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 120 pills per month of Nucynta 50 mg (once every six hours). The submitted documentation does not support that the requested medication regimen is medically necessary. In the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication, and several requirements for opioid prescribing have not been documented. The need to use opioids as the primary medication treatment strategy for pain has not been established in this documentation. The CDC states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to 90 MME/day or carefully justify a decision to titrate dosage to 90 MME/day. In this case, the patient was recently taking 160 MME/day. No medical evidence based rationale is given by the physician or the patient, nor is there recognition of the long term consequences with the continual increase in opioids. Risk and benefit analysis must be done to justify the requested level of 80 MME/day. No clear objective goals with this high of a dose of opioid has been established by the physician or the patient. Moreover, pure mu agonists are not considered evidence based treatments for Fibromyalgia, not to mention the adverse effects in Fibromyalgia patients specifically. Also, not all non-opioid medications classes have been documented to have been optimized or tried. Under these circumstances, the request for 120 pills per month of Nucynta 50 mg (once every six hours) is not medically necessary for treatment of the enrollees medical condition.Final Result: The reviewer determined that the requested medication regimen 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 management. 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 Norco 10/325 mg, quantity 270, every 30 days, and morphine ER 30 mg, quantity 30, every 30 days. The submitted documentation does not support that the requested medication regimen is medically necessary. Records reflect that the patient is on high dose opiate therapy for non-malignant pain. The use of anti-Paget Disease agents is not documented, and opiates are not appropriate to treat the pain of Paget's Disease. Furthermore, the rationale for continuing opiates as presently requested is not consistent with clinical practice guidelines as set forth in the CDC Guideline for Prescribing Opioids for Chronic Pain--United States. Under these circumstances, the request for Norco 10/325 mg, quantity 270, every 30 days, and morphine ER 30 mg, quantity 30, every 30 days, is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication regimen 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 management. 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 custom orthotics. The nationally-recognized, evidence-based Official Disability Guidelines (ODG) state that both prefabricated and custom orthotic devices are recommended for plantar fasciitis. Wrobel and colleagues conducted a randomized, controlled trial of custom foot orthoses for the treatment of plantar heel pain. They concluded that custom foot orthoses demonstrated 5.6-fold greater improvements in spontaneous physical activity versus pre-fabricated orthoses or sham insole treatment for plantar fasciitis. A study concluded that there was strong evidence for the prescription of custom-made foot orthoses in painful pes cavus and for foot pain in juvenile idiopathic arthritis, rheumatoid arthritis, plantar fasciitis and hallux valgus.Here, the patient presents with worsening bilateral foot pain with associated functional mobility limitations. Signs/symptoms and clinical exam findings are consistent with plantar fasciitis. She has failed to improve despite long-term conservative treatment, including over-the-counter orthotics, shoe wear modifications, exercise, ice, massage, topical and oral NSAIDs, corticosteroid injections, and activity modification. Current evidence-based medical guidelines and literature support the use of custom foot orthotics for the treatment of plantar fasciitis in this setting. Therefore, this request for custom orthotics is medically necessary for treatment of the enrollees plantar fasciitis. Final Result: The reviewer determined that the requested items 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin 10mg/2mL. Consensus guidelines establish that the dose of growth hormone in young men (0.2 mg/day) is much lower than a pediatric dose. Across the majority of studies, growth rates used to define near-adult height and consideration of growth hormone discontinuation vary from rates between 2 to 2.5 cm/year. Definition by bone age also varies across studies, with 1415 years used for girls and 1617 years used for boys. In this case, the patients height at his most recent office visit was 167.3 cm, and the measurement at his prior office visit, three months earlier, was also 167.3 cm, so there was no growth in the last 3 months. Both of these findings are consistent with the end of the growing period, and at this point it is appropriate to stop growth hormone treatment and monitor for adult growth hormone deficiency. If growth hormone therapy is continued at the requested dose, the patient could start to develop signs of acromegaly and thus it is not medically necessary that the requested medication be continued at the requested dose. Therefore, Nutropin AQ Nuspin 10mg/2mL is not medically necessary for the 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 subspecialty 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Oncotype Dx colon cancer assay test. The provider recommended Oncotype Dx colon cancer assay testing to help determine if the patient should receive s deferential amount of cycles of FOLFOX chemotherapy for treatment of stage II colon cancer. Recent literature and guidelines were reviewed, at this time; there is no conclusive evidence supporting the utility of Oncotype DX in treatment determination (predictive markers) or prognosis in patients with colon cancer. The use of OncotypeDx for determining duration of therapy is not an established standard of care. It is not likely to be more beneficial for this patient than any other standard treatment.Final Result: The reviewer determined that the services in 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 internal medicine with subspecialty certification in hematology and 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 reimbursement and prospective authorization and coverage intensive outpatient program (IOP) services provided. The APA established a set of guidelines for determining the appropriate level of care for patients with eating disorders. Per medical guidelines, intensive outpatient programs (Level 2) are recommended for patients are:Medically stable; Self-sufficient or require minimal structure to  facilitate weight gain; Avoid compulsive exercising; Achieve and maintain a weight greater than 80-85% of normal;Exhibit no suicidality;Show fair to good motivation for change, adequate environmental support; Have no psychiatric co-morbidities requiring hospitalization or residential treatment, geographic proximity to treatment center; and Demonstrate the ability to control or eliminate purging.In this case, the patient began receiving IOP services.Laboratories drawn at that time and repeated a week later showed metabolic markers within normal range. There is no documentation suggesting suicidality or purging.  The patient was participating in group sessions indicating fair motivation.  By the 4th week, the patient no longer met APA criteria for IOP services. Daily notes indicate that the patient was able to control eating and was not purging. The patient was noted to have supportive parents. The patient did not require structured eating and did not need to be monitored for avoidance of excess exercise. Per the submitted records, the patient had improved greatly, was adhering to a meals program, had medications adjusted appropriately and was stable for transition to a lower-intensity outpatient treatment program. Therefore, in accordance with APA guidelines, intensive outpatient program (IOP) services were not and are not medically necessary for 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right hip arthroplasty. The submitted documentation supports the medical necessity of the requested procedure. Official Disability Guidelines (ODG), nationally recognized evidence based medical guidelines, recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. A study concluded that six months after total joint replacement (TJR), severely or morbidly obese patients reported excellent pain relief and substantial functional gain that was similar to the findings in other patients. While obesity is associated with a greater risk of early complications, obesity in itself should not be a deterrent to undergoing TJR to relieve symptoms. In this case, a patient presents with a history of chronic right hip/groin pain and associated functional mobility limitations. Clinical exam findings have been consistent with imaging evidence of severe right hip osteoarthritis. Detailed evidence of reasonable and/or comprehensive non-operative treatment, including activity modification, medications, corticosteroid injections, physical therapy, acupuncture, weight loss, and chiropractic, and failure has been submitted. This patient has a markedly elevated body mass index above 50 and has been unable to lose more than 50 pounds. There is evidence of significant weight loss attempts including weight loss programs and bariatric surgery. There is evidence of significant psychological barriers to additional weight loss. She is requesting authorization to proceed with total hip replacement with an out-of-network orthopedic specialist who has discussed the increased risk factors and is willing to proceed with total hip replacement. There is evidence based medical literature support to proceed with total hip replacement for pain relief and functional improvement in the setting of morbid obesity and as a relative exception to guidelines. Therefore, the requested right total hip arthroplasty is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested procedure 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation (TMS). Findings:  Three physician reviewers found that the services in issue were likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. The patient had received approximately 36 TMS treatments prior to receiving the services in issue. The Health Plan stated that additional TMS sessions, beyond 36 sessions, is investigational. The exact number of TMS treatments needed for successful depression symptom resolution, however, is not clearly defined in the evidence based literature. It does appear that certain patients need more than 30 treatments to come to successful resolution of their symptoms. The optimal TMS protocol remains unclear. Due to the fact that there are no hard and fast guidelines for the exact number of necessary TMS treatment sessions, and the fact that many patients respond slightly or drastically different to TMS, it appears that the number of sessions often needs to be considered on a clinical basis instead of a numerical basis. In this case, the patient was treated with very close to the current recommendation of approximately 30 sessions. It appears that the patient was tolerating treatment well and that the eventual sessions administered during the period in issue were more effective for him. The patients number for treatment sessions was not drastically outside of the loose recommendations for TMS, and the evidence base is unclear on the exact number recommended treatments. Therefore, the transcranial magnetic stimulation (TMS) received was likely to be more beneficial for treatment of the patient's condition than any other available standard therapy.Final Result: The reviewers determined that the services in issue were likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in psychiatry 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 warfarin/Coumadin and standing orders for Protime and international normalized ratio (INR) laboratory testing to be performed every three months. The medical evidence supports the requested medication and requested services in this clinical setting. This patient has recurrent PE/DVT and likely requires lifelong anticoagulation regardless of his factor V Leiden. Based on this patients medical history, warfarin/Coumadin is medically necessary. Coumadin is a drug that requires close monitoring. A level too low can result in increased risk of further blood clots, and a level too high can increase the risk of bleeding. Thus, ongoing INR testing is medically necessary. In sum, warfarin/Coumadin and standing orders for Protime and INR laboratory testing to be performed every three months are medically necessary for the evaluation and treatment of this patient. Final Result: The reviewer determined that the requested medication and requested services are medically necessary for evaluation and 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 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: Upheld Decision of Health Plan

A female enrollee has requested authorization and coverage for eye movement desensitization and reprocessing (EMDR) for two hours per day for 90 days, or at any frequency or duration, cognitive behavioral therapy (CBT) twice per week, or at any frequency and duration, and residential treatment center (RTC) level of care with dual diagnosis. In review and consideration of additional documentation provided, the requested services including EMDR for two hours per day for 90 days, or at any frequency or duration, CBT twice per week, or at any frequency and duration, and RTC level of care with dual diagnosis are not medically necessary for treatment of this patients behavioral health issues. There is no new information to show that the patients condition warrants these treatment interventions. The patient is not documented to be a danger to herself or others, or demonstrate emotional, behavioral, or cognitive factors necessitating residential level of care. The patient has been medically stable. She had demonstrated the ability to maintain an extended period of sobriety while travelling between two states, and attending meetings and having sponsors in both states, showing motivation for sobriety. The patient has a history of extensive residential and IOP levels of care, as well as extensive EMDR and DBT. Her Clinical Institute Withdrawal Assessment (CIWA score was 3, with mild symptoms of non-observable tremors, mild anxiety, and agitation was 1. There were no subjective or objective findings of post-traumatic stress disorder (PTSD) symptoms including severity which would substantiate the request for EMDR or CBT. The patients presentation supports treatment at the ambulatory level of care with the aid of ongoing AA and her sponsor. All told, the requested EMDR for two hours per day for 90 days, or at any frequency or duration, CBT twice per week, or at any frequency and duration, and RTC level of care with dual diagnosis, are not medically necessary for treatment of this patients behavioral health issues.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A parent of a minor enrollee has requested reimbursement for intensive outpatient (IOP) services from 7/27/18 going forward. Applying the Child and Adolescent Level of Care Utilization System (CALOCUS), the IOP services provided to this patient from 7/27/18 forward were and are medically necessary. The records indicate the patient presents with some risk of harm due to recent self-harm urges (score 2). The patients functional status is moderately compromised with deterioration in expected level of functioning in relationships with peers, adults and family (score 3). The patient presents with no co-morbid medical condition or history of substance abuse (score 1). The patients recovery environment is moderately stressful as the patient has severe problematic issues with family relationships (score 3). In addition, the patients recovery environment is supportive as her family is actively participating in treatment, but have their own issues that are hampering her progress including enabling behaviors (score 2). Further, the patient has demonstrated limited response to treatment due to minimal progress in the IOP (score 3). The patient has been obstructive to treatment as she intermittently participates, but appears non-committal (score 3). Further, her parents have been working actively and constructively with the patients providers (score 2). This gives the patients presentation a composite score of 19, which correlates with IOP level of care services. The progress notes indicate the patient has made minimal behavioral improvements since starting IOP services. The patient was noted to continue to have stressful relationships with her family due to her behavioral issues. She was documented to have continued thoughts of hopelessness and was anxious on a consistent basis. The progress notes indicate that she has difficulty following through with therapeutic activities and appears to be only minimally invested in treatment. The provider documented episodes of impulsive behavior in the last several weeks. This presentation supports treatment at the IOP level of care. Given these findings, the IOP services provided from 7/27/18 forward were and are medically necessary for treatment of this patients behavioral health issues.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 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.