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

The patient has requested authorization and coverage for gabapentin 600 mg five times per day and Norco 10-325 mg five times per day. The Federation of State Medical Boards (FSMB) guidelines noted that, continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. The FSMB opined that dosage should be maintained as low as possible and continue[d] only if clear and objective outcomes are being met. The Centers for Disease Control and Prevention (CDC) guidelines state that providers should evaluate benefits and harms of continued therapy with patients every three months or more frequently. 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 this case, the patient has a diagnosis of chronic back pain with radiculopathy. She is unable to tolerate non-steroidal anti-inflammatory drugs (NSAIDs) due to a history of cardiomyopathy. A recent urine drug screen was positive for THC and a repeat urine drug screen is pending. The patient endorses use of cannabis for insomnia. Based on the current guidelines from the CDC and FSMB, the risks of combining opioid therapy with cannabis outweigh the potential benefit of chronic opioid therapy. Based on the available records for review and the guidelines regarding prescribing opioids for non-cancer pain, Norco is not medically necessary for treatment of this patient. However, the patients diagnosis of chronic low back pain with radiculopathy and intolerance to NSAIDs supports treatment with gabapentin. Consistent with the available data, gabapentin 1200 mg three times per day is medically necessary to treat the patients chronic back pain with radiculopathy, while Norco 10-325 mg three times per day is not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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

The parent of the enrollee is requesting authorization and coverage for 15 minutes per week of sensory integration therapy services and 30 minutes per week of occupational therapy services. The enrollee has a diagnosis of autism spectrum disorder.  The enrollees occupational therapy evaluation described functional impairments, such as the enrollee becomes upset around transitions, spins until he falls, wakes for four hours during the night, and uses a fork independently but will not use a spoon. The goals addressing function include family identification of three to five strategies to improve self-regulation, the enrollee will sleep through the night, four to seven nights per week, and the enrollee will scoop food with a spoon and feed himself without spillage. Literature indicates sensory information forms the building blocks for higher-order social and cognitive functions, and sensory problems are considered a core symptom of autism spectrum disorder. Studies showed the use of Ayres Sensory Integration can be considered an evidence-based practice for children with autism between the ages of four and twelve. The Autism Science Foundation indicates occupational therapy is often used as a treatment for sensory integration issues in those with autism spectrum disorder.  It is used to improve skills that involve fine-motor movements, such as dressing, using utensils, cutting with scissors, and writing. Occupational therapy works to improve the individuals ability to participate fully in daily activities. Occupational therapy for young children focuses on improving sensory integration and sensorimotor issues.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for orthotic shoe inserts. This enrollee remained pain-free only with the use of the orthotics. He reports his pain is so bad that after periods of rest he has to brace himself when he first gets up and his walking is strained. A review of the literature reveals that while there is a vast amount of research with regard to conservative therapy for plantar fasciitis, literature shows there is no optimal answer regarding specific orthotic therapy for plantar fasciitis.  While some people may benefit from over-the-counter orthotics, others may require the use of custom orthotics. It is clear from this enrollees medical records that disuse of the custom orthotics caused a recurrence of his plantar fasciitis.  Given the available literature on this topic and this enrollees history, in this reviewers expert opinion, the enrollee requires the orthotics to resolve his recurrent plantar fasciitis.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in podiatric 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Spinraza. Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disorder characterized by degeneration of spinal motor neurons. The disease poses significant adverse outcomes in the affected patient population. Survival motor neuron 1 (SMN1) protein encoded by the SMN1 gene is critical for survival and the functioning of motor neurons. An almost identical gene, survival motor neuron 2 (SMN2), is present on the same chromosome but produces a truncated protein. The number of copies of the SMN2 gene in a patient determines the severity of disease, as fewer copies suggest the presence of more severe disease. Spinraza is U.S. Food and Drug Administration (FDA) approved for the treatment of child and adult patients with SMA. Clinical trials have demonstrated the safety and efficacy of Spinraza. One study reported such favorable results in the interim analysis that all of the patients were transitioned to receive Spinraza in an ongoing open-label, phase 3 study. This patient has a diagnosis SMA with zero copies of SMN1 and three copies of SMN2. She has not been able to crawl, sit, or walk independently. Given the current support in the medical literature, Spinraza 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 neurology with expertise in neurodegenerative diseases 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 enrollee is requesting authorization and coverage for the prescription medication Buprenorphine, 2 mg sublingual tablets (quantity of 90 tablets for 30 day supply, three tablets per day). The enrollee has chronic pain from abdominal surgery. She has achieved stable pain control with buprenorphine. The enrollee was referred to pain management after failure of conservative management over six months; including physical therapy, home exercises, acetaminophen, and non-steroidal anti-inflammatory drugs. The enrollee reports she has been on this medication for years. She switched to buprenorphine to avoid the necessity of more short-acting opiates. Literature shows Buprenorphines unique properties allow it to play a special role in the treatment of complex chronic pain. It is also effective for those with both chronic pain and opioid dependence. A regulatory agency reports the maintenance dose for buprenorphine is generally in the range of four milligrams to 24 milligrams per day. This enrollees pain has been controlled with buprenorphine at her current dosage without side effects. As the enrollee has utilized the medication effectively, without significant adverse effects, it would be medically imprudent to lower her dosage or discontinue the medication.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential 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. For dimension 1, the patient has mild to moderate withdrawal symptoms per Clinical Institute Withdrawal Assessment (CIWA) scoring. The patient does not have any reported biomedical conditions to meet the requirements for dimension 2. However, the patient meets the criterion for dimension 3, given the presence of post-traumatic stress disorder (PTSD) and major depressive disorder (MDD), which complicate his substance use presentation and treatment. For dimension 4, the patient is willing to change, but not yet ready or able as evidenced by continued avoidance of skills that would promote independence and sobriety. For dimension 5, the patient has been self-medicating his trauma symptoms with substances. The patients symptoms will persist without new adaptive skills firmly in place. The patient does not have significant family support and he lacks a supportive structured environment at home, as required by dimension 6. The patient requires a safe and stable living environment in order to develop his recovery skills. He qualifies for ASAM Level III treatment similar to what patient has received at the current RTC facility. Given the severity of the patients illness, RTC 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for the O-arm stealth machine for 3D imaging, to be used during the L3-4 and L4-5 laminectomy, discectomy, and instrumented fusion procedure. The enrollee has low back pain; extending into his bilateral hip, posterior thighs and calves. The enrollee has diminished sensation to his right posterior thigh and calf. Magnetic resonance imaging of the lumbar spine demonstrates degenerative changes and stenosis at L3-4 and L4-5. He has failed conservative measures of physical therapy and epidural steroid injections. The recommendation from a neurosurgeon was for the enrollee to undergo L3-4 and L4-5 laminectomy/discectomy. This request is medically necessary for both the enrollees safety and for operating room safety, and to decrease the risk of pedicle screw misplacement. The use of the O-arm stealth machine for 3D imaging during lumbar, i.e., L3-4, instrumented fusion significantly reduces radiation exposure and improves the accuracy of screw placement. Studies showed that O-arm navigation, combined with microscope-assisted minimally invasive transforaminal lumbar interbody fusion, results in less blood loss, a shorter hospitalization stay, higher accuracy of pedicle screw placement, and a faster recovery time for the treatment of one-level lumbar degenerative disease.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurosurgery 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 enrollee is requesting authorization and coverage for residential treatment center (RTC) level of care services. The enrollee has opioid use disorder, severe; suicidal ideations; major depressive disorder, and generalized anxiety disorder. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. For risk of harm there is no active suicidal/homicidal ideation exists, but extreme distress and/or a history of suicidal/homicidal behavior exists. The enrollee engages in excessive use of substances, resulting in potentially harmful behaviors, without current involvement in such behavior. For functional status, there is significant disturbances in vegetative activities, such as sleep, eating habits, activity level, or sexual appetite, which do not pose a serious threat to health. Recent gains and or stabilization in function have been achieved while participating in treatment in a structured and /or protected setting. For comorbidity, the enrollee has significant psychiatric symptoms and signs are present which are themselves somewhat debilitating, and which interact with and have an adverse affect on the course and severity of any co-existing substance use disorder. For recovery environment level of stress, the enrollee has difficulty avoiding exposure to active users and other pressures to partake in alcohol or drug use. For recovery environment level of support, the enrollee has a few supportive resources that exist in the current environment and may be capable of providing some help if needed. For treatment and recovery history, the enrollee attempts to maintain whatever gains that can be attained in intensive treatment have limited success, even for limited time periods or in structured settings. The enrollee does not use available resources independently, or only uses them in cases of extreme need. The enrollees composite LOCUS score is 23, which correlates with Level 5, medically monitored residential services.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The composite score is then used to determine the level of care needed. Applying CALOCUS, this patient meets the criteria for RTC services. The patients composite score is 22. However, the patients scores for risk of harm and functional impairment, combined with scores for environmental stress and support, support treatment at a Level Five, medically monitored residence based services, similar to the services provide at the current RTC. Given these findings, the RTC level of care services provided 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 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 Tasigna 300 mg twice daily. This patient has an atypical chronic myelogenous leukemia that is PDGFR alpha positive with hypereosinophilia, similar to a hypereosinophilic syndrome. Medical literature states that hypereosinophilic syndrome is characterized by sustained overproduction of eosinophils and organ dysfunction. The authors studied Tasigna in a phase 2 trial that included 12 patients with hypereosinophilic syndrome, and were able to follow-up with seven patients. On follow-up, the study concluded that Tasigna was effective in four patients, including one patient who achieved complete hematologic response. In addition, Tasigna demonstrated a safety profile consistent with other studies. This patient demonstrated hematologic response with imatinib, but was intolerant to this agent due to toxicity. As noted by the provider, Tasigna is an alternative for imatinib. Tasigna is a reasonable next line of therapy for treatment of atypical chronic myelogenous leukemia-type disease. Given this support, the requested Tasigna 300 mg twice a day 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 certifications in medical oncology and hematology 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

The enrollee requested authorization and coverage for a right hip sacroiliac joint fusion. The enrollee has severe and persistent bilateral back and buttock pain, appearing to originate from the sacroiliac joint. Due to persistent pain and failure of conservative treatment, sacroiliac joint injection was recommended for diagnostic and therapeutic reasons. This was performed and provided complete pain relief for one day; afterwards, the pain slowly returned. The symptoms are worsening, despite anti-inflammatory medication. She attended four to five sessions of physical therapy, but stated the therapy aggravated her pain. The orthopedic surgeon believes sacroiliac joint fusion would benefit her. Literature shows surgical fusion of the sacroiliac joint is an option for those who have not improved with comprehensive, non-operative treatment. Minimally invasive surgery has yielded good outcomes, high satisfaction, and lower morbidity and earlier recovery than traditional open approaches. Additionally, minimally invasive sacroiliac joint fusion has become the preferred intervention because it has demonstrated superior outcomes to open sacroiliac joint fusion and non-operative care.   Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in orthopedic surgery and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.