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 an Euflexxa injection series for the right knee. 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 tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, an Euflexxa injection series for the right knee is 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 methotrexate subcutaneous autoinjector. This patient presents with seropositive non-erosive rheumatoid arthritis. The patients provider has recommended a change in therapy from oral methotrexate to subcutaneous autoinjector methotrexate due to gastrointestinal side effects and a continued low level of rheumatoid disease with the oral formulation. In the medical literature, researchers reported that patients with an inadequate clinical response to oral methotrexate may benefit from switching to subcutaneous methotrexate. Bianchi and colleagues noted that subcutaneous methotrexate is more effective than oral methotrexate in both in methotrexate-naive patients with early rheumatoid arthritis and in patients who switch from oral methotrexate to subcutaneous methotrexate due to previous treatment failure, lack of efficacy, or adverse events. In this case, the patient indicated she has a fear of utilizing an open exposed needle to self-inject. Due to this fear of needles, the patient is unable to tolerate administration of intramuscular methotrexate. Per the submitted documentation, she is able to tolerate subcutaneous needle injections via autoinjector pen. She is tolerating subcutaneous injection with Enbrel. Methotrexate can be administered subcutaneously via autoinjector pens.  Due to fear and anxiety reported by the patient caused by viewing open exposed needles, her ability to administer methotrexate intramuscularly is impaired. Therefore, the requested methotrexate subcutaneous autoinjector is medically necessary for 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 board certified 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: An enrollee has requested authorization and coverage for an increased dosage of the medication Norco 10/325mg tablets to a quantity of ninety (90) tablets per month.Centers for Disease Control and Prevention (CDC) guidelines for the prescribing of opioids for chronic pain state that clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. The guidelines state that clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. Federation of State Medical Boards guidelines for the chronic use of opioid analgesics state that continuation, modification or termination of opioid therapy for pain is contingent upon a clinicians evaluation of evidence of the patients progress toward treatment objectives and the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. The Federation of State Medical Boards guidelines recommend opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. Opioid dosage should be maintained as low as possible and continued only if clear and objective outcomes are being met.In this case, the patient has significant comorbid health conditions including obesity and sleep apnea. The patient is also noted to have had an inconsistent urine drug screen result and apparent drug seeking behavior demonstrated during a recent clinic visit. For these reasons, the healthcare provider did not endorse further escalation of the patients opioid prescription. The provider recommended a pain management plan that focuses on non-opioid therapies, which is consistent with the CDCs current guidelines and recommendations from the Federation of State Medical Boards. Under these circumstances, the requested increased dosage of the medication Norco tablets to a quantity of ninety (90) tablets per month is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested increased dosage of medication is not medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Xifaxan 200 mg tablet three (3) times a day for 14 days. The U.S. Food and Drug Administration (FDA) approves the use of Xifaxan (generic name rifaximin) for the treatment of irritable bowel syndrome with diarrhea. In a study of 50 children with irritable bowel syndrome (IBS), Scarpellini and colleagues found that rifaximin was effective and safe in treating small intestinal bacterial overgrowth (SIBO) treatment and IBS symptoms in children. In this case, the patient has tried and failed multiple treatments, including metronidazole. Given that the patient continues to have persistent abdominal pain, the requested medication is medically indicated. Therefore, Xifaxan 200 mg tablet three (3) times a day for 14 days 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 pediatrics with sub-specialty certification in pediatric 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 reimbursement and prospective authorization and coverage for (1) PHP level of care and (2) future PHP level of care. 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. With regard to risk of harm, the records support a score of 3. The patient had a moderate risk of harm, due to the presence of suicidal ideation and struggles with sticking to her meal plan and exercising excessively. In terms of functional status, the records support a score of 3. The documentation showed moderate impairment due to her disordered eating, depression, and anxiety affecting her physical health, resulting in her taking two quarters off from graduate school. With regard to comorbidity, the records support a score of 3. The records documented the presence of tachycardia and weight loss due to the patients disordered eating.In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a mildly stressful environment due to disruptions in her life caused by the pandemic.With regard to level of support of the recovery environment, the records support a score of 2 as the patient identified friends and family who could support her recovery efforts. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment, reporting persistent disordered eating despite several admissions at varying levels of care over the past several years.With regard to treatment acceptance and engagement, the records support a score of 3. The patient expressed motivation to change, although she struggled with adhering to her eating plan and limiting exercise outside of the treatment setting. Thus, the patient had a total score of 21. In this case, the recommended level of care is Level 4, medically monitored non-residential care. Therefore, (1) PHP level of and (2) future PHP 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 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 home infusions of Gamunex-C and atovaquone. The current guidelines and medical literature do not recommended treatment of low pneumococcal antibody titers with immunoglobulin replacement therapy without the demonstration of poor response to vaccination with pneumovax. Many patients have low pneumococcal antibody titers and mount a normal response with normalized titers once vaccination is received with pneumovax. In addition, the medical records do not document a history of recurrent sinopulmonary infections, which would need to be demonstrated to meet the criteria for specific antibody deficiency and an indication for treatment with Gamunex-C and atovaquone. For these reasons, the requested home infusions of Gamunex-C and atovaquone are not medically necessary for 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 board certified in internal medicine with subspecialty certification in allergy and  immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Magnetic Resonance Imaging (MRI) of the cervical spine and Magnetic Resonance Imaging (MRI) of the right wrist and elbow.American College of Radiology (ACR) Appropriateness Criteria for Chronic Cervical or Neck Pain indicate that magnetic resonance imaging (MRI) of the cervical spine is felt to be usually appropriate, and the addition of a radiculopathy is a further justifiable indication for cervical spine MRI. Often, it can be argued that in the clinical setting of an acute onset of pain or neurological signs it would be appropriate for a patient to first undergo a six week trial of conservative therapy such as physical therapy, strengthening exercises, and anti-inflammatory medications. The argument for delaying imaging studies for six weeks is more reasonable when a patient is only dealing with pain. In this case, however, the patient has developed objective, measurable neurological deficits (the ulnar neuropathy diagnosed by EMG) that reflect that the process is more chronic in nature. The patients development of muscle wasting is further supportive evidence that the process is chronic. Under these circumstances, the requested Magnetic Resonance Imaging (MRI) of the cervical spine is medically necessary to treat the patients medical condition.American College of Radiology (ACR) Appropriateness Criteria for Chronic Wrist Pain also reflect that MRI is usually appropriate for chronic wrist pain on the ulnar side. The ulnar nerve can become entrapped at several levels, the most common at the elbow and wrist. While conservative therapy is most commonly utilized, there are various surgeries designed to free the entrapment. As such, it is necessary to better direct the surgery with imaging modalities. Researchers have stated that in certain cases, a preoperative evaluation of the exact lesion localization would be a valuable benefit for the surgeon. Researchers noted that there are several studies arguing that T2-weighted MR neurography is a highly accurate tool to identify, localize, and quantify ulnar nerve damage in patients with ulnar nerve entrapment. In this case, considering the severity of the patients symptoms and the apparent chronicity (based on muscle wasting), the MRI of the right wrist and elbow are reasonable and will help to clarify therapeutic options including possible surgery. Accordingly, the requested Magnetic Resonance Imaging (MRI) of the right wrist and elbow 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xyosted 75 mg/0.2 mL. Findings:  The physician reviewer found that records provided for review support this patients diagnosis of hypogonadism. The patients laboratory evaluation shows normal testosterone levels while on therapy, normal prostate specific antigen (PSA) levels for prostate cancer screening, and normal complete blood count. Clinical documentation outlines the patients hypogonadal symptoms while off therapy and improvement while on therapy. The patient has experienced side effects with testosterone cypionate, and inadequate relief of symptoms with Clomid. The patient has requested continuation of testosterone replacement therapy with Xyosted, given his positive response to this therapy, instead of intramuscular testosterone cypionate. On review of the available documentation, Xyosted for this patient meets the American Urological Association (AUA) and Endocrine Society guidelines for the treatment of hypogonadism. For these reasons, the requested Xyosted 75 mg/0.2 mL is medically necessary for 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronic series injections of left knee. Findings:  The physician reviewer found that 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 benefit from prior viscosupplementation, lasting almost six months. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, hyaluronic series injections of left knee 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a motor scooter to perform one or more mobility-related activities of daily living (ADLs) or instrumental ADLs in or out of the home, including access to the community. Hagan and colleagues note that exercise therapy has beneficial clinical effects for most musculoskeletal conditions. In this case, the patient reported multiple health conditions, including pain, neuropathy, and arthritis, that may be helped through gradually increased levels of light physical activity and exercise, such as the use of a manual wheelchair. Given that the records reflect that the patient is able to ambulate with a walker and has the capacity to propel a manual wheelchair, the requested equipment is not medically indicated. Therefore, a motor scooter is not medically necessary for this patient to perform one or more mobility-related ADLs or instrumental ADLs in or out of the home, including access to the community.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the left breast. Contrast-enhanced breast MRI is a highly sensitive examination which has specific indications to help identify abnormalities that are occult on mammography and ultrasound. The indications for breast MRI include high-risk screening and when mammography or ultrasound findings are inconclusive. According to the American College of Radiology (ACR), MRI may be used for lesion characterization in the setting in which mammographic and sonographic findings are inconclusive and biopsy cannot be performed. This indication is applicable after additional diagnostic mammographic views and targeted ultrasound examinations have been performed. Contrast-enhanced breast MRI was indicated for this patient as it was unclear if the distortion was pathologic in etiology or secondary to prior biopsy. The MRI demonstrated no abnormal enhancement in the left breast and the provider concluded that the architectural distortion was post-surgical and benign. All told, the MRI of the left breast was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the MRI of the left breast 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 diagnostic radiology 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.