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

The patient has requested reimbursement and prospective authorization and coverage for oxymorphone immediate-release (IR) 10 mg every eight hours as needed for breakthrough pain (60 tablets/20 day supply) and oxymorphone extended-release (ER) 15 mg twice a day for chronic pain. The Federation of State Medical Boards guidelines state, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. The Centers for Disease Control and Prevention (CDC) guidelines noted that, non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. In this case, the patient has experienced intractable debilitating migraines for several years. The providers note outlines the numerous prophylactic and abortive medications that were ineffective to manage the patients condition. The patients treatment plan includes non-opioid- based therapy. The letter from the provider reports that the patient has shown functional benefit with oxymorphone. The patients CURES report and urine drug screens have been consistent with his treatment regimen and the patient has not demonstrated aberrant drug behavior. Furthermore, the patients treatment plan is to wean the patients opioids over the next six months. Given these findings, oxymorphone IR 10 mg every eight hours as needed for breakthrough pain (60 tablets/20 day supply) and oxymorphone ER 15 mg twice a day for chronic pain were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the medications 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 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Dupixent 200 mg/1.14 mL syringe. The records provided for review document that this patient has experienced a history of a diffuse itchy pink rash that has required topical steroids and corticosteroids. She was treated with Dupixent with substantial improvement. There is evidence that she has failed topical steroids, as well as two courses of oral prednisone. Researchers found that Dupixent has dramatically improved outcomes for adults with severe atopic dermatitis. All told, the requested Dupixent 200 mg/1.14 mL syringe 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 authorization and coverage for lidocaine infusion therapy in an inpatient hospital setting. This patient presents with erythromelalgia, which is characterized by erythematous, warm, painful extremities. The patient has tried and failed multiple pharmacological agents for her neuropathic pain. The records document that her condition is interfering with her ability to perform activities of daily living. Medical literature states that recent investigations have identified sodium channelopathy as a genetic cause for this condition, classified as primary inherited erythromelalgia. The authors noted that although there is a lack of standard therapies for the management of pain related to erythromelalgia, lidocaine has been used with success in this clinical setting. Therefore, treatment in an inpatient hospital setting is appropriate. Based on the current medical literature, the requested lidocaine infusion therapy in an inpatient hospital setting 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for a Repatha SureClick 140 mg/mL pen injector. The patient has been diagnosed with borderline hyperlipidemia, type 1 diabetes mellitus, and polycystic ovarian syndrome. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol (LDL-C). In this case, the patient has some coronary risk but no documented coronary disease. The patients reported lipid levels are only modestly elevated, and there is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. The medical evidence does not support the requested medication in this clinical setting. Therefore, the requested Repatha SureClick 140 mg/mL pen injector 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Euflexxa injections for both knees, once a week for three weeks. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of a good result from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections for both knees, once a week for three weeks 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for bronchial thermoplasty. Ideal candidates for bronchial thermoplasty include adults with severe persistent asthma who require regular maintenance medications of inhaled corticosteroids and long-acting beta agonist, with add-on therapies such as leukotriene modifiers, steroids, or biologic agents. These agents reduce inflammation or decrease airways narrowing by relaxing airway smooth muscle but do not prevent the chronic structural changes that occur. Bronchial thermoplasty is an alternative therapy for this patient population. The U.S. Food and Drug Administration (FDA) has approved bronchial thermoplasty for use in this clinical setting. This patients treatment has included treatment in the hospital and emergency department, in addition to standard treatments for asthma including immunotherapy with Nucala. Thus, the requested bronchial thermoplasty 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 certifications in pulmonary disease and critical care medicine and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in pulmonary disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in pulmonary disease 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for computed tomography (CT) of the heart without contrast, with quantitative evaluation of coronary calcium. Based on the records provided for review, this patient has a low to intermediate 10-year risk of coronary artery disease (CAD). However, she is close to the low-density lipoprotein (LDL) cholesterol cutoff for recommending statin therapy. In addition, the patients risk is enhanced based on her strong family history of early CAD. According to the American College of Cardiology Foundation (ACCF) treatment guidelines, although she does not meet the standard requirements for starting stain therapy, she has additional risk enhancing factors consisting of a family history of early CAD and persistent LDL over 160. The patient is reticent to start lifelong statin therapy due to concern for side effects. Thus, coronary CT calcium scanning is recommended to help determine whether this patient would benefit from lifelong statin therapy. Given this support, the requested CT of the heart, without contrast, with quantitative evaluation of coronary calcium is likely to be more beneficial for evaluation 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 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 internal medicine with subspecialty certification in cardiovascular 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for viscosupplementation therapy, hyaluronan or derivative, Hyalgan, Supartz or Visco-3, for intra-articular injection (CPT J7321), one unit weekly for three doses.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 patient has tried and failed other conservative treatments including frequent intra-articular injections of corticosteroids, which only provided short term relief. The patients alternative is total knee arthroplasty at a relatively young age. Under these circumstances, the requested viscosupplementation therapy, hyaluronan or derivative, Hyalgan, Supartz or Visco-3, for intra-articular injection (CPT J7321), one unit weekly for three doses, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are 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 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 been diagnosed with major depressive disorder. The patient reported feeling as if her depression was in remission. The patient was noted to have begun transcranial magnetic stimulation (TMS) treatment for maintenance in January 2020 after completing acute phase treatment. In a letter, the provider noted that the patient received TMS treatments in 2017 with a remarkable change in the patients condition, although the improvement was not sustained. The provider noted that the patient had rapid decompensation and was treated with additional TMS treatments 2018 and 2019. Per the records, the Patient Health Questionnaire (PHQ-9) scores were noted to have increased from zero in February 2020 to 10 in April 2020. The patients Beck Depression Inventory (BDI) scores had increased from eight in March 2020 to 20 in April 2020, indicating worsening depressive symptoms. The patient has requested reimbursement and prospective coverage for repetitive transcranial magnetic stimulation (rTMS) services provided  forward. The Health Plan denied the request and reported the services at issue were not and are not medically necessary for the treatment of this patient. At issue in this case is whether rTMS services provided forward were and/or are medically necessary for the treatment of the patients medical condition. Authors reported, Repetitive TMS could represent a novel strategy for preventing relapse in treatment resistant depression patients who respond to rTMS treatment. These results should be confirmed in a larger sample. Researchers reported, Once a determination of maximum benefit is made, the TMS treatments should be tapered and a continuation and then maintenance regimen developed for the patient. In this case, the provider noted that the patient had rapid decompensation and required additional TMS treatments in 2018 and 2019 after initial rTMS treatment in 2017. The medical evidence supports the services at issue in this clinical setting. Therefore, repetitive transcranial magnetic stimulation (rTMS) services provided forward were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 Xyosted 75 mg/0.5 mL injection. This patient has a reported history of low testosterone levels with symptoms of fatigue and erectile dysfunction. The provider noted that the patient underwent penile injections for erectile dysfunction, likely due to corporovenous occlusive disease. According to the Endocrine Society guidelines, hypogonadal patients with low testosterone levels and symptoms can be treated with a variety of testosterone preparations including gels, pellets, and injectable therapies. The goal of treatment is to normalize a patients testosterone level. Most symptoms of fatigue, overall wellbeing and sexual dysfunction should improve with normalization of the levels. This patients testosterone levels were noted to be within normal limits with testosterone replacement through pellets and gels, attaining levels as high as 814 ng/dL. Despite this improvement, he has continued to complain of fatigue and persistent erectile dysfunction. The patient reported improvement in his symptoms with Xyosted. However, the records fail to demonstrate that the patient has been treated with and failed standard testosterone preparations to support an indication for Xyosted. Therefore, the requested Xyosted 75 mg/0.5 mL injection 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 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 residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets 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. Given these findings, the RTC level of care services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Humira 40 mg/0.8 ml weekly. The patient has been diagnosed with Crohns disease. Researchers reported that higher adalimumab levels are associated with biologic remission. An optimal level of greater than 8.5 g/mL was identified. Medical literature states that adalimumab concentrations greater than or equal to 12 g/mL were independently associated with endoscopic and histologic remission in Crohns disease. Researchers also reported that 40 mg adalimumab every other week or every week was superior to placebo for maintenance of clinical remission to week 54. In this case, the patient has undergone two operations and has had a recurrence of active disease revealed on recent colonoscopy. Per the records, the patient has been treated with Humira 40 mg every other week for approximately six months but is still having loose stools five to six times per day and two times overnight. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, Humira 40 mg/0.8 ml weekly is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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.