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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with Crohns disease and axial spondyloarthropathy. The provider noted the patient has tried and failed treatment with Remicade, Humira, and Cimzia. She underwent laparoscopic ileocolic resection with creation of an end-ileostomy and drainage of a perianal access. The patient was taking Stelara 90 mg every four weeks. The patient reported her current ankylosing spondylitis symptoms were acceptable. The patient has requested authorization and coverage for Rinvoq extended release 15 mg tablet. 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 Rinvoq extended release 15 mg tablet is medically necessary for the treatment of the patients medical condition. Serhal and Edwards reported that upadacitinib is U.S. Food and Drug Administration (FDA) approved for the treatment of rheumatoid arthritis. Axial spondyloarthropathy includes both sacroiliitis and spinal arthropathy. Ward and colleagues did not include upadacitinib as a treatment option for axial spondyloarthropathy. In this case, the patient was diagnosed with Crohns disease with axial spondyloarthropathy. The patient has tried and failed Remicade, Humira, and Cimzia; however, there are no details provided regarding the duration of therapy and compliance with these medications. The medical evidence does not support the requested medication in this clinical setting. Therefore, upadacitinib (Rinvoq) extended release 15 mg tablet is not medically necessary for 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 in internal medicine with sub-specialty certification 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

Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. 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 where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections received. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injections to the right knee are medically necessary for the 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 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

The patient has requested authorization and coverage for endoscopy and monitored anesthesia care during the endoscopy procedure. Based on the available documentation, the requested endoscopy is medically necessary for evaluation of this patient. The patient has had rectal bleeding. Per the most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines, endoscopy is supported when there is active or recent gastrointestinal bleeding. Endoscopy is appropriate to evaluate the patient for bleeding sources such as a duodenal ulcer. Given this support, the requested endoscopy is medically necessary for evaluation of this patient. However, the records do not support the medical necessity of monitored anesthesia care during the endoscopy procedure. The ASGE guidelines state that monitored anesthesia care may be appropriate for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, American Society of Anesthesiology (ASA) class IV or V, or risk for airway obstruction due to anatomic variant. Per the ASA, monitored anesthesia care is warranted in prolonged or painful procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. This patients records do not report the presence of any anatomical variant to support an increased risk of airway obstruction, likelihood of intolerance or allergy to standard sedatives, or another indication for monitored anesthesia care during the endoscopy over conscious sedation. For these reasons, the requested monitored anesthesia care during the endoscopy procedure is not medically necessary for this patient. All told, the requested endoscopy is medically necessary for evaluation of this patient while the requested monitored anesthesia care during the endoscopy procedure is not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services 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 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

The patient has requested authorization and coverage for Lenvima 24 mg daily dose pack, 90 each per 30 days. This patient presents with stage IV metastatic recurrent vulvar cancer. She has been treated with chemotherapy regimens. The patients provider recommended treatment with Lenvima based on molecular profiling results. However, Lenvima is not U.S. Food and Drug Administration (FDA) approved for the treatment of vulvar cancer. Moreover, there is a paucity of peer-reviewed medical literature demonstrating improved patient health outcomes, or major drug compendia supporting an indication for Lenvima in this clinical setting. Researchers reported findings that Lenvima has antitumor activity consistently across diverse unresectable hepatocellular carcinoma models. Overall, the medical literature includes case reports on Lenvima, but there is a lack of larger trials establishing the safety and efficacy of Lenvima in patients with vulvar cancer. Given these findings, the requested Lenvima 24 mg daily dose pack, 90 each per 30 days is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Stelara 90 mg/mL administered every four weeks. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, The records noted that the patient experienced diarrhea if the prednisone dose was decreased below 20 mg daily. The patient has failed multiple biologic and conventional alternatives. Additionally, the patients joint pain may be due to insufficient control of Crohns disease, given that the pain was better controlled while on Remicade previously. Continuation of dosing every eight weeks or a change to another medication may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications.  Therefore, Stelara 90 mg/mL administered every four 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endoscopic revision of gastrojejunal anastomosis (CPT code 43999) and anesthesia (CPT code 00731). Thompson and colleagues studied the safety and efficacy of transoral outlet reduction for the treatment of weight regain in Roux-en-Y gastric bypass patients. Weight loss or stabilization was achieved in 96% of patients six months after outlet reduction. Researchers noted, When implemented as part of a multidisciplinary intervention, transoral outlet reduction using endolumenal suturing is safe, reproducible, and effective approach to manage weight recidivism after Roux-en-Y gastric bypass surgery. In this case, the patient has coronary artery disease requiring intervention at a young age. Due to the anatomic defect of a dilated gastrojejunal anastomosis, she is now at risk for weight regain after Roux-en-Y gastric bypass. As medications for weight loss are no longer usable in her case, she is at risk for recurrence of weight regain. This can re-institute the cardiac risks of obesity that had been reduced by the Roux-en-Y gastric bypass. Given the patients history of coronary artery disease requiring intervention, weight regain after Roux-en-Y gastric bypass in the setting of anatomic defect (dilated gastrojejunal anastomosis), and now inability to continue medications for weight loss, endoscopic revision of gastrojejunal anastomosis (CPT code 43999) is supported as medically necessary to address the anatomic defect leading to weight regain in this case. The request for anesthesia (CPT code 00731) care is also supported. The American Society for Gastrointestinal Endoscopy recommends monitored anesthesia care for prolonged procedures requiring deep sedation. As endoscopic revision of gastrojejunal anastomosis (CPT code 43999) requires endoscopic suturing and is a complex and prolonged procedure, the medical necessity of anesthesia (CPT code 00731) care is supported in this case. Therefore, endoscopic revision of gastrojejunal anastomosis (CPT code 43999) and anesthesia (CPT code 00731) are medically necessary for the 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: The patient has a history of seizures, frequent falls, chronic lumbar radiculopathy affecting the right lumbar level 4 nerve root, and distal polyneuropathy. At issue is whether the requested use of a power wheelchair is medically necessary for the enrollee. The patients physical and functional assessment for a motorized wheelchair notes that she is independent with the activities of daily living and instrumental activities of daily living. She is noted to be able to travel independently on public transportation to doctor visits using the four-wheeled walker. Her sitting and standing balance is intact and bilateral muscle strength is noted to be good (4+/5). The patients best distance traveled with a four-wheeled walker is 1000 feet with a controlled gait. Literature reports that the use of a passive mobility device such as a motorized wheelchair can place individuals at risk of de-conditioning and cardiovascular morbidity. Based on the medical records provided, the patient is functionally independent and fully ambulatory at home and in the community with a four-wheeled walker with a seat, therefore, a motorized (power) wheelchair is not medically necessary for the patient. Final Result: The reviewer determined that the requested service was not 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

At issue is whether the requested percutaneous tibial nerve stimulation (PTNS) is medically necessary to treat the enrollees medical condition. The urologist noted the patients complaint of worsening urinary incontinence, and that behavioral modifications, anticholinergic therapy, and pelvic floor muscle training had decreased the use of urinary pads from 3 to 1 pad per day with less nocturia and minimal incontinence. The urologist noted that the medications were only partially controlling the patients incontinence. PTNS can be considered for a diagnosis of overactive bladder (OAB) per the American Urological Association guidelines after other treatments have been tried (behavioral modifications, pelvic floor muscle therapy and medications). Current literature review of various forms of electrical stimulation for OAB found that in 3 studies involving 269 women, PTNS was more effective than no active treatment, placebo or sham treatment. While there has been some improvement, this patient remains symptomatic despite treatment with pelvic floor physical therapy, behavioral modification with lower pad usage, and the use of oxybutynin and Myrbetriq. 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 urology 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: An enrollee has requested authorization and coverage for two (2) additional hours of Direct Applied Behavioral Analysis (ABA) therapy services (15 hours total) per week.At issue is whether the requested additional two (2) hours of Direct Applied Behavioral Analysis (ABA) therapy services (15 hours total) per week are medically necessary for the patients condition.In this case, the goals being addressed by the provider fit well within the description of focused treatment found in CASP guidelines, and the intensity requested reflects the patient's response to treatment and his individual needs (as is well documented in the provider's treatment authorization request). With 15 goals being addressed, covering both skill acquisition and interfering behavior reduction, 15 hours of direct ABA per week is an appropriate level of intensity to meet the patient's medical needs. Providing fewer hours will likely result in the overall duration of treatment being extended. Accordingly, the requested additional two (2) hours of Direct Applied Behavioral Analysis (ABA) therapy services (15 hours total) per week are medically necessary for the patients condition.Final Result: The reviewer determined that the requested services are medically necessary for the patients condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is a licensed psychologist who is a board certified behavior analyst 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 requested authorization and coverage for brand name Nuvigil 150 mg daily. The patient underwent an adequate normal in lab polysomnogram (PSG) with an apnea/hypopnea index (AHI) of zero events per hour, oxygen nadir of 95% and adequate sleep time. The PSG was followed by a multiple sleep latency test (MSLT), which noted that the patient had four naps with a sleep latency 7.5 minutes and no SOREM, which is consistent with a diagnosis of idiopathic hypersomnia. A negative MSLT for narcolepsy does not rule out narcolepsy when the clinical suspicion is high, as in this patients case. Nuvigil is an oral non-amphetamine wake-promoting agent, the R-isomer of racemic modafinil. Nuvigil and modafinil share many clinical and pharmacologic properties and are distinct from central nervous system stimulants. Nuvigil is supported as safe and effective for the treatment of excessive daytime sleepiness secondary to idiopathic central hypersomnia. The records document that treatment with modafinil 200 mg twice daily was inadequate to control the patients excessive daytime sleepiness. Moreover, the patient has a diagnosis of celiac disease, for which the provider recommended the brand name Nuvigil, which is gluten free. Given these findings, the requested brand name Nuvigil 150 mg daily is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in sleep 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

The patient has requested authorization and coverage for eight weeks of continued physical therapy. The records provided for review document that this patient has undergone extensive physical therapy consisting of 24 visits for her feet and ankles. The notes from her foot and ankle physical therapy suggest that the repeated objective examination findings of flexibility, joint integrity, muscle testing, palpation of soft tissues and pain levels do not reveal significant improvement from the start of physical therapy. The patient has not completed physical therapy for her low back pain. There is documentation of a lumbar x-ray revealing facet disease. However, there is no objective magnetic resonance imaging (MRI) or electrodiagnostic study to rule out a possible radicular etiology causing the patients back and ankle symptoms. The records indicate that the patient has received instruction on a home exercise program for her foot and ankle pain. The documentation reviewed does not demonstrate that the patient requires the unique skills of a therapist for continued rehabilitation or that the patient has made objective gains to support an indication for additional physical therapy. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design or deliver a program to maintain the patients current condition or to prevent or slow further deterioration. All told, the requested eight weeks of continued physical therapy is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

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 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. Given these findings, the patient meets the six ASAM criteria for RTC level of care services. Therefore, the 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 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.