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

An enrollee has requested authorization and coverage for H.P. Acthar Gel.The medical literature does not support that the requested medication is medically necessary. At this time, there are no good, randomized, double blinded, placebo-controlled studies in support of H.P. Acthar for rheumatoid arthritis, but rather small reports. H.P. Acthar is still being studied in clinical investigations as well as for other indications such as rheumatoid arthritis and sarcoidosis. Acthar is not proven to be superior to oral steroids or immunosuppressive medications such as Imuran and may actually result in increased ocular issues with progressive cataracts and glaucoma. Acthar Gel is also not superior to combination therapy for rheumatoid or other anti-tnf agents or biological medications. Acthar Gel remains the subject of many clinical trials at this time. In this case, H.P. Acthar Gel is not intended to be a form of chronic therapy for this patient, who has a history of non-response to various oral steroids as well as DMARDS and Humira. H.P. Acthar has a corticotropin effect and with that, the same potential side effect profile as steroids with respect to osteoporosis, glaucoma, cataracts, weight gain, increased blood pressure and glucose intolerance. Under these circumstances, H.P. Acthar Gel is not medically necessary for treatment of the patients medical condition.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 certification in rheumatology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for custom orthotic shoe inserts. The records provided for review do not support the medical necessity of a replacement pair of custom orthotic shoe inserts for this patient. The patient states that she needs a new pair of custom orthotics. However, the provider does not report whether the patient is currently wearing her worn out orthotics, or whether the orthotics need to be replaced. In addition, there is no physical examination of the patients foot structure to support an indication for orthotics. There is no evidence of palpable pain and or edema to either foot. The patient states that she requires orthotics because she underwent surgical correction of hammertoes and bunions in the past. Surgical correction should have corrected her hammertoes and bunions. The two most recent progress notes advise that the does not have foot pain, only right hallux toenail pain. All told, the requested custom orthotic shoe inserts are not medically necessary for treatment of this patient.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 podiatry 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 residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met 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. For dimension 1, the provider noted that the patient had a CIWA score of 13, and he was treated for alcohol withdrawal with lorazepam. The patients COWS score was 11, which was managed with suboxone. This supports that the patients conditions were moderately severe. For dimension 2, the patient has a history of chronic low back pain, which contributed to his use of oxycodone for pain relief. The patient is also noted to have OSA treated with CPAP. These problems were stable during RTC admission, but pain interfered with his recovery. The patients OSA is concerning given his ongoing usage of alcohol and opioids. Dimension 3 is satisfied as the patient has diagnoses of PTSD, depression, and GAD. The patient complained of severe anxiety, psychomotor agitation, restlessness, and poor sleep. He indicated that he used substances to manage his psychiatric symptoms. The patient demonstrated difficulty controlling his use and poor impulse control. He had significant functional deficits. For dimension 4, the patient minimized his substance use. He attributed his substance use to external factors such as trauma, marital stress, and family dynamics. Dimension 5 was met, as the patient continued to use opiates and other substances despite assisted outpatient treatment with suboxone. He reported distressing psychiatric symptoms that resulted in overwhelming urges to use oxycodone. The patient would have continued to abuse substances without 24-hour monitoring and structure. For dimension 6, the patient had a high level of tension in his home due to his addictions. The patients social network was comprised of others who used alcohol and other substances. Given these findings, the RTC services were 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 expertise 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 enrollee is requesting authorization and coverage for Stelara, 90 mg every four (4) weeks. This enrollee has psoriatic arthritis and Crohns disease. She began treatment with Stelara, 90 milligram injections every eight weeks. The enrollees rheumatologist reports that, due to rapid metabolism of the drug, dose escalation for biologics is commonly required for medically unresponsive, severe Crohns disease. There is a body of literature addressing an administration frequency of every four weeks. Studies report the benefit of this dosing schedule; without increased toxicity. It is a matter of clinician judgment as to whether it is riskier to utilize an every-four-week regimen of a medication the enrollee has used and tolerated, or to change to another type of treatment. Her options are limited. Any change to her medication introduces the risk of either inferior results or toxicity.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting reimbursement for monitored anesthesia care. The enrollee underwent a screening colonoscopy. She has had prior surgeries and has not experienced issues with anesthesia. She is an American Society of Anesthesiologists class II risk and Mallampati class II. She was given intravenous propofol for monitored anesthesia care. A professional societys clinical practice guidelines indicate anesthesia provideradministered sedation comprises a sizeable proportion of procedural sedation for outpatient endoscopic procedures in the United States. Estimates are that over half of the colonoscopies are currently performed with monitored anesthesia care. The potential advantages to anesthesia provideradministered sedation for routine colonoscopy and upper endoscopy may include improved individual satisfaction, decreased distractions for the endoscopist, and shorter sedation and recovery times.Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for a customized oral device/appliance. The submitted documentation does not support that the requested device is medically necessary. An oral appliance is used in patients with significant obstructive sleep apnea who are unable to tolerate positive airway pressure therapy. In this case, the patient had a home sleep study. Home sleep studies are generally not very accurate. With no significant daytime sleepiness and a very mild sleep apnea, oral appliance therapy is not indicated. Accordingly, a customized oral device/appliance is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested device 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 otolaryngology 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 enrollee is requesting authorization and coverage for the drug, mupirocin powder 100%. The enrollee has a history of asthma, chronic sinusitis, allergic rhinitis, and atypical aspirin-exacerbated respiratory disease. She has been treated with medications and endoscopic sinus surgeries. The enrollees otolaryngologist prescribed mupirocin powder, 100%, and reports this is the only medication suited to treat her symptoms. A randomized, controlled study of the use of nasal lavage, with and without mupirocin, in 20 subjects showed the subjects in the mupirocin nasal lavage group demonstrated lower nasal endoscopy scores post-operatively, and a statistically significant, larger difference in nasal endoscopy scores at one month, compared to one week. The mupirocin group also showed better Sino-Nasal Outcome Test scores at one month, compared to the group without mupirocin. The use of mupirocin powder rinse is reasonable approach for this enrollee with a very complicated sinus disease.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in otolaryngology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for OnabotulinumtoxinA (Botox) injections. The enrollee has daily headaches, secondary to migraine headache without aura, and right occipital neuralgia. Previous medication trials have not been effective. The provider reports the enrollees headache frequency was previously 15-17 days per month. While being treated with onabotulinumtoxinA (Botox) and Aimovig, the enrollee is having seven headache days per month and an improved quality of life. Because Aimovig is relatively new, there does not appear to be any peer-reviewed literature specifically addressing the combination of onabotulinumtoxinA (Botox) and Aimovig.  However, current clinical practice is to add a drug such as Aimovig to a migraine enrollees current anti-migraine regimen. This enrollees neurologist reports the enrollee has failed many other anti-headache agents and requires both Botox and Aimovig for headache control. Additionally, the Headache Society reports that certain properties of the Aimovig drug class enables individuals to avoid interactions with other drugs, and this drug class may be added to, or used in conjunction with, other oral or injectable preventive treatments for migraine.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollees parent is requesting authorization and coverage for early childhood partial hospitalization program services. The enrollee was diagnosed with autism. The enrollee demonstrates behavioral issues and a movement disorder. She was admitted to a partial hospitalization program. The enrollees mother reports the applied behavioral analysis therapy was not addressing her daughters skill needs at the level of care required for progress. She asserts that, after her daughters treatment in the partial hospitalization program, her daughters level of functioning dramatically increased. Literature shows early intensive behavioral intervention, a treatment based on the principles of applied behavior analysis, delivered for multiple years at an intensity of 20 to 40 hours per week, is one of the better-established treatments for autism spectrum disorder. Research shows treatment intensity and duration were both significant predictors of mastered learning objectives across treatment domains.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage, and reimbursement, for residential treatment center (RTC) services. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. This enrollee was no longer suicidal, but struggled with cravings. She had developed a supportive environment and was responding well to treatment. The enrollees composite LOCUS score placed her at a high intensity community-based services.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for gene analysis. Testing for all five inherited thrombophilias is recommended in patients with deep vein thrombosis (DVT) under the age of 45. The prothrombin G20210A mutation is the second most common inherited thrombophilia after the factor V Leiden mutation. Testing for inherited hypercoagulability is recommended in patients with thrombosis at a young age, such as this patient, despite the provoked nature of her condition. Knowing whether this patient carries a mutation may not dictate duration of anticoagulation but will help determine her risk in situations that my increase her risk of a blood clot, such as pregnancy. Accordingly, the requested gene analysis 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 reviewer 1 is board certified in oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 2 is board certified in oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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

The patient has requested reimbursement and prospective authorization and coverage for a hospital-grade breast pump. The records provided for review support a diagnosis of granulomatous mastitis. The peer-reviewed medical literature discusses the lack of a consensus regarding optimal treatment for this condition. In order to reduce the patients risk of lactation mastitis, it is beneficial for the patient to use the highest quality breast pump available during lactation. Providing a hospital-grade breast pump to lower the patients risk for worsening of her condition is appropriate and supported by the current medical literature. All told, the hospital-grade breast pump was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the equipment at issue was and 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 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

The patient has requested reimbursement for residential treatment center (RTC) services.  The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, 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) developmental, medical, substance use 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. This gives the patient a composite score which is consistent with medically monitored community based services. Due to their functional status score the recommended level of care is: medically monitored residence based services. Furthermore, the patient is scored at intermediate stay medically monitored residential programs. Per CALOCUS, these programs are sometimes referred to as short-term residential rehabilitation facilities and length of stay usually does not exceed 60 days. Thus, the first 60 days of treatment at the RTC were medically necessary for treatment of the patients condition. It was prudent to continue this level of care after the wilderness program, given patients recent gains and continued struggles, as well as family conflict. All told, a portion of the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue were 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement for substance abuse subacute detoxification residential treatment center (RTC) services.  Per the American Society of Addiction Medicine (ASAM) criteria, this patient met the 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. The records document that the patient was at high risk of continued substance use, which placed her at serious risk for potential withdrawals and seizures. Given these findings, the substance abuse subacute detoxification RTC services were 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 expertise 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.