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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Cimzia for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication. The American College of Rheumatology guidelines for the treatment of rheumatoid arthritis suggest that the first-line therapy for this condition includes biological disease-modifying antirheumatic drugs such as Plaquenil or sulfasalazine alone or in combination with steroids. These therapies are recommended prior to anti-tumor necrosis factor therapy, such as Cimzia. Prednisone and Plaquenil have been considered safe for nursing patients with rheumatoid arthritis. The medical evidence does not support the requested medication in this clinical setting. Therefore, Cimzia 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 sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for speech therapy. The requested speech is medically necessary for treatment of this patients medical condition. The patient has severe receptive and expressive language impairment due to Down syndrome, with co-existent autism spectrum disorder. Speech and language impairment are typically found in patients with Down syndrome, and that impairment of expressive language is significantly worse than receptive language. Ongoing speech therapy in adolescents and young adults with Down syndrome enable their integration into the work force and community. Although he is still below the first percentile for both receptive and expressive language, his functional language has significantly improved in excess of normal expected maturation. The patient is committed to continuing speech therapy, and follows recommendations given by the provider. Given these findings, the requested speech therapy is medically necessary for treatment of the patients severe receptive and expressive language impairment. 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 pediatrics and neurology with special qualification in child 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for weekly outpatient psychotherapy services.  The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health condition.Findings:  There is support in the medical literature for the requested services in this clinical setting. There is no defined frequency or duration for the amount of psychotherapy required for each patient; however, it is generally accepted that patients in crisis require more frequent sessions than patients who are stable. The medical literature also supports that in unrestricted therapies, each additional psychotherapy session has a diminished effect. An article by colleagues reports: our findings suggest that, at least in unrestricted therapies, the average rate of change during psychotherapy can be expected to diminish with each additional session irrespective of the length of treatment. These results are consistent with previous studies. Given this information, the patients symptoms impair the patients functionality. According to the medical literature and standard practice, this patient requires a period of intense, frequent psychotherapy sessions to help improve her symptoms. Intense treatment psychotherapy protocol is usually 12 to 14 sessions. The patient could then reduce the frequency of her psychotherapy sessions to bimonthly and then to monthly depending on the patients progress. Accordingly, a portion of the requested outpatient psychotherapy services has been demonstrated as medically necessary for treatment of this patients medical condition. Specifically, this patient would benefit from weekly psychotherapy sessions for up to sessions. The patient should then be re-evaluated to determine the frequency of psychotherapy sessions going forward.Final Result: The reviewer has determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications:  The reviewer is board certified in 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: A female enrollee has requested authorization and coverage for bilateral total hip arthroplasty. Total hip arthroplasty is the final and definitive treatment for patients with severe hip arthrosis which remains painful and limiting despite conservative treatment. In this case, there is limited documentation of prior conservative treatments that have been exhausted. In addition, the imaging studies forwarded for review do not support a diagnosis of severe bilateral hip arthrosis. Specifically, the radiology report notes that the patients hip joint cartilage spaces are preserved. Further, the patient is young and would be at statistically increased risk of eventual failure of the artificial joints and need for further surgery. Overall, the medical records provided for review do not support the need for this request for bilateral total hip arthroplasty in this patient. Therefore, the requested bilateral total hip arthroplasty is not medically necessary for treatment of this patients hip pain. 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 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: An enrollee has requested authorization and coverage for buprenorphine (Subutex) 8 mg for the duration of 30 days for treatment of this patients chronic pain. Findings:  The physician reviewer found that studies state that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. However, in the documentation available for review, not all non-opioid medications classes have been optimized or tried either before surgery or are in the plan to be used after surgery. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. Moreover, there is no mention that behavior therapy has been completed despite much research to support its use. All told, the requested buprenorphine (Subutex) 8 mg for the duration of 30 days is not supported as medically necessary for treatment of this patients chronic pain. 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 anesthesiology with sub-specialty 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: An enrollee has requested authorization and coverage for cardiac rehabilitation therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees coronary heart disease.Findings:  Based on the records provided the patient has several ongoing coronary risk factors as well as recent coronary artery bypass surgery.  In this circumstance of recent coronary artery bypass, a formal cardiac rehabilitation program is reasonable, appropriate and considered standard accepted practice in the medical community.  Usual indications for cardiac rehabilitation therapy include acute myocardial infarction within the preceding 12 months, coronary bypass within the preceding 12 months, stable angina, heart valve replacement/repair, coronary intervention with or without stenting, or heart/heart-lung transplantation.  Evidence of benefit with cardiac rehabilitation therapy in these settings has been well demonstrated in scientific literature as summarized in a recent review.  Accordingly, the requested cardiac rehabilitation therapy is demonstrated as medically necessary for treatment of this patients medical condition.Final Result: The reviewer has determined 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 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

Nature of Statutory Criteria/Case Summary: A 47-year-old male enrollee has requested authorization and coverage for Synvisc One injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. This patient has previously benefitted from Synvisc One injections, with symptomatic improvement for over one year. Given this support, the requested Synvisc One injections are medically necessary for treatment of this patients knee osteoarthritis. 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for services received on multiple dates on the basis that the services were emergent in nature. Findings:  The physician reviewer found that the services at issue were not necessary for treatment of an emergency medical condition. The medical records indicate that the patient had stable orthopedic injuries at the wrist and shoulder. The surgery and associated services could have waited until the patient travelled to an in-plan facility. A sling could have been safely prescribed to manage the injury while the patient was in transit to an in-plan facility. Emergent surgery was not needed. The patient was stable for travel back to California for treatment. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined the patient did not receive emergency medical services on the multiple dates of service presented. Therefore, the Health Plans denial should be upheld.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: An enrollee has requested authorization and coverage for lumbar spinal fusion surgery. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient presents now eight years status post L5-S1 decompression and instrumented fusion. The enrollee reportedly did well following surgery, until approximately one year ago, with gradual development of low back pain exacerbated with motion. The enrollee has persistent severe pain and difficulty in activities of daily living. Her pain is relieved in the supine position and worsened with sitting or standing for prolonged periods. Conservative treatment has included activity modification, physical therapy and injection therapies, without sustained improvement. However, there is no imaging evidence (x-ray, MRI or CT) of pseudoarthrosis, hardware failure, or segmental instability to support the medical necessity of surgical intervention at the L5-S1 level. There is no documentation of a positive diagnostic hardware block to support hardware as the pain generator. There is no compelling rationale presented to support the medical necessity of the requested revision lumbar fusion request in the absence of documented hardware failure, pseudoarthrosis, or segmental instability. Therefore, the requested lumbar spinal fusion surgery is not medically necessary for the 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 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: An enrollee has requested authorization and coverage for two uninterrupted cycles of residential treatment center services (one cycle is 28 days). The documentation does not support the medical necessity of residential placement at this time. Modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. In this case, the patient has a history of emotional dysregulation during level of care transitions. Per the records, the patient expressed suicidal ideation in the absence of an acute psychiatric syndrome only after being notified that the request for ongoing residential treatment was denied. Aside from a letter and self-report rating scale, the case file did not include records from the residential program including documents critical to the determination process, such as a psychiatric evaluation, psychosocial assessment, interpretative summary, physician narrative, multidisciplinary treatment plan or progress notes.  There was no evidence to suggest that comprehensive, evidence-based services provided in a less restrictive treatment setting would be unsafe, insufficient or inadequate. Thus, the requested two uninterrupted cycles of residential treatment center services (one cycle is 28 days) are not medically necessary for the 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an increase of Korlym 300 mg to a quantity of 150 for the duration of 30 days for treatment of the enrollees Cushings syndrome. Findings:  The physician reviewer found that Cushings syndrome, a collection of signs and symptoms due to prolonged exposure to cortisol, is associated with poor quality of life and morbidity.  While optimum treatment typically consists of selective and complete resection of the causative tumor, the development of new drugs offers clinicians several choices to treat patients with residual cortisol excess following the surgery. The U.S. Food and Drug Administration (FDA) has recently approved the antiprogestin Korlym (mifepristone) for control of hyperglycemia secondary to hypercortisolism in adults with endogenous Cushings syndrome who have type 2 diabetes/glucose intolerance and have not responded to, or are not candidates for, surgery. Multiple case reports and small series have suggested that mifepristone administration leads to clinical improvement in the majority of Cushings syndrome patients and does not pose the risk of hepatotoxicity, a rare but potentially serious side effect of ketoconazole.  This patient has responded well to Korlym. The medical evidence supports the requested medication quantity in this clinical setting. Therefore, an increase of Korlym 300 mg to a quantity of 150 for the duration of 30 days is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 endocrinology, diabetes and metabolism 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 selective internal radiation therapy (SIRT) using Yttrium-90 microspheres. The Health Plan has denied this request indicating that the requested services are considered investigational for the evaluation of the enrollee who has a history of pancreatic cancer.Findings: The use of Yttrium-90 liver directed SIRT in this clinical setting is supported in the medical literature. The patient has abdominal pain due to the liver metastases and she has exhausted many of the standard options available for treatment. Therefore, she fulfills the criteria for selective internal radiation therapy (SIRT) using Yttrium-90 microspheres. The Health Plan maintains that the patient does not meet criteria for SIRT because it is indicated for neuroendocrine tumors, symptoms from non-carcinoid neuroendocrine tumors with hepatic metastases (e.g., diabetes), or for specific liver-related symptoms due to tumor bulk. However, SIRT is not a targeted therapy used only for certain tumors. SIRT is commonly used for metastatic liver tumors which are not responsive to systemic chemotherapy in patients with ocular melanomas, gastric cancers, carcinoid tumors, and as well as other cancers. . As such, there is adequate support for the use of SIRT in this patients case. For these reasons noted, SIRT using Yttrium-90 microspheres is likely to be more effective than the available standard methods of treating this patients medication.Final Result: Two of the three reviewers have 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:  All three reviewers are board certified diagnostic radiology and are actively practicing. All three 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.