Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block therapy and prospective authorization and coverage for continued occipital nerve block therapy.Findings:  Two of the three physician reviewers found that occipital nerve blocks are a safe and medically reasonable treatment for occipital neuralgia and cervicogenic headache. In this case, the patient has documented objective findings consistent with occipital neuralgia. The patient also has a past medical history that is significant for occipital neuralgia, chronic pain syndrome, chronic myofascial pain, chronic cervical pain, facet arthropathy, and cervical and cervicogenic headache. Furthermore, the patient has previously undergone occipital nerve blocks with documentation of efficacy and durability of 4 months. Therefore, the patient has documented occipital neuralgia as well as documentation of the efficacy and durability of prior injection therapy to substantiate the need for repeat injection. Accordingly, the service at issue were and are likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in anesthesiology, with subspecialty certification in pain management, and are actively practicing. The 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensive outpatient program services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees substance abuse and depression. At issue in this case is whether the requested intensive outpatient program services are medically necessary for treatment of the enrollees behavioral health condition.The American Psychiatric Association treatment guideline for major depressive disorder notes that admission to an intensive day program, may also be indicated for severely ill patients who lack adequate social support outside of a hospital setting, who have complicating psychiatric or general medical conditions, or who have not responded adequately to outpatient treatment. The American Psychiatric Association treatment guidelines for substance use disorders recommends that residential treatment or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use.. lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.The patient requires a safe and stable living environment in order to develop recovery skills thus qualifying for American Society of Addiction Medicine level III treatment at least i.e. residential or inpatient treatment similar to what patient received at the facility. Patients conditions wax and wane: a relatively positive documentation by one person on one day does not indicate spontaneous cure or that the patient is in the clear, it simply denotes progress and that treatment is working, which is an indication to continue not cease treatment.Given the severe illnesses, continuing to drive despite a driving under the influence arrest and lack of support in the community, treatment with an intensive outpatient program is consistent with standards of good medical practice in the United States, not costlier than an alternative similar service and is thus medically necessary.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 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 abdominal and leg ultrasounds.  The Health Plan denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees chronic abdominal pain, right knee joint pain and right knee arthritis. Regarding the request for an abdominal ultrasound, researchers compared the accuracy of CT scans versus ultrasound in patients with abdominal pain. They found that CT scans were more accurate and able to detect both soft tissue, viscus and bone abnormalities more accurately than ultrasound. Since the patient has already had two normal CT scans recently, ultrasound would be expected to add little additional information for pain management, and is therefore not medically necessary. With respect to the request for leg ultrasounds, the American College of Radiology does not recommend ultrasound for evaluation of patients with chronic knee pain.  Magnetic resonance imaging (MRI) of the knee taken previously confirmed the osteoarthritis in the right knee. Although the patient has a distant history of pulmonary embolism, an ultrasound previously showed only mild greater saphenouos vein reflux. A physician exam previously did not show low leg edema or calf tenderness. In the absence of demonstrable warning signs (edema, calf tenderness), a repeat ultrasound is unlikely to add any additional management information beyond the already performed MRI and ultrasound. Therefore, ultrasounds of the legs are not medically necessary.Final Result: The reviewer determined that the services at issue are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance guided high intensity focused ultrasound ablation. According to current literature the utilization of magnetic resonance guided high intensity focused ultrasound may be a feasible treatment option for desmoid tumors per preliminary investigation. However, further investigation is necessary to better define the indications, efficacy, role, and long-term oncologic outcomes of focused ultrasound treatment. Currently, the standard of care does not include the utilization of the requested treatment. Although the provider noted the patient has been treated with chemotherapy with progression, magnetic resonance guided high intensity focused ultrasound ablation has not been demonstrated to result in improved health outcomes when compared with standard alternative therapies. As such, the requested high intensity focused ultrasound ablation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that high intensity focused ultrasound ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not and are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology and is 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly allergy/immunotherapy injections (CPT codes 95117 and 95144). The submitted documentation fails to demonstrate the medical necessity of the requested services. Allergy shots are indicated for persistent symptoms on a seasonal and/or perennial basis for patients with an inadequate or partial response to environmental control and medications. The medical evidence supports skin testing and allergy shots as an effective treatment for allergic rhinitis, asthma and atopic dermatitis. As noted by researchers, the maintenance phase begins when the effective therapeutic dose is reached. Once the maintenance dose is reached, the intervals between allergy injections are increased. The dose generally is the same with each injection, although modifications can be made based on several variables. The researchers noted the intervals between maintenance immunotherapy injections generally range from four to eight weeks for venom and every two to four weeks for inhalant allergens but can be advanced as tolerated if clinical efficacy is maintained. In this case, the medical records indicate that the patient is on maintenance therapy. The maintenance therapy is for inhalant allergies and would typically be every four weeks, and up to every two weeks, if needed. The medical records fail to demonstrate the need for weekly injections during the maintenance phase. Therefore, weekly allergy/immunotherapy injections (CPT codes 95117 and 95144) 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 allergy and immunology 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 aquatic therapy; OxyContin 30mg 90 pills for 30 days; Valium 10mg 120 pills for 30 days; Soma 350mg 90 pills for 30 days; a consultation with an orthopedic specialist; a consultation with a neurologist; and magnetic resonance imaging of the head. The Health Plan has denied these requests indicating that the requested services are not medically necessary for treatment of the enrollees chronic left sided low back pain with left sided sciatica; chronic pain; chronic left knee pain; chronic neck pain; mandibular pain; left retinal disease; concussion without loss of consciousness; and anxiety.At issue in this case is whether the requested aquatic therapy; OxyContin 30mg 90 pills for 30 days; Valium 10mg 120 pills for 30 days; Soma 350mg 90 pills for 30 days; a consultation with an orthopedic specialist; a consultation with a neurologist; and magnetic resonance imaging of the head are medically necessary for treatment of the enrollees medical condition.The submitted documentation fails to demonstrate the medical necessity of the requested services. The patient has no new findings to warrant the above treatments. He is non-compliant. There are issues of diversion. The medical evidence does not support the requested services in this clinical setting. Therefore, the requested services are not medically necessary.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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Linzess capsules. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic idiopathic constipation. A review of the records indicates that the enrollee has been diagnosed with chronic idiopathic constipation, gastroesophageal reflux disease with esophagitis, with a history of anorexia. The records indicated ongoing constipation issues despite referral to the registered dietician and eating disorder coach, as well as use of fiber, Colace, and administration of enemas several times per week. The enrollee is noted to have adequate hydration and activity level.The submitted documentation supports the medical necessity of the requested medication. The patient has reported that use of an osmotic laxative (Miralax) has not been successful. The provider has reported, additionally, that such laxatives are to be avoided due to the patients history of anorexia. Findings note that Linzess is indicated to restore colonic function in chronic constipation, and is FDA-approved for chronic constipation. It is not specifically a laxative, has a different mechanism of action than osmotic laxatives, and can be effective even if agents such as laxatives and fiber failed. Findings note, in multicenter, randomized, blinded, placebo-controlled Phase III clinical trials, Linzess significantly increased weekly spontaneous bowel movements while reducing abdominal pain in patients with chronic constipation. In this case, the patient reports failure of multiple alternatives (including Miralax, or polyethylene glycol), and the provider reports that her eating disorders are a contraindication to laxatives in this case. The current medical evidence supports the use of Linzess in this clinical setting. Therefore, the request for Linzess capsules is supported as medically necessary for the treatment of the patients chronic idiopathic constipation.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 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: An enrollee has requested authorization and coverage for 4 additional lidocaine trigger point injections. The submitted documentation supports the medical necessity of the requested services. A trigger point is a focus of hyperirritability in a tissue that, when compressed, is locally tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness. Trigger points may also give rise to referred autonomic phenomena and distortion of proprioception. Once trigger points are formed, they are thought to be self-perpetuating. Although trigger points may cycle between active and latent, they do not typically self-resolve. Trigger point injections have been shown to provide relief. In this case, the patient has masticatory myalgia. Contributing factors to the patients masticatory myalgia are abnormal skeletal and dental alignment and structural abnormality of her TMJ. Given this, the requested additional trigger point injections will likely provide the patient with relief as one element of her oral surgeons recommendations. Under these circumstances, 4 additional Lidocaine trigger point injections are medically necessary for treatment of the patients medical condition.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 oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for one-to-one applied behavior analysis (ABA) program, 40 hours per week, and a behavioral aide 5.5 hours per day. ABA therapy has been identified as the most evidence-based treatment for individuals with autism. The Behavior Analysis Certification Board (BACB) indicates that treatment for autism can be focused (25 hours or less per week), or comprehensive (30 to 40 hours per week). The BACB notes that behavior that threatens the health or safety of the patient or that constitutes a barrier to quality of life should result in more intensive ABA services. In this case, it is not clear from the data presented that the patient has behavioral excesses that pose a threat to his safety or constitute a danger to himself or others. Specifically, the provider report dated October 2018 noted the current target behavior to be emotional dysregulation, which was defined at school as frequent peer altercations and intimidation, all of which have decreased over time since baseline data was collected in March 2017. Finally, research support for intensive ABA therapy provided to children older than seven years of age is mixed. Studies indicate that younger participants aged two through seven show a greater benefit from increased treatment hours when compared to older participants. This provides additional support for maintaining the current number hours approved in this patients case. In sum, the hours previously approved are sufficient for the patient, and increased ABA therapy is not medically necessary. The patient does not present with the type or intensity of problematic behaviors that warrant more intensive support. Therefore, the requested one-to-one applied behavior analysis (ABA) program, 40 hours per week, and a behavioral aide 5.5 hours per day were not and are not medically necessary for the 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 a board certified behavior analyst and licensed psychologist 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 the medication armodafinil. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees multiple sclerosis (MS). At issue in this case is whether the requested medication armodafinil is medically necessary for treatment of the enrollees medical condition.Armodafinil is not FDA approved for fatigue management in relation to multiple sclerosis. There is no indication of mitigating circumstance. The records report fatigue in condition of MS. Findings noted multiple therapeutic treatments for MS related fatigue, but armodafinil is not supported as having peer reviewed literature in support of treatment. Findings note that armodafinil has not shown benefit in treatment of fatigue related to MS. Armodafinil is not medically necessary for treatment of the 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 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.