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

The patient has requested authorization and coverage for Remicade infusions every four weeks. The request for Remicade 10 mg/kg every four weeks is supported as medically necessary for treatment of this patient. Remicade doses higher than 10 mg/kg every eight weeks can be effective for patients with Crohns disease, and may prevent disease complications. Dose intensification is commonly required during therapy with Remicade, and can include increased dosing and frequency. In addition to clinical trial data, there is other literature to support Remicade at 10 mg/kg every four weeks, with improved response in well-selected patients. This patient has experienced uncontrolled symptoms related to Crohns disease before Remicade infusions while on a dose of 10 mg/kg every eight weeks. Testing revealed a low trough Remicade level, which indicates a risk for more severe complications. The American Gastroenterological Association (AGA) guidelines recommend that in patients with a low Remicade level, the dose should be increased. Additionally, perianal Crohns disease requires higher Remicade trough levels to permit healing. Continuation of the Remicade dose of 10 mg/kg every eight weeks may result in a disease flare or complications for this patient, who has failed treatment, and had an initial good response to Remicade. Switching to another medication given the patients presentation and partial response to Remicade might result in loss of disease control. Given these findings, the requested Remicade infusions every four weeks are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication dosage 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet 10/325 mg, 1 tablet, 4 times per day.The patient has been on chronic opioid therapy for the past 10 years, primarily due to chronic shoulder pain related to rotator cuff tears and shoulder joint arthritis. The patients previous treatments include medication management with a variety of drug classes as well as physical therapy. The submitted documentation indicates that the patient has demonstrated self-prescribing behavior with an inconsistent urine toxicology screen that was positive for non-prescribed benzodiazepines. Both the patients primary care and pain management providers expressed concerns regarding her inconsistent urine toxicology screen and the combination of unprescribed benzodiazepines and opioids. The patients primary care provider has attempted to modify the patients opioid therapy, as suggested by the current guidelines, and to refer the patient to pain management and physical therapy. Records reflect that the patients treating providers have managed the patients care in a manner that is consistent with current recommendations from the national guidelines regarding chronic opioid therapy for non-cancer pain. Under these circumstances, Percocet 10/325 mg, 1 tablet, 4 times per day, is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication dosage is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty certification in pain 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: The patient has requested authorization and coverage for skilled nursing facility (SNF) services. Based on the records provided for review, by the date of the Health Plans denial, this patient did not require skilled nursing or rehabilitation services on a daily basis. The patient did not require skilled therapy to prevent deterioration with mobility or activities of daily living. She did not require skilled therapy to establish a safe and effective maintenance program. She did not require any skilled services on an inpatient basis at the SNF level of care. The patient did not have any parenteral medications, complex wound care, or nutrition given via a feeding tube. She received skilled care and improved. However, her function had plateaued and she did not require any further inpatient skilled rehabilitation services as her functional status was at or near her baseline. Given these findings, the SNF services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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 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

The patient has requested authorization and coverage for hysteroscopy to remove uterine septum under laparoscopic guidance. Anatomic correction can be effective treatment to restore normal anatomy. Hysteroscopic septum removal may improve fertility outcome while restoration of the patients normal anatomy is beneficial to her overall gynecologic and obstetric health. Clinical evidence supports that a uterine septum can cause recurrent pregnancy loss and dysmenorrhea. It is reasonable and appropriate for this patient to undergo septum removal of her uterus via hysteroscopy in order to restore normal anatomy and optimize her chances of carrying a healthy pregnancy to term. 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 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

The patient has requested authorization and coverage for HP Acthar gel 400 units/5 mL vial. This patient has a diagnosis of multiple sclerosis. She has failed to respond to multiple medications. Acthar gel has received U.S. Food and Drug Administration (FDA) approval for the treatment of multiple sclerosis exacerbation. The use of Acthar gel is appropriate for patients intolerant to intravenous (IV) steroids. Acthar gel is clinically indicated for this patient as she has been unable to tolerate IV steroids, and has not substantially improved with several standard therapies. Given these findings, HP Acthar gel 400 units/5 mL vial 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 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 patients parent has requested reimbursement for intensive outpatient program (IOP) psychiatric 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 six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use 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. The patients composite score is consistent with high intensity community based services. This level of care is consistent with the IOP level of care. Given these findings, the IOP psychiatric services were medically necessary for treatment of this patient.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 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 patients parent has requested authorization and coverage for mental health services using the family based therapy (FBT) modality. FBT for anorexia nervosa is a supported form of treatment developed for children and adolescents with anorexia nervosa. Multiple treatment guidelines support FBT as superior to individual treatment in this clinical setting. The American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters support the effectiveness of FBT for treatment of adolescents with anorexia nervosa, as this patient. The APA noted that current studies and a meta-analysis of randomized controlled trials suggests that FBT empowers parents to take charge of the weight restoration of their child by taking action to disrupt symptoms of self-starvation and over exercise. The records provided for review indicate that this patients provider is trained in FBT and the patient has responded positively to this treatment modality. Given these findings, the requested mental health services using the FBT modality are 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) level of care services including occupational therapy and physical therapy services. Based on the documentation provided for review and medical literature, this patient does not require SNF services with the specialized skill, knowledge and judgment of a skilled nurse to administer medical treatment. The records do not indicate that the patient has a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This patients functional level with limited weight bearing did not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist. The patient does not require daily skilled nursing, skilled therapy services, or a combination of these services. Although the patient is likely to benefit from occupational therapy and physical therapy services, the patient does not require these services on a daily basis. For these reasons, SNF level of care services including occupational therapy and physical therapy services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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

The patient has requested authorization and coverage for Harvoni 90-400 mg tablets for 12 weeks. The patient has been diagnosed with hepatitis C. The American Association on the Study of Liver Diseases and Infectious Diseases Society of America reported, From a medical standpoint, data continue to accumulate that demonstrate the many benefits, both intrahepatic and extrahepatic, that accompany hepatitis C virus (HCV) eradication. Therefore, the panel continues to recommend treatment for all patients with chronic HCV infection, except those with a short life expectancy that cannot be remediated by HCV treatment, liver transplantation, or another directed therapy. The authors noted that a daily fixed-dose combination of ledipasvir (90 mg)/sofobuvir (400 mg) for 12 weeks is recommended for treatment-naive patients with hepatitis C genotype 1b without cirrhosis. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, Harvoni 90-400 mg tablets for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 infectious disease 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 Orthovisc injections in the right knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of relief from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments including corticosteroid injections, an unloading brace, and physical therapy, with the alternative being a total knee arthroplasty. Under these circumstances, the requested Orthovisc injections in the right knee are medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Radicava infusions. The enrollee has been diagnosed with the neurodegenerative disorder amyotrophic lateral sclerosis. He has been taking the medications riluzole, baclofen, and gabapentin. His physician has prescribed Radicava infusions. Radicava is Food and Drug Administration (FDA) - approved to slow the progression of amyotrophic lateral sclerosis. It is approved for all patients with amyotrophic lateral sclerosis and not just those meeting certain functional criteria. According to the FDA, the pivotal medical trial on which approval for this medication was based had strict enrollment criteria for the subjects, requiring that amyotrophic lateral sclerosis be recently diagnosed and relatively mild in order to maximize the likelihood of detecting the drugs effect on progression in a short period of time. The medical trial was designed to be applicable to all patients with amyotrophic lateral sclerosis, and Radicava is approved for all patients with amyotrophic lateral sclerosis. Radicava is medically necessary for this enrollee. 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 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 reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) level of care services. This patient underwent rehabilitation but plateaued with respect to her functionality considering her baseline condition, her bilateral lower limb impairments, and bilateral leg weight bearing restrictions. She remained dependent for transfers, non-ambulatory and requiring maximum assistance for lower body self-care. By the date of the Health Plans denial, there were no ongoing goals, medical, or nursing needs requiring SNF level of care services. Moreover, there is a paucity of evidence to support significant rehabilitation interventions during the period of immobilization and weight bearing restrictions following significant lower limb fractures, outside of obtaining compensatory skill. The records demonstrate that the patient requires custodial care services, not SNF level of care. All told, SNF level of care services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with attention deficit hyperactivity disorder (ADHD) and anxiety disorder. The patient reported difficulty sustaining attention. The records noted difficulty in school. The provider noted that the patient exhibited signs of hyperactivity, restlessness, and fidgeting. In the Independent Medical Review Application/Complaint Form, the patients parent reported the patient had a binge eating disorder, suicidal ideation, and episodes of self-harm via cutting. The patient appeared to be stressed and unhappy. The patient denied suicidal ideation. The patient reported panic attacks, paranoia, and vomiting to stay thin. The patients parent has requested authorization and coverage for a one-year supply of Vyvanse 20 mg. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether a one-year supply of Vyvanse 20 mg is medically necessary for the treatment of this patients medical condition. Researchers reported, Binge eating disorder in adolescents was highly comorbid with attention deficit hyperactivity disorder, mood and anxiety disorders, and severe obesity. Authors reported that Vyvanse is currently the only drug to be approved in the United States for the treatment of moderate to severe binge eating disorder (BED) in adult patients. Najib reported, The chronic nature of ADHD extends well beyond childhood and, in adolescents, may lead to a variety of risk-taking behaviors, which can have a significant adverse consequence for development and adult well-being. Lisdexamfetamine, a prodrug of d-amphetamine, is a once-daily medication indicated for the treatment of ADHD in children and adolescents. In this case, the patient has been diagnosed with ADHD. The patient was noted to have a history of binge eating disorder. The medical evidence supports the requested medication in this clinical setting. Therefore, a one-year supply of Vyvanse 20 mg 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 pediatrics 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.