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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxycodone 20 mg, one to two every four hours for a total of 240 per month. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. In the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. Moreover, there is no mention that behavior therapy has been completed despite much research to support its use. Moreover, not all non-opioid medications classes have been optimized or tried. All told, the requested oxycodone 20 mg, one to two every four hours for a total of 240 per month is not supported as medically necessary for treatment of this patients chronic pain. 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 sub-specialty 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Venclexta. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees acute myeloid leukemia (AML).Findings: Venclexta (venetoclax) is a BH3 mimetic drug that inhibits the function of the anti-apoptotic BCL2 protein. It is approved in chronic lymphocytic leukemia (CLL) that has TP53 deletion. It targets a new class of cancer causing proteins. Venetoclax has been tested in relapsed or refractory AML patients demonstrating safety and efficacy as a single agent. Furthermore, it has been combined with hypomethylating agents, decitabine and azacytidine, also demonstrating safety and responses in treatment naive AML patients. The combination has also been tested in the relapsed setting where patients had complete remissions from the combination. The records note the patient has exhausted standard AML treatment options but has a performance status and age amenable to allogeneic hematopoietic stem cell transplant, a curative approach. However, allogeneic hematopoietic stem cell transplant cannot be applied unless a complete remission is induced. Thus, based on the published data, decitabine in combination with venetoclax has been demonstrated as medically appropriate. As such, in this clinical setting, Venclexta has been demonstrated as medically necessary for treatment of this 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 internal medicine with sub-specialty certification in medical oncology 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 eating disorder intensive outpatient program level of care services. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient was admitted to the hospital for her eating disorder. The patient reported that she had eaten very little in three weeks. The discharge summary states that this statement was not likely given her normal weight and laboratory testing. The patient did not have any laboratory abnormalities, and when the patient left against medical advice, the provider reported that she was medically stable for discharge. Per the records, the patients interpersonal difficulties with healthcare providers is a barrier to effectively engaging and participating in eating disorder treatment. In this clinical setting, dialectical behavior treatment (DBT) is appropriate to gain emotional stability and would allow the patient to engage in eating disorder treatment. However, the records do not document the medically necessity for intensive outpatient program treatment at this time. Therefore, eating disorder intensive outpatient program level of care services are not medically necessary for the 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 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 parent of a patient has requested authorization and coverage for Genotropin. The submitted documentation does not support the medical necessity of the requested medication. The patient does not meet standard criteria for growth hormone deficiency. The patients insulin-like growth factor-1 level prior to initiation of growth hormone therapy was normal, and provocative growth hormone testing revealed normal results. The patient does not meet criteria for treatment with growth hormone therapy for idiopathic short stature.  a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests, but who meet most of the following criteria. The criteria include height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; growth velocity less than the 25th percentile for bone age; bone age more than two standard deviations below the mean for age; low serum insulin-like growth factor-1 and/or insulin-like growth factor binding protein and/or other clinical features suggestive of growth hormone deficiency. This patient does not meet the above criteria. This patients clinical presentation is most consistent with a diagnosis constitutional delay. Therefore, Genotropin 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 pediatrics with sub-specialty certification in pediatric endocrinology 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Euflexxa knee injections. The submitted documentation supports the medical necessity of the requested medication. One study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of hyaluronan therapy were safe and effective in the treatment of pain associated with osteoarthritis of the knee. The medical evidence supports hyaluronic acid injections in the knee as a possible option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. There is no maximum amount of injections established by high quality scientific evidence. This patient presents with recurrent right knee pain and functional limitations. Clinical examination findings are consistent with the diagnosis of osteoarthritis of the right knee, including medial and lateral joint line tenderness. The records indicate that reasonable conservative treatment, including pain medications and activity modification, has failed to provide adequate symptom relief. The patient reports gastric intolerance to nonsteroidal anti-inflammatory drugs. Prior viscosupplementation has provided significant pain reduction and improved mobility for six months. The medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the requested Euflexxa knee injections are 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 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

The parent of an enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.Findings: The documentation provided does not support the medical necessity for the services at issue in this clinical setting. The records do not indicate that this patient had any episodes of self harm. She did not have any suicidal thoughts or thoughts of self harm. The patient was described as sleeping well and had good energy. She had a good appetite and good focus. The provider reported that the patient had no side effects from the medication. The provider did not make any medication changes at the time. A record noted the patient was given a pass to leave the residential treatment facility to visit home. Other notes corroborate the patient did not have self harming behaviors and had an improved mood.  While the patient continued to need treatment for her behavioral health condition, her treatment could have been provided in a less restrictive environment. Therefore, residential treatment center services were not supported as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined the services at issue 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 expertise 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: A 62-year-old female enrollee has requested authorization and coverage for Benlysta auto injectable. Benlysta is U.S. Food and Drug Administration (FDA) approved for the treatment of ANA or double stranded DNA positive Lupus. Per published medical literature, the precise profile of the SLE patient who would derive the most benefit from belimumab treatment remains to be defined. This patient is not documented to have positive ANA or double stranded DNA antibodies. The patient is receiving treatment with antivirals and her chest pain has not been diagnosed as pleurisy or pericarditis. There are no echocardiograms, electrocardiogram changes of pericarditis or chest films showing pleural effusions. Moreover, fibromyalgia can cause chest tenderness and pain. She has not failed two prior standard of care therapies despite failing Plaquenil. Overall, the patient does not meet the current literature based standard of care guidelines for treatment with Benlysta. Thus, the requested Benlysta auto injectable is not supported as 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. Findings: Review of the submitted documentation reveals the patient remained symptomatic during the period at issue. The patient was documented as struggling with mood lability, anxiety, and impulse control. The patient had difficulty with completing all meals and had documented weight loss. The patient had difficulty with emotion regulation, at times reported suicidal ideation, and engaged in self injurious behavior. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth. The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services.  Based on the patients clinical history provided and documentation as outlined above, the patient met CASII criteria for non-secure 24 hour psychiatric monitoring. The patients clinical status, in addition to current medical literature, support that the treatment at the residential level of care was medically necessary for this patient (AACAP).  Final Result: The reviewer determined that the services at issue were 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 sub-specialty 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 parent of an enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) services. In the medical literature, researchers reviewed the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder and found no correlation between the number of hours provided per week and outcomes. The authors noted that the age at which ABA therapy was started and duration of treatment was correlated with outcome. Other researchers reached similar conclusions. The records indicate that this patient has been receiving 30 hours per week of ABA therapy and has made significant progress in language skills, social skills and independent living skills. There has been an overall decrease in maladaptive behaviors since ABA therapy was introduced. Thus, continued ABA services are indicated. However, the records do not support that the requested 40 hours per week of ABA services are medically necessary for treatment of this patients medical condition. 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 pediatrics and neurology with special qualification in child 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: An enrollee has requested authorization and coverage for monitored anesthesia care (MAC) services to be used during bilateral selective nerve root block. The records provided for review indicate that this patient has an American Society of Anesthesiology (ASA) preoperative physical status classification score of 2. According to the American Society of Anesthesiologists (ASA), intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported for patients with a low preoperative physical status classification score. Although the location of the procedure is a high risk area, this risk would be reduced by avoiding the use of local anesthetic. The high risk of a total spinal or seizure from the injection of Lidocaine would be minimized and the need for another provider to be present for resuscitative purposes would likewise be decreased. Since this patient has already had the procedure done for diagnostic purposes, the addition of a local anesthetic would be for therapeutic purposes. For these reasons, the requested MAC services, to be used during bilateral selective nerve root block, are not medically necessary for treatment of the patients medical condition.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 anesthesiology with sub-specialty 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation with an orthopedic surgeon for evaluation of the enrollee who has a history of multiple neurofibromatosis.  Findings:  The physician reviewer found that this patient presents with chronic neck pain located at the C7 level. Clinical examination findings are consistent with imaging evidence of local fibrotic changes and connective tissue changes at C7. Past medical history is positive for neurofibromatosis type 1 and 2 with known lesions in his neck. The lesion on the back of his neck at C7 has been diagnosed as a sarcoma.  A referral for surgical removal was recommended with an orthopedic spine surgeon who is now out-of-network. The patient has not established care with the orthopedic spine surgeon. Instead, the Health Plan has approved a referral to neurosurgeons within the patients geographic area for evaluation and treatment. As such, the documentation provides no compelling rationale to support the medical necessity of an orthopedic surgeon. Therefore, the requested consultation with an orthopedic surgeon has not been demonstrated as medically necessary for evaluation of the patients medical condition. 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 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: An enrollee has requested authorization and coverage for Stelara 90 mg injections every four weeks. Current medical literature supports the requested dose escalation of Stelara in this enrollees case. A large randomized controlled trial demonstrated the safety and efficacy of Stelara for induction and maintenance of remission in enrollees with moderate-to-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. Another study showed a 73% response in enrollees with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for at least one year. The mechanism of Stelara is different than that of anti-TNF medications which this enrollee has failed. Moreover, one study showed dosing at 90 mg every four weeks allowed a large proportion of enrollees to maintain adequate response  As this enrollee has failed treatment with prednisone, 6-mercaptopurine, methotrexate, thalidomide, Remicade Humira, Cimzia, Tysabri, and Entyvio, and shown improvement on Stelara 90 mg injections every four weeks, this requested dosage is supported as medically necessary. Final Result: The reviewer determined that the requested medication dosage is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.