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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ruxolitinib. Findings:  The physician reviewer found that Ruxolitinib is U.S. Food and Drug Administration (FDA) approved for the treatment of polycythemia vera with an inadequate response to or intolerance to hydroxyurea. Ruxolitinib is currently considered the standard of care in well selected patients as shown in several clinical trials. Vannucchi and colleagues concluded that for patients who had an inadequate response to or had unacceptable side effects from hydroxyurea, ruxolitinib was superior to standard therapy in controlling the hematocrit, reducing the spleen volume, and improving symptoms associated with polycythemia vera. This patient is intolerant of Hydrea and carries a mutation making him at higher risk for myelofibrosis. All told, the requested ruxolitinib is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections. This patient has been diagnosed with bilateral knee osteoarthritis. She has worsening knee pain and functional impairment in activities of daily living that has failed to respond adequately to conservative treatment. Prior Orthovisc provided pain reduction and functional improvement lasting at least six months, followed by recurrence of pain and functional limitations. She is not currently a candidate for total knee replacement due to her age. Evidence-based medical guidelines and peer-reviewed medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given this patients previous response and to assist in delaying total knee replacement, repeat Orthovisc injections are indicated. Therefore, the request for bilateral Orthovisc 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pelvic magnetic resonance imaging (MRI) with and without contrast. Plexopathy will typically manifest as pain with a neuropathic character affecting more than one peripheral nerve distribution. Associated weakness or other neuropathic symptoms may be present. MRI of the lumbar plexus with and without contrast is the appropriate examination to determine if the cause of the plexopathy is intrinsic or extrinsic. In this patients case, her symptoms may be due to a plexopathy. The records document symptoms that may be attributed to both the L2-3 and L5 distribution. Prior MRI of the lumbar spine did not demonstrate findings that would account for the patients symptoms. In this setting, MRI of the pelvis with attention to the lumbosacral plexus is medically indicated. There is sufficient support for the requested services in this clinical setting. Therefore, the requested pelvic MRI with and without contrast is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trokendi. Long-acting topiramate (Trokendi) is U.S. Food and Drug Administration (FDA) approved for migraine therapy. Moreover, data suggests that Trokendi offers a lower side effect profile than immediate release topiramate. This patient has chronic migraine as well as Lupus. She was treated with immediate release topiramate, which provided a good result with regard to her headaches. However, she is experiencing tingling with topiramate, which caused her providers to recommend Trokendi. It is within the current standard of care to provide A study finds that Trokendi to patients who respond to the therapeutic effect for migraine, but have significant side effects with immediate release topiramate. Given this support, the requested Trokendi is medically necessary for treatment of this patients migraines. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for the following inpatient neuro-rehabilitation treatment program services: physical therapy, occupational therapy, speech therapy, educational therapy, counseling, nursing, behavior management, clinical case management and family counseling and education. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient is likely to benefit from a facility dedicated to neuro-rehabilitation. Per the records, he is displaying symptoms that are behavioral as well as cognitive secondary to anoxic brain injury from carbon monoxide poisoning. Neuro-rehabilitation programs typically have a team-based approach to treating neurobehavioral problems. These teams usually include psychologists, psychiatrists, social workers, occupational therapists and physical therapists. The use of specialized mental health workers is unique to neuro-rehabilitation facilities. This patient requires inpatient level of care as he poses a danger to himself and others. He requires constant supervision. The requested services are medically appropriate in this clinical setting. Therefore, the following inpatient neuro-rehabilitation treatment program services: physical therapy, occupational therapy, speech therapy, educational therapy, counseling, nursing, behavior management, clinical case management and family counseling and education 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone/acetaminophen. In this case, the patient reports lumbar back pain secondary to lumbar spondylosis and vertebral body hemangiomas. The records document that the patient has a signed opioid contract on file. However, as noted in the current medical literature, chronic opioid therapy is not considered the first-line treatment for chronic lumbar back pain. In this case, there is no documentation of trials of first-line medications or non-medication attempts at conservative care. Without documentation of attempts at conservative care or evidence of adequate trials of first-line medications to control the patients pain, the requested oxycodone/acetaminophen 7.5 mg/325 mg every four hours, for a quantity of #180 every 30 days, or oxycodone/acetaminophen 5 mg/325 mg, two tablets every four hours, for a quantity of #360 every 30 days, is not medically necessary. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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

An enrollee has requested cryoablation. Consensus guidelines from the American Society for Radiation Oncology (ASTRO) and National Comprehensive Cancer Network (NCCN) do not support the use of cryoablation therapy in this clinical setting. Further, there is a lack of medical literature to suggest that treatment with cryoablation offers a substantial benefit compared to proven therapies for treatment of pleural metastases. Standard treatment with photon radiation therapy is associated with a low risk of toxicity and has been demonstrated in the peer-reviewed medical literature to be safe and effective. In addition, there are limited data demonstrating that treatment with cryoablation will improve sparing of the surrounding normal structures compared to radiation therapy. Based on these findings, cryoablation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found cryoablation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the cryoablation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with alcohol use disorder, severe and unspecified anxiety disorder. This patient was originally admitted as an inpatient, secondary to trauma that was sustained while intoxicated. The patient was admitted, underwent detoxification, and was discharged. Upon discharge, he was admitted to intensive outpatient program (IOP) services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. For the dates in question, the patient denied suicidal and homicidal ideation, auditory and visual hallucinations, and psychosis. There was no report of this patient requiring assistance with activities of daily living. The patient was cooperative with care and actively participated in his treatment. He was attending 12-step groups, counseling, and psychoeducation. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary level of care for adults. Using LOCUS, treaters 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) medical, addictive 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 American Society of Addiction Medicine (ASAM) criteria are is a set of objective guidelines used by clinicians to assist with treatment planning and advocates for service intensity provided in the least intensive but safe treatment setting. Thus, the patient has a composite score of 10, which correlates with treatment in a community-based outpatient clinic setting. Treatment in the outpatient setting is also consistent with the ASAM criteria. All told, the IOP services provided from 5/10/17 through 5/19/17 were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry 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 Xeljanz. The Health Plan has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The current guidelines continue to recommend a second necrosis factor inhibitor over Xeljanz (tofacitinib). In this case, the patient has a history of seropositive rheumatoid arthritis and fibromyalgia. At this time, the records fail to demonstrate that she has a contraindication to a second necrosis factor inhibitor trial. As such, Xeljanz 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 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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 12 physical therapy sessions. Overall, the documentation does not support that skilled physical therapy services are required to treat the patients illness or injury, improve or maintain her condition, or to prevent deterioration of the patients condition. The records do not report that the patients condition requires the services of a skilled physical therapist or require direct supervision of a skilled therapist. Physical examination on 12/14/18 did not reveal significant objective findings. In addition, the documentation does not include evidence of significant objective functional improvement from prior physical therapy visits to support additional services. Moreover, the patient has had extensive prior knee therapy and should be well versed in a home exercise program. Accordingly, the requested 12 physical therapy sessions are not medically necessary for treatment of this patients knee pain. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperthermic intraperitoneal chemotherapy. Findings:  Three physician reviewers found that hyperthermic intraoperative chemotherapy involves instillation of heated chemotherapy at the time of surgery. Major concerns about this approach include its inherent potential morbidity, the lack of randomized trials confirming the theoretical advantage of hyperthermia, and that longer postoperative recovery time may result in delay, decreased dose intensity, or even withdrawal from subsequent systemic chemotherapy, thereby worsening prognosis. The National Comprehensive Cancer Network guidelines do not mention the use of hyperthermic intraperitoneal chemotherapy as a treatment option. Therefore, the requested hyperthermic intraperitoneal chemotherapy is not likely to be superior over other treatment options.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 tadalafil 11 mg troche daily. There is sufficient support for the requested medication in this patients case. Phosphodiesterase type 5 inhibitors have been shown to be effective following radical prostatectomy. Daily phosphodiesterase type 5 inhibitors are generally recommended. This patient was appropriately placed on daily tadalafil. Tadalafil troche is efficacious for erectile dysfunction in this clinical setting. Therefore, the requested tadalafil 11 mg troche daily 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a transgender male to female with a diagnosis of gender dysphoria and reports continued symptoms despite conservative treatments. She shared that she experiences emotional distress and anxiety daily. FFS would provide reconstructive surgical services for an abnormality as a result of the patients disorder of gender dysphoria. The outcome of reconstructive surgery would be enhancement of psychological and social functioning. The guidelines for the medical necessity of FFS exist in two reviews from World Professional Association for Transgender Health (WPATH) and the Transgender Law Center. The WPATH states that in addition to hormonal balancing, facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. This patient has a documented history of gender dysphoria and has been treated with cross-gender hormone therapy. The patient is noted to have emotional distress daily due to the presence of masculine physical facial features. Based on the documented history of gender dysphoria and evidence in support of the medical necessity of FFS, all of the requested surgeries are found to be medically necessary for treatment of this patients gender dysphoria. 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.