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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for dextroamphetamine (generic Adderall) 30 mg twice/day.Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurobehavioral condition that affects most patients throughout their lives and is associated with occupational and functional impairment, psychiatric comorbidity, and substance abuse. Treatment and diagnosis often starts in childhood and is treated by pediatricians, and then continues on to adulthood and is treated by primary care physicians at that time. Due to challenges in access, as well as a shortage in mental health professionals, many people seek treatment of their psychiatric disorders through their primary care physician. A patient may often choose to be treated by his or her primary care physician for several factors including reduced stigma and increased comfort. This practice is the most cost effective way to manage mild to moderate psychiatric disorders, including ADHD. For this reason, treatment of psychiatric disorders in a primary care setting, known as Integrated Behavioral Health, has been a growing trend in primary care settings. Psychiatric organizations have made statements that assert that primary care clinicians should develop competence in ADHD diagnosis and treatment for several of the above reasons. To expect that a patient receive a diagnosis of ADHD from a mental health professional is unrealistic and unreasonable as well as inconsistent with the current standard of care. In this case, the patient has a diagnosis of ADHD from two mental health providers in the past 10 years. She is currently diagnosed with ADHD by her primary care physician, who is an associate professor of medicine at a highly respected academic medical center. Records reflect that the patient has been stable on this medication for over 10 years, and discontinuation of the medication would pose a risk of decompensation. Under these circumstances, the requested dextroamphetamine (generic Adderall) 30 mg twice/day is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement and prospective authorization and coverage for hyperbaric oxygen therapy (HBOT) services. Based on available clinical documentation, some of the requested services for HBOT were likely to be more beneficial in managing the patients sudden sensorineural hearing loss than other available standard therapies. The U.S. Food and Drug Administration (FDA) has not approved HBOT for the treatment of sudden sensorineural hearing loss. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) lists salvage HBOT plus steroids as an option within one month of onset of symptoms, compared with a recommendation rating for steroids for salvage therapy two to six weeks after onset of symptoms. Although there is a lack of data demonstrating an accepted HBOT protocol with proven effectiveness, the Undersea and Hyperbaric Medical Society supports a 20-day treatment duration with HBOT in this clinical setting. Therefore, a portion of the HBOT services was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found that a portion of the HBOT services was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in otolaryngology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Neuroendocrine tumors are diverse group of neoplasms typically treated with radionuclide therapy. In the present case, the patient had a neuroendocrine tumor that grew to cause airway obstruction. She underwent treatment that included radiation and placement of a tracheostomy tube. Computed tomography (CT) imaging demonstrated a persistent paratracheal mass surrounding the tracheostomy. This precludes decannulation or use of a Passy Muir valve for speech. The patient has been undergoing rehabilitation services while at the SNF. Her function has fluctuated, but she has plateaued at a level where she requires assistance for activities of daily living, including lower body self-care, and contact guard assistance for basic mobility. The records do not support that the patient requires ongoing medical, nursing, or rehabilitative care at the inpatient SNF level of care. Therefore, the SNF services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 back surgery (including CPT codes 22558, 22585, 22612, 22614, 22842, 22845, 22853, 49010, 20936, 20931, and 76000). Wood and colleagues recommended that fusion should be considered for patients with low back pain and isthmic spondylolisthesis who have failed non-operative treatment. Researchers support surgery for spinal stenosis in patients who do not improve with conservative treatment. The authors noted that the inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. Studies concluded that the body of literature supports fusion surgery as a viable treatment option for reducing pain and improving function in patients with chronic lower back pain refractory to nonsurgical care in the setting of disc degeneration. This patient presents with progressively worsening back pain radiating to the right lower extremity with numbness, tingling and weakness. She has reported bowel and bladder changes. Overall, the patients signs and symptoms are consistent with neurogenic claudication. Clinical examination findings have documented a significant motor deficit consistent with imaging evidence of severe L4-5 central canal stenosis with crowding of the nerve roots and thecal sac, and severe facet arthrosis at L5-S1 with foraminal stenosis and moderate degenerative disc disease. There is radiographic evidence of spondylolisthesis at L4-5 measuring 3-5 mm and L5-S1 measuring 12-15 mm with documented spinal segmental instability on flexion and extension x-rays. The patient will likely require a wide decompression that would result in temporary intraoperative instability and necessitate fusion. Evidence of a long-term reasonable and comprehensive non-operative treatment protocol trial and failure was provided for review. Current evidence based medical literature supports surgical intervention for the treatment of this patients spinal stenosis, degenerative disc disease, and unstable spondylolisthesis. In the setting of L4-5 and L5-S1 spondylolisthesis with documented spinal segmental instability, the need for wide decompression would likely result in temporary intraoperative instability and necessitate fusion. Given these findings, the requested back surgery (including CPT codes 22558, 22585, 22612, 22614, 22842, 22845, 22853, 49010, 20936, 20931, and 76000) 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 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 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. Applying the ASAM guidelines, this patient meets the criteria for RTC services. The patient has post-acute withdrawal symptoms of anxiety, agitation, and tremors. The patients Clinical Opiate Withdrawal Scale (COWS) score was 10 and her pulse was elevated at 106. She has been treated with Zubsolv in addition to Sublocade. The patient has type I diabetes. She is on insulin but does not follow her recommended diet and her sugar levels range from 64-289. Her medical condition distracts from her recovery. The patient is noted to have comorbid PTSD and bipolar disorder. She demonstrated numerous symptoms of hypomania on admission and has longstanding difficulties with impulse control and distractibility due to mild cognitive impairment. She has history of non-adherence with psychiatric medications. The patient has exhibited difficulty with impulse control in the community despite being residing in a sober living facility. She relapsed while there due to feeling depressed and not having the skills to manage her emotions. She continues to require structured therapy and a 24-hour program milieu. The patient has experienced ongoing cravings to use heroin. She is being stabilized with daily Sublocade injection and Zubsolv. She has undergone repeated treatment episodes with little positive effect on her level of functioning. She has poor skills to cope with and interrupt her issues with addiction. The patient is currently homeless and her social environment consists of others who abuse drugs. 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 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right sacroiliac (SI) joint fusion surgery (CPT 27280). The International Society for Advancement of Spine Surgery (ISASS) support SI joint fusion surgery for well-selected patients who have failed conservative treatment. Documentation should support the presence of significant SI joint pain confirmed by at least three positive SI joint provocative tests, confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block, and failure to respond to at least six months of non-surgical treatment. Moreover, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability should be ruled-out. Evidence based medical literature supports the use of open SI joint fusion as safe and effective for patients with SI dysfunction refractory to non-operative management. This patient presents with a history of constant moderate to severe right SI joint pain with functional limitations in activities of daily living. Clinical examination findings have documented right SI joint pain and five positive SI joint provocative tests. There is radiographic evidence of minimal degenerative changes. She has failed to improve with long-term conservative treatment including physical therapy, chiropractic care, medications, and lumbar support. She underwent a diagnostic SI joint injection with 90% reduction in pain, and a previous SI joint injection with benefit. In this case, there is evidence of SI joint pain that has failed to respond to long-term comprehensive conservative treatment. The patient has positive signs and clinical examination findings demonstrating that the SI joint is the source of her pain. Moreover, these findings were confirmed with a diagnostic SI joint injection. All told, the requested right SI joint fusion surgery (CPT 27280) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested right SI joint fusion surgery (CPT 27280) 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with encephalopathy, hemiplegia and hemiparesis following cerebrovascular infarction, and dysphagia. The patient was admitted to a skilled nursing facility. The patient received physical therapy, occupational therapy, and speech therapy. The patient was noted to be status post eight cerebrovascular accidents and percutaneous endoscopic gastrostomy (PEG) tube placement for dysphasia. The patient utilized safe swallowing strategies with 80% plus accuracy with moderate to maximal cues. In cognitive communication therapy and instruction, the patient recalled four out of four steps. The patient completed swallow rehabilitation exercises with 100% accuracy with moderate to maximal cues. The physical therapist noted that the patient was able to safely complete transfers requiring contact guard assist/stand by assistance (CGA/SBA). The patient required a front-wheeled walker (FWW) and CGA for safe ambulation. The patient has requested reimbursement and prospective authorization and coverage for (SNF) services. 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 skilled nursing facility (SNF) services were and/or are medically necessary for the treatment of the patients medical condition. In this case, the documentation does not indicate that the patient has a tracheostomy tube, complex wound care or other SNF level skilled nursing need. The patient has been able to tolerate oral intake. His PEG tube does not require a SNF admission. This patients current functional level does not require ongoing SNF level skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment only in a SNF. He does not require these skilled nursing or skilled therapy services (or a combination of these services) daily. The medical evidence does not support the services at issue in this case. Therefore, skilled nursing facility (SNF) services were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
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 residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying LOCUS guidelines, this patient meets the criteria for RTC level of care services. The patient has demonstrated some risk of self-harm (score 2) given her reports of passive suicidal ideation. The patient has also been hydroloading. The patient has shown severe functional impairment (score 4) as she has not been attending to ADLs. The patient has significant comorbidity (score 2) with tachycardia as well as orthostatic hypotension as a result of her food restriction. The patients recovery environment is moderately stressful (score 3). The records document that the patient lives with her mother, who also has psychiatric issues. The patients recovery environment is supportive (score 2) as she lives with her mother. The patient has demonstrated moderate response to treatment (score 3) due to her eating disorder that started in her teenage years. The patient has been constructive in treatment (score 2) as the provider noted that the patient has been adherent with treatment although she struggles with her eating plan. This gives the patient a composite score of 18, which is consistent with high intensity community based services. However, the patients score of 4 for functional status supports medically monitored residence based services, such as RTC level of care. RTC for eating disorders is an intensive group-based and individual intervention, with 24-hour monitoring and 12 or more active hours of treatment daily. This intermediate level of care can treat many of the acute aspects of eating disorders. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with hepatitis B. The provider noted that the patients hepatitis B was undetectable while being treated with Viread. She had been treated with Viread since 2017, and she has had a successful pregnancy while taking Viread. The provider noted that the patients hepatitis B was well-controlled on Viread. The patient was noted to be planning a pregnancy. The patient has requested authorization and coverage for the brand name medication Viread. The Health Plan has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether the brand name medication Viread is medically necessary for the treatment of the patients medical condition. Authors reported, Tenofovir and entecavir are preferred because of their potency and minimal risk of resistance, decompensation, and serious side effects. The authors also noted that tenofovir disoproxil fumarate (TDF) is classified as pregnancy category B. Researchers reported, In a cohort of hepatitis B e antigen (HBeAg) positive mothers with an hepatitis B virus (HBV) DNA level of more than 200,000 IU per milliliter during the third trimester, the rate of mother-to-child transmission was lower among those who received TDF therapy than among those who received usual care without antiviral therapy. Studies reported, We conclude that TDF treatment initiated at 24 weeks of gestation in high-viremia, HBsAg/HBeAg-positive mothers efficiently prevents mother-to-child HBV transmission without adverse events in mothers and infants. In this case, the patient has been treated with Viread since 2017 and had a successful prior pregnancy. The medical evidence supports the requested medication in this clinical setting. Therefore, brand name medication Viread is 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 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.