immune deficits for treatment of cryptococcal meningitis. There is a lack of support for genetic testing in this clinical setting. Therefore, the requested whether exome sequence analysis (CPT 81415 and 81416) is not 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 requested whether exome sequence analysis (CPT 81415 and 81416) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in infectious disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for hydrogel spacer (SpaceOAR). Researchers found that although there are data suggesting positive clinical outcomes, there are a number of severe and debilitating complications recently reported in proximity to gel injection. The authors highlighted the need for additional study on the potential complications associated with SpaceOAR including acute pulmonary embolism, severe anaphylaxis, prostatic abscess and sepsis among others. This patient presents with a diagnosis of adenocarcinoma of the prostate. There is a lack of adequate data to support SpaceOAR use as safe and effective in this clinical setting. Therefore, the requested hydrogel spacer (SpaceOAR) for use during an upcoming prostate procedure is 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 requested services are 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 reviewers 1, 2, and 3 are board certified in urology 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 patient has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The 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. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, this patient meets the criteria for IOP services. The patient has been at some risk of harm (score 2) given her fluctuating passive and active suicidal ideation. Just within the past few days, the patient denied suicidal ideation or urges to self-harm. The patient has demonstrated moderate functional impairment (score 3) due to her inability to attend school or continue working due to her symptoms. The patient has minor comorbidities (score 2) with headaches and shoulder pain due to shoulder surgery. The patients recovery environment has been mildly stressful (score 2) as she lives with her parents, but is socially isolated from work and school. The patients recovery environment is supportive (score 2) as she lives with her parents who are supportive of her treatment goals. The patient has exhibited moderate response to treatment (score 3) as she has failed outpatient care and with several different providers. She is still at high risk of decompensation at a lower level of care. The patient has been constructive in treatment (score 2) as her providers report that she has been adherent with therapy and motivated for change. This gives the patient a composite score of 16, which is consistent with low intensity community based services. However, per LOCUS, the patients score of 3 on functional status meets the criteria for IOP level of care services. Although she has demonstrated improvement, she is still at significant risk of decompensation and harm should she not receive IOP services. The patient needs to work on applying her recently acquired DBT skills to the real world environment. Given these findings, 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 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 metaxalone 800 mg tablet, one tablet twice per day #60/30 days. This patient presents with multiple joint pain, memory lapses, and excessive sleep. Treatment has included baclofen, carisoprodol, cyclobenzaprine, tizanidine, and methocarbamol with adverse effects or ineffectiveness. The medical records demonstrate an allergy to Flexeril, baclofen, and methocarbamol. The patients current medications include Dibucaine, loratadine, metoclopramide, Skelaxin, and Voltaren 1% topical gel. The patient reports chronic pain as well as side effects of excessive sleep and memory lapses. Shaheed and colleagues performed a systematic review to evaluate the use of muscle relaxants for the treatment of low back pain. The authors found that muscle relaxants, such as metaxalone, may be helpful for short-term acute low back pain but not for chronic low back pain. The authors noted that, there is limited evidence of their clinical efficacy and tolerability. This patient has been on metaxalone for longer than six months for chronic joint pain. The records fail to demonstrate evidence of significant pain reduction or functional improvement. Moreover, the medical literature does not support long-term use of metaxalone. For these reasons, the requested metaxalone 800 mg tablet, one tablet twice per day #60/30 days, 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 internal medicine with subspecialty certifications in allergy and immunology and 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

The patient has requested authorization and coverage for proton beam radiation therapy (five times weekly for 39 treatments). A study was conducted to compare intensity modulated radiation therapy (IMRT) with proton beam radiation therapy to assess patient outcomes and toxicity. The study concluded that proton beam radiation was associated with a statistically significant reduction in genitourinary toxicity at six months compared with IMRT. This patient presents with prostate cancer with less than 30% of the core involved. In addition, the patients prostate specific antigen (PSA) has steadily risen over the past years. His provider has recommended treatment instead of surveillance given the rising PSA. Based on current medical literature, the requested proton beam radiation therapy is an appropriate intervention for this patient considering his age and increasing PSA. All told, the requested proton beam radiation therapy (five times weekly for 39 treatments) is medically necessary for 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 urology 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

The patient has requested authorization and coverage for eight weeks of continued physical therapy. The records provided for review document that this patient has undergone extensive physical therapy for her medical condition. She has continued back, left foot and distal calf pain. The patient has already received extensive instruction on a home exercise program for her specific condition. The literature supports a multimodal approach to chronic pain with exercise and physical therapy as one component. However, for patients with chronic pain, extending physical therapy beyond three months is determined based on measurable objective clinical improvement. The documentation reviewed does not demonstrate that the patient requires the unique skills of a therapist for continued rehabilitation or that the patient has made objective gains to support an indication for additional physical therapy. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design or deliver a program to maintain the patients current condition or to prevent or slow further deterioration. Accordingly, eight weeks of continued physical therapy is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular 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.