Persius/hicric huggingface dataset:
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) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient meets the six ASAM criteria for treatment at the RTC level of care. For these reasons, 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 subspecialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. The records support residential treatment level of care. The six-week treatment course was and is medically indicated. Thus, the residential treatment center services at issue were, and are, medically necessary to treat the patients conditions.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat the patients conditions. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Gazyva (obinutuzumab) 1,000 mg infusion on day one and day 15. In this case, the patient has refractory nephrotic syndrome. The patients degree of proteinuria places him at high risk of progressive renal failure and/or long-term dialysis. Gazyva works in a similar mechanism as rituximab, which was noted to have been beneficial in the past. Other therapy could cause substantial side effects. The medical evidence supports the requested medication in this clinical setting. Therefore, Gazyva (obinutuzumab) 1,000 mg infusion on day one and day 15 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 nephrology 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 Lyrica.  The submitted documentation supports the medical necessity of the requested medication. Researchers evaluated various uses of Lyrica for peripheral neuropathy and found that Lyrica should be used as a first line agent in cases where a patient fails to respond to gabapentin. Researchers also reported that there are data demonstrating the efficacy of pregabalin in some patients with painful diabetic peripheral neuropathy (pDPN) who have not responded to other pharmacological treatments, including those unresponsive to treatment with gabapentin. Clinical guidelines acknowledge the paucity of head-to-head data among treatment options, but consistently recommend pregabalin as a first-tier treatment for pDPN. In this case, the medical records indicate the patient tried several doses of gabapentin as instructed by his provider, with marginal benefit. Given the patient has tried and failed gabapentin, and based on the current medical literature, the requested medication is medically indicated. Therefore, Lyrica is medically necessary for the treatment of this patient.Final Result: The reviewer determined 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. 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 an integrative medicine consultation.In this case, the patient reports chronic non-cancer pain that started after a motor vehicle accident several years ago. This accident caused the patient to experience traumatic injury to the head and neck region with fractures to the sternum, and while her recovery was uneventful, the accident has affected the patient in ways that continue to manifest in her current symptomology. Records reflect that the patient has had medical evaluation and treatment for any physical ailments including cardiac and gastrointestinal etiologies. The patient did have an incidental finding of a large benign hepatic cyst which was successfully removed surgically. Even with these essentially negative findings, the patient has continued to complain of frustration with persistent abdominal pains, constipation, dry mouth, hyperalgesia and sleep disturbance, and records suggest that she does also exhibit some amount of depression. The submitted records do not reflect that the patient has received treatment in a chronic pain clinic with multispecialty support or that she has received treatment centered around cognitive behavioral therapy, counseling, physical therapy or treatment for possible depression. While the patient currently seeks an integrative medicine consultation, there is no indication that this service would be provided in conjunction with appropriate management by a medical team specialized in chronic pain treatment. Under these circumstances, the requested integrative medicine consultation is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal 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 parent of an enrollee has requested reimbursement for Intensive Outpatient Program (IOP) services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 2. The patient had some risk of harm, due to impulsivity and substance abuse. In terms of functional status, the records support a score of 3. The patient had moderate functional impairment due to conflict with his mother and lack of engagement with schoolwork. With regard to comorbidity, the records support a score of 2. The patient had a recent relapse with alcohol use as well as symptoms of attention deficit/hyperactivity disorder, anxiety, and depression. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment, due to sheltering-in-place due to the COVID-19 pandemic and discomfort with expectations set by his mother and the Intensive Outpatient Program. With regard to the level of support of the recovery environment, the records support a score of 2. The patient had a supportive environment due to his mothers participation in the program. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, due to persistence of symptoms despite extended and intensive treatment exposure. With regard to treatment acceptance and engagement of the patient, the records support a score of 4. The records noted a lack of participation in treatment. Thus, the patient has a total score of 19. The records support Intensive Outpatient Program level of care in this setting. Therefore, the Intensive Outpatient Program (IOP) services at issue were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for sclerotherapy/Varithena injection. The enrollee has a ten-year history of varicose veins and spider veins in both lower legs. A progress note reports the enrollees symptoms include aching, burning, restless legs, and swelling. The symptoms adversely affect the enrollees participation in activities of daily living. Over the last year, the enrollee has implemented conservative measures of compression stockings, leg elevation, exercise, and avoidance of long periods of standing, sitting or walking; however, these measures have not resulted in significant symptom improvement. The enrollee has not had any past vein treatment. The provider is recommending treatment with ultrasound-guided foam sclerotherapy. The enrollee is not considered a good candidate for sclerotherapy/Varithena injection. Evidence-based peer reviewed published literature is replete with studies consistently documenting that the majority of enrollees will achieve relief of their symptoms following ablation of the dominant refluxing vein in the leg. The procedures requested do not qualify as medically necessary as previous vein treatment has not bene attempted. Routine follow-up exams or ultrasound tests showing the presence of veins, with or without minor symptoms, do not constitute a standard of care indication for the requested service.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 vascular 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Follistim AQ 300 IU cartridge (quantity of 8) and Menopur 75 IU vial (quantity of 8).The submitted records do not support that the medications at issue were medically necessary. The submitted records reflect that the patient had a progesterone level that was in the ovulatory range without treatment. Records reflect that the medications at issue were being taken electively to attempt to get embryos for a gestational carrier, and not for any apparent medical indication. There is no indication in the patients medical records that she is infertile, nor a medical reason specified for why the patient had decided to have another person carry her baby. There is also nothing to support the need for ovulation induction other than a planned egg retrieval. Under these circumstances, the medications Follistim AQ 300 IU cartridge (quantity of 8) and Menopur 75 IU vial (quantity of 8) were not medically necessary for the patients medical condition.Final Result: The reviewer determined that medications at issue were not medically necessary for 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for speech therapy services.According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), autism spectrum disorder (ASD) is characterized by deficits in social communication, social interaction, and restricted and repetitive patterns of behavior or interests. Depending upon the severity level, individuals with ASD may have deficits in verbal and nonverbal communication. According to the American Speech-Language-Hearing Association (ASHA), it is important to accurately diagnose and address co-morbid speech sound disorders, in addition to addressing the language and communication difficulties associated with ASD. The ASHA state that in the case of ASD, social communication impairment is a core feature and that a diagnosis of ASD therefore indicates the inclusion of communication services. The ASHA notes that individuals with ASD can continue to develop communication abilities across their lifespan. They also note that when determining the language of treatment for an individual with ASD, speech language pathologists (SLP) should carefully consider the individual's linguistic environments. Treatment is provided either by a bilingual SLP or through the use of trained interpreters, when necessary.In this case, the patient has autism spectrum disorder. Although he was not found to have stuttering or dysfluencies during his speech therapy evaluation, the patient was noted to have speech and language deficits characteristic of autism. According to the AHSA guidelines, it is important to address language and communication difficulties associated with ASD and a diagnosis of ASD indicates the inclusion of communication services. In addition, the patient is not too old to benefit from communication services, as individuals with ASD can develop communications abilities regardless of age. Finally, in accordance with AHSA guidelines regarding cultural and linguistic factors, it is important to address the family's preference in considering the choice of a specialist who is fluent in their language. Accordingly, the requested speech therapy services are medically necessary to treat the patient's medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's 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

The patient has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) 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. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, this patient met the criteria for PHP services already provided. These findings give the patient a composite score which is consistent with medically monitored community based services. Per LOCUS algorithm, reviews should not be required more often than every two weeks for acute care settings such as PHP. In this case, the patients history of serious disordered eating including multiple recent hospitalizations, and her continued struggles with body image and urges to exercise, support the PHP services already provided as medically necessary. However, based on the available documentation, the records do not support a current indication for PHP level of care services. Therefore, the PHP services were medically necessary for treatment of this patient, while the requested return to PHP level of care is not medically necessary for this patient. Final Result: The reviewer determined that a portion of the services at issue was 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

The patient has requested authorization and coverage for percussion vest, mechanical tilt-in-space wheelchair, and custom gait belt. On review of the additional medical records, there is a lack of clinical rationale to support an indication for a percussion vest for treatment of this patient. The patient was hospitalized with COPD and bilateral pneumonia. There is no indication that she has persistent issues with respect to pulmonary toilet that are unmet by routine management including assisted coughs. The most recent visit with her provider reports no coughing and no dyspnea. The patient had clear lungs on examination, without rales, rhonchi, or wheezing. Without an appropriate indication, the requested percussion vest is not medically necessary for treatment of this patient. There is no report that the treating providers have made any recommendations or training to the caregivers to transfer the patient with anything other than a Hoyer lift, or to use a gait belt for transfers or ambulation. The use of a gait belt without adequate training could result in unwarranted and unsafe attempts by caregivers to transfer or ambulate a patient resulting in serious injury. Lacking documentation of an appropriate indication, the requested custom gait belt is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition, or medically necessary for the enrollee to perform one or more mobility related activity of daily living or instrumental activity of daily living in or out of the home, including access to the community. 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

An enrollee has requested authorization and coverage for OxyContin 12-hour extended release 20 mg, two times daily. The Centers for Disease Control and Prevention guidelines state that non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The 2017 Federation of State Medical Boards guidelines for the chronic use of opioid analgesics recommends, opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. The guidelines recommend that providers, maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. In this case, the patient has chronic pain involving the cervical spine and lumbar spine. She has had severe headaches related to hydrocephalus affecting her activities of daily living. She has attempted several forms of conservative non-opioid therapy, with marginal results. She is not a candidate for further surgery and spinal injections according to her provider. She has been on chronic opioid therapy for several years, and she has tried and failed several medications. Her urine toxicology screening and CURES reports have been consistent with therapy. There is sufficient support for the requested medication in this clinical setting. Therefore, the requested OxyContin 12-hour extended release 20 mg, two times daily is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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.