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

The patient has requested authorization and coverage for oxycodone. The Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain state that 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. In addition, the CDC guidelines noted that providers should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible. Moreover, the CDC states that reasons for discontinuing opioid therapy includefailure to comply with the treatment agreement. In this case, the patient is taking high dose opioid therapy along with concurrent benzodiazepines to manage her coexisting chronic pain and PTSD. The medical records do not document that the patients chronic opioid therapy has led to significant functional improvements. Moreover, the patient has returned drug screens inconsistent with her prescribed medications. All told, the requested oxycodone is not medically necessary for treatment of this 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Viibryd 80 mg. In the medical literature, there is a lack of randomized controlled trials demonstrating that Viibryd 80 mg per day is more effective than placebo or Viibryd 40 mg for the treatment of major depressive disorder. According to the U.S. Food and Drug Administration (FDA), Viibryd can be taken at 80 mg per day if the patient is receiving concomitant CYP3A4 inducers for more than 14 days. The records provided for review do not demonstrate that the patient will be taking a CYP3A4 inducer with Viibryd 80 mg. The provider noted that the patient is an ultra-rapid metabolizer based on history of failed trials of previous medications. However, pharmacogenetic testing, or blood levels of Viibryd at lower doses that demonstrate that the patient may be a rapid metabolizer, have not been reported to confirm the patients rapid metabolizer status. Based on the available documentation and medical research, the maximum effective dose of Viibryd is 40 mg per day. For these reasons, the requested Viibryd 80 mg is not medically necessary for treatment of this 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 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 reimbursement for air ambulance services that were provided. The Centers for Medicare and Medicaid Services (CMS) state that air ambulance services (rotary or fixed wing) are generally reserved for use in emergent situations in which there is a need for immediate and rapid transportation to a health care facility where specialized services can be provided for a patients condition. In general, ambulance services are covered for inter-facility transportation to the closest facility available to address a patients clinical needs. The fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patient does not warrant a finding that a closer institution does not have appropriate facilities. In this case, the patients transport was non-emergent in nature. It was not to facilitate an urgent or emergent clinical need. In addition, the documentation did not demonstrate that the transport was provided to the closest facility prepared to address the patients rehabilitation needs. At the time of transport, the patients GCS score was 15 and he was noted to be hemodynamically stable.Final Result: The reviewer determined that the patient did not receive emergency medical service on the date of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is requesting approval of brand-name Vivelle-Dot Patch to control her symptoms. The Health Plan has denied the requested brand name formulary exception.Hormone replacement therapy is an effective treatment for menopausal symptoms such as vasomotor symptoms. According to multiple professional groups, including the Endocrine Society and American College of Obstetricians and Gynecologists (ACOG), all forms of systemic estrogen replacement therapy have been found to be equally effective for the treatment of menopausal symptoms. The patients formulary contains multiple systemic estrogens. The patient's specific indication for this treatment is not clear in the clinical documentation. The patient states in a letter that she has used generic versions in the past, but there is no supporting clinical documentation by her provider. There is no clinical documentation to support that she has tried and failed any alternative hormone replacement medications, or that that they cause adverse effects. There is also a lack of evidence in the peer-reviewed medical literature that Vivelle-Dot Patch would be more effective than the available formulary medications. Therefore, the requested brand name formulary exception for Vivelle-Dot Patch is not medically necessary for treatment of this 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient requested residential treatment program services that were provided were medically necessary for the treatment of the patients medical condition. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. During treatment, the patient was noted to be cooperative and showed insight into her need for continued treatment. The patients composite CALOCUS score is 15, which indicates an outpatient services level of care. Given these findings, the patient did not require the intensity, supervision and medical management provided at the residential treatment center level of care. Therefore, residential treatment program services that were provided were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar spine magnetic resonance imaging (MRI) without contrast. The records provided for review document a normal neurological examination including strength and reflexes. The provider recommended a MRI of the lumbar spine to begin the patients work-up. However, the provider also recommended evaluation with an electromyography (EMG), which is not documented in the records provided for review. Further, the patients records report normal neurological examinations. If EMG and serological tests are normal, and the patient still complains of bilateral buttock and right foot paresthesias, the next course of treatment would include a six-week trial of conservative management prior to MRI of the lumbar spine. As noted in the medical literature, MRI of the spine may be indicated to exclude disease entities such as demyelinating disorders, unusual disc disease, or congenital malformations. As noted in the medical literature, MRI of the spine may be indicated to exclude disease entities such as demyelinating disorders, unusual disc disease, or congenital malformations. Based on the available documentation, the patient does not meet the criteria for MRI for the lumbar spine. Therefore, the requested lumbar spine MRI without contrast is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiology 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 total right knee replacement. Based on the recent medical literature with regard to total knee replacement in the presence of obesity, the prevalence of obesity and the utilization rate of total knee arthroplasty are increasing. The data suggests that the rate, as well as proportion, of total knee arthroplasties performed in the presence of obesity and morbid obesity has become more prevalent. Although the presence of obesity increases the risk of cardiovascular complications, with proper precautions, satisfactory in-hospital outcomes are observed after primary total knee arthroplasty. Researchers reported findings of increased mid- to long-term revision rates following primary total knee arthroplasty in the presence of obesity. However, the authors also noted that obese patients experienced functional recovery comparable to non-obese patients. Thus, obesity is not an absolute contraindication to total knee arthroplasty. With regard to the patients age, a total right knee replacement will likely help preserve her quality of life and functional status. The records document the patients right knee pain has failed to improve despite treatment with arthroscopy, partial medial meniscectomy, abrasion chondroplasty, and microfracture, as well as NSAIDs, physical therapy, and corticosteroid injections. Given these findings, the request for a total right knee replacement is medically necessary for treatment of this patients knee pain.Final Result: The reviewer determined that the requested surgery 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 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 HP Acthar Gel 80 Units injected twice a week. The American College of Rheumatology (ACR) guideline recommends methotrexate (MTX) with or without a tumor necrosis factor inhibitor (TNFi) as the next treatment in those who have failed MTX alone. There are also multiple studies demonstrating the efficacy and safety with TNFi in treating moderate to severe rheumatoid arthritis (RA). Further, there is evidence that a second TNFi may be effective in patients who have tried and failed a previous TNFi or have had adverse reactions to other TNFi. Given safety data and efficacy rates, a second TNFi with or without MTX is recommended over tofacitinib. At this time, the guidelines recommend a trial of two different TNFi prior to trying another agent. Moreover, the guidelines do not recommend Acthar Gel for the treatment of RA. There are a few small studies demonstrate efficacy of Acthar Gel, but further studies are necessary prior to its routine use. In this case, the records fail to demonstrate that the patient is refractory to all standard RA treatments. As such, the request for Acthar Gel 80 Units injected twice a week is not medically necessary for treatment of this patients RA.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 certifications in allergy and immunology and 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: The patient has requested authorization and coverage brand name medications Norco 10/325 mg tablets or brand name Vicodin tablets (Vicodin-HP and Vicodin ES formulations). According to the U.S. Food and Drug Administration (FDA), generic drugs are created to be the same as an already marketed brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use. These similarities help to demonstrate bioequivalence, which means that a generic medicine works in the same way and provides the same clinical benefit as its brand-name version. The FDA statement on generic drugs states that there is no difference in strength, quality or performance between generic and brand name medications. Further, generic medications have the same risks and benefits as brand name medications, and this would include any adverse drug reactions, such as hives. In this case, the patient reports that the generic formulations of Norco and Vicodin cause hives and are ineffective, whereas prior treatment with the brand name formulations of these medications was successful. However, the documentation does not demonstrate that the patient is intolerant to the generic formulations of the requested medications. The providers notes state the patient has been taking brand name Norco at the dose of 5/325 mg, which was noted to be ineffective, but without any side effects. The provider also noted that the patients only known drug allergies are from Sulfa and Penicillin exposure. The patient was planned to discontinue Norco and switch to Vicodin 10/325 mg. The notes report the patient developed hives and found Norco ineffective. In addition, the notes from the previous clinic visits do not document that the provider attempted to increase the dose of generic hydrocodone to 10/325 mg to assess for an improvement in efficacy. Overall, the records fail to demonstrate that the requested brand name medications Norco 10/325 mg tablets or brand name Vicodin tablets (Vicodin-HP and Vicodin ES formulations) are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested brand name medications 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stage I level anterior lumbar interbody fusion at L5-S1 with structural allograft and anterior fixation and demineralized bone allograft, followed same day by stage II posterior revision laminectomy at L4-L5 with laminectomy extending into the L3-4 segment and laminectomy of L5-Sl with posterior spinal fusion from L5-Sl with instrumentation at L5-S1. The submitted documentation supports the medical necessity of the requested services. This patient has a history of spinal stenosis with adjacent segment disease following a laminectomy and subsequent single level fusion at L4-5. The literature indicates moderate evidence of good outcomes from standalone lumbar fusions for chronic pain with or without instability.  In this case, there is evidence of adjacent segment disease with spinal stenosis and neurogenic claudication. As such, wide decompression will be necessary. Additionally, this will necessitate a fusion at L5-S1. Therefore, the requested anterior lumbar interbody fusion at L5-S1 with structural allograft and anterior fixation and demineralized bone allograft, followed the same day by posterior revision laminectomy at L4-5 with laminectomy extending into the L3-4 segment, and laminectomy of L5-S1 with posterior spinal fusion from L5-S1 with instrumentation at L5-S1 is medically indicated. Thus, the requested stage I level anterior lumbar interbody fusion at L5-S1 with structural allograft and anterior fixation and demineralized bone allograft, followed same day by stage II posterior revision laminectomy at L4-L5 with laminectomy extending into the L3-4 segment and laminectomy of L5-Sl with posterior spinal fusion from L5-Sl with instrumentation at L5-S1 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 is a 48-year-old female diagnosed with primary osteoarthritis (OA) of both knees. She reported chronic pain in both knees that was not controlled with corticosteroid injections. Prior treatment with viscosupplementation was reported to be effective. Physical examination findings included bilateral knee joint line tenderness, no effusion, full quadriceps and hamstring strength, and the absence of instability in both knees. The patient has requested coverage for Euflexxa injections. The Health Plan denied the request and reported that the requested treatment is not medically necessary for the treatment of this patient. At issue in this case is whether Euflexxa injections are medically necessary for the treatment of this patients medical condition. Intra-articular hyaluronic acid (IAHA) injections provide a symptomatic benefit for patients with knee OA without major safety concerns. IAHA offers one of the best benefit-to-risk ratios among pharmacologic options, as measured by improvements in knee OA health outcomes, gain in quality-adjusted life years and substantial delays in time to total knee replacement. Viscosupplementation increases functional scores in patients with osteoarthritis of the knee, especially within three months of injection. Viscosupplementation is recommended for patients with a history of lasting benefit from prior injections. The patient has reported benefit with previous viscosupplementation injections to the knees with reduced use of over-the-counter medications and improved pain and activity level. In this case, medical evidence supports the requested treatment in this clinical setting. Therefore, Euflexxa injections are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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.