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

The patient has requested authorization and coverage for physical therapy and occupational therapy, five times a week. The records provided for review document that this patient does not require the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment five days per week. The documentation does not reveal that the patient can tolerate five days per week therapy, given his inguinal pain, which is causing mobility limitations. The patient remains non-ambulatory and his progress in physical and occupational therapy has been slow due to right groin hernia. All told, the requested physical therapy and occupational therapy five times per week is not medically necessary for 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 physical medicine and rehabilitation with subspecialty 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

An enrollee has requested authorization and coverage for Rituxan 10 mg injections. The submitted documentation supports that the requested medication is medically necessary. Multifocal motor neuropathy is a treatable immune disorder of the peripheral nerves that is characterized clinically by slowly progressive or stepwise asymmetric, distal more than proximal, upper more than lower limb, weakness in multiple motor nerve distributions. The patient has been diagnosed with multifocal motor neuropathy. The patients EMG studies demonstrate multifocal motor demyelination, specifically partial motor conduction block, and her laboratory results show evidence of high serum anti-GM1 IgM antibodies. The patients Neurologist has noted that the patient has received IVIG treatment but has had an inadequate response and has continued to decline. Under these circumstances, Rituxan 10 mg injections are medically necessary to treat the patients medical condition.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 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 the medication Dupixent. Dupixent (dupilumab) is a fully human Ig4 monoclonal antibody directed against the interleukin-4 receptor subunit a (IL-4Ra) of IL-4 and IL-13 receptors. In clinical studies, it has been demonstrated to significantly reduce the molecular signature in the skin of patients with atopic dermatitis and to significantly reduce the clinical manifestations of moderate to severe atopic dermatitis. It also significantly reduces the pruritus of moderate to severe atopic dermatitis, thus improving patients' quality of life. Dupixent is administered by subcutaneous injection every other week. It was approved by the FDA in March 2017 for the treatment of moderate to severe atopic dermatitis. In this case, the patient suffers from severe, disseminated atopic dermatitis, and he has tried and failed systemic treatments for his condition. Under these circumstances, Dupixent is medically necessary to treat the patients medical condition.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 dermatology 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 enrollees parent is requesting authorization and coverage for speech therapy, three hours (180 minutes) per month. The enrollee has autism spectrum disorder, attention deficit hyperactivity disorder, and developmental expressive language disorder. He received services from a speech therapy facility. He has received applied behavioral analysis services since age three. His mother states the speech therapy facility was not supportive due to her sons attention deficit hyperactivity disorder. His mother reports that they tried medication for his attention deficit hyperactivity disorder, but it was not beneficial, resulted in side effects, and they discontinued the medication. The enrollees mother is requesting three hours (180 minutes) per month of speech therapy with a new vendor. The enrollees applied behavioral analysis provider noted his deficiency in joint attention skills and his disruptive behaviors during speech therapy sessions. The applied behavioral analysis provider recommended the enrollee continue working on improving his behavioral and attentional skills through applied behavioral analysis therapy. The enrollees treating speech language pathologist noted the enrollees progress had plateaued. The enrollees mother feels that if the enrollee stays at the current speech therapy facility, he will not be supported. The enrollees mother states the current speech therapy facility designed a plan and discharge without consultation or input from her or any other providers. She is requesting coverage for a change in vendor. This enrollee was having difficulty with attention.  The enrollee had constant extraneous movements of the arms and legs.  The enrollee engaged in attention-seeking behaviors intermittently throughout the session, which impeded therapy progress.  The behaviors were escalating and unpredictable.  Documentation noted minimal improvement of progress-to-goal was seen throughout the authorization. The enrollee met zero of four goals during the therapy period. Literature notes most children with autism spectrum disorder will benefit from therapies designed to improve their ability to communicate and engage in social interactions. However, while this enrollee had been receiving speech therapy, the speech language pathologist noted the enrollees inattention to tasks continued to negatively impact his progress towards his goals. It did not appear the enrollee had the appropriate behavioral skills to allow for improvement in speech through speech therapy services. Therefore, the therapy would not be effective.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in pediatric 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast reduction surgery. The American Society of Plastic Surgeons (ASPS) state that reduction mammoplasty is based on documentation of the severity of macromastia symptoms and impact on health-related quality of life. Documentation should include evidence at least two symptoms such as intertrigo unresponsive to medical management, headache, upper back, neck, and shoulder pain and/or shoulder grooving from straps. Additional indications include chronic breast pain due to weight of the breasts, kyphosis, upper extremity paresthesia, and congenital breast deformity. The ASPS has indicated the decision to perform reduction mammoplasty considers a patients symptoms and providers assessment of the likelihood of benefit. Applying the ASPS guidelines, the requested surgery is not medically necessary. This patient complains of back, shoulder and neck pain. The providers physical examination and photographs provided for review do not document shoulder grooving. Based on ASPS criteria, the requested breast reduction surgery is not medically necessary for 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 plastic 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

The patient has requested authorization and coverage for Novolog 100 Units/mL FlexPen. Strict glucose control using multiple doses of insulin is the standard treatment for insulin dependent diabetes mellitus. Recent findings from clinical trials suggest that insulin lispro, insulin aspart, and insulin glulisine are equally safe and efficacious. The records provided for review do not demonstrate that treatment with Admelog has been ineffective to support an indication for Novolog. Based on the available documentation, the requested Novolog 100 Units/mL FlexPen 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 subspecialty certification in diabetes, endocrinology, 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) mental health 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. Based on LOCUS criteria, this patient met the criteria for past RTC services, as well as continuation of RTC services going forward. The patient is at moderate risk of harm. The records document suicidal ideation during her days prior to discharge. The patient did not have an active plan, but she does have a history of a suicide attempt. Thoughts of suicide have been intermittent throughout her stay. She did report that she would go home and kill herself if discharged although did not have an active plan. The patient has demonstrated moderate functional impairment. She has few relationships and her mother is her main support. She has problems completing schoolwork, she is not employed, and her difficulties with hygiene led to her being placed on a showering plan. The patient presents with significant comorbidity with a history of OCD and an eating disorder with food restrictions that have resulted in unstable vital signs. These behaviors occurred at the beginning of her stay in RTC and have a moderate likelihood of recurring. The patients recovery environment is mildly stressful. The patient has limited support within her recovery environment. She has few supports aside from her mother. The patient has required multiple hospitalizations, including one for overdose. She has demonstrated poor response to treatment. The patient has been obstructive to treatment. She has intermittently refused to come to groups and meals, especially during the days approaching her discharge. She was distrusting and hostile at times towards staff and her providers. The patients composite score is consistent with medically monitored residence based services, such as RTC. Therefore, the RTC mental health treatment and continuation of residential mental health 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: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for the medication Tremfya. The enrollee has psoriasis on her abdomen, arms, and lower legs. The enrollee is consistent with her injections of Cimzia and would like to try adjuvant treatment with Xtrac. The provider noted that if the enrollee did not improve with adjuvant Xtrac in six months, a different biologic, such as an IL 23 molecule would be trialed. All other biologic classes and systemic therapies, including Cimzia, have failed to control or improve the enrollees symptoms without significant side effects. The provider is requesting Tremfya, which has been approved for use regulatory agencies for the treatment of plaque psoriasis. Literature describes biologic agents as the most effective therapies for moderate to severe psoriasis. The formulary-approved medications Taltz (ixekizumab) and Cosentyx (secukinumab) are supported in the studies to be appropriate treatment options for the enrollee.                                                          Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in dermatology 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 patient has requested authorization and coverage for acute inpatient spinal cord rehabilitation. The complexity of the patients nursing, medical and rehabilitation needs supports an indication for acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. A review of the literature reveals that the provider directing the rehabilitation program of spinal cord injury patients must be skilled at performing neurological assessment of the patient and possess the knowledge to accurately predict the likely neurologic and functional outcomes based on this assessment. The provider can then direct an appropriate multidisciplinary treatment plan that will address the medical, functional, psychosocial, vocational, and avocational needs of the patient. This patients medical and rehabilitation needs require the services of a specialized spinal cord injury facility to ensure proper monitoring and teaching and prevention of complications that accompany this type of traumatic injury. Given these findings, the requested acute inpatient spinal cord rehabilitation 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 physical medicine and rehabilitation with subspecialty 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

The patient has requested authorization and coverage for Xeljanz. Although Xeljanz is not recommended for first-line treatment for ulcerative colitis, there is data demonstrating improvement in patients who have failed standard therapies. The records provided for review document that this patient has failed standard treatment with 5-aminosalicylate (5-ASA) therapy and Entyvio. Xeljanz has a different mechanism of action than anti-tumor necrosis factor (TNF). Moreover, Xeljanz has been shown to be safe and effective in a double-blind placebo-controlled trial of patients with moderate to severe ulcerative colitis. In this patient with marked improvement on Xeljanz, a discontinuation of Xeljanz or change to an alternate therapy such as Humira may result in a disease flare or complications. Given these findings, the requested Xeljanz is medically necessary for 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 subspecialty 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for in-office balloon sinus dilation. This patient has chronic sinusitis and polyps. The records document failure of treatment with prednisone, Advair Diskus, and Claritin. The peer-reviewed medical literature suggests that chronic rhinosinusitis requires documentation of continued symptoms, such as nasal obstruction, altered sense of smell, persistent mucopurulent discharge, or facial pain or pressure, for 12 weeks or more. In addition, records should include objective evidence of nasal endoscopy to show polyps or obstruction and computed tomography (CT) evidence of objective findings showing chronic sinus disease. Balloon sinus dilation is a potential technique to improve a patients symptoms of recurrent acute rhinosinusitis to help widen and dilate the sinus pathways. However, studies lack randomization of patient symptomatology and long-term follow-up demonstrating improved health outcomes when compared to standard available interventions. Researchers found that at one year, symptom improvements and revision rates between standard sinus surgery and balloon dilation showed no statistical difference. Researchers also found an unacceptable failure rate of 65%, which led to the abandonment of further studies. Therefore, the requested in-office balloon sinus dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested in-office balloon sinus dilation is not 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 not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Cimzia. Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling. Psoriasis has a high negative impact on the quality of life, especially in patients who are moderately or severely affected by the disease. Cimzia is considered to have similar efficacy to other tumor necrosis factor alpha drugs therefore, it was significantly more effective versus placebo in the treatment of psoriasis. Given that this patient has failed treatment with other medications, and the patient has symptoms consistent with psoriatic arthritis, treatment with Cimzia is appropriate. Although there are other tumor necrosis factor drugs available, Cimzia is considered equally efficacious and is therefore a reasonable choice in view of evidence that it is effective for moderate to severe psoriasis in patients with possible psoriatic arthritis. For these reasons, Cimzia 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 dermatology 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.