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

Nature of Statutory Criteria/ Case Summary:  The enrollees representative is requesting reimbursement and authorization and coverage for residential treatment center services. The enrollee has diagnoses of moderate recurrent major depressive disorder, combined presentation attention deficit hyperactivity disorder, intermittent explosive disorder, nicotine dependence, cannabis use disorder, and alcohol abuse. The Child and Adolescent Level of Care Utilization System (CALOCUS) developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. This tool was used in this review. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. For risk of harm, the enrollees score is 3, as he has no active suicidal or homicidal ideation, but he displays extreme distress and there is a history of suicidal/homicidal behavior. For functional status the enrollees score is 2, as the enrollee demonstrates significant improvement in function following a period of deterioration. For comorbidity the enrollees score is 2, due to the presence of transient, occasional, stress-related psychiatric symptoms that have no discernable impact on his presenting condition. For recovery environment level of stress, the enrollees score is 3, due to exposure to substance abuse and its effects. For recovery environment level of support, the enrollees score is 2, as the family/primary caretakers are willing and able to participate in treatment if requested to do so and have the capacity to effect needed changes. For resiliency and treatment history the enrollees score is 3, since previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. Also, developmental pressures and life changes have caused some deterioration in function. For acceptance and engagement the enrollees score is 2, as the enrollee has developed a positive therapeutic relationship with clinicians and other primary care givers. The enrollees composite CALOCUS score is 17, which correlates with high intensity community-based services, as provided at the intensive outpatient program (IOP) level.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting reimbursement for Euflexxa injections for both knees. The enrollee has bilateral knee primary osteoarthritis. Physical exam notes describe bilateral bony changes to the knees, but no warmth or effusions. A progress note shows normal knee alignment, with the joint line/retropatellar area noted as tender to palpation. Records indicate the enrollee has utilized ice packs and medications including gabapentin, 600 milligrams twice a day; and Percocet on an as-needed basis, for pain control. This enrollee has received hyaluronic acid injections with good interval relief. She has developed recurrent pain and would like to repeat the injections bilaterally. The enrollee continues to receive the injections regularly because they are effective for her pain. The enrollee has bilateral knee pain secondary to osteoarthritis (OA). Management with hyaluronic acid injections has yielded positive results. Literature notes clinical studies indicate hyaluronic acid injections are effective for treatment of local osteoarthritis, with a high rate of responders among those with osteoarthritis of the knee. Hyaluronic acid injections improve pain and function, while avoiding the use of anti-inflammatory treatment and corticosteroids. Individuals usually tolerate the injection well and, with careful administration, the rate of complications is low. Researchers commented on previous systematic reviews of hyaluronic acid injections, noting the clinical benefit of hyaluronic acid injections is underestimated using conventional analysis methods. When accounting for control group effects in hyaluronic acid injection studies, it can be reasonably concluded that hyaluronic acid injections may be beneficial for a large number of those with knee osteoarthritis.  This enrollee has used over-the-counter medications and assistive devices. Hyaluronic acid injections provided a positive result in terms of decreased pain, decreased use of oral medications and increased function.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for the BRCA 1 and 2 gene test. The enrollee has ductal carcinoma in situ. She is status-post bilateral nipple-sparing mastectomy and immediate reconstruction with implant. The enrollee presented for genetic counseling due to her personal history of breast cancer and her family history of breast and other cancers. The enrollee indicates she is under the age of 50 and still has her ovaries; which have a high cancer risk should the BRCA test show a positive result. Professional society guidelines provide recommendations for genetic testing and counseling and risk management recommendations for those diagnosed with hereditary cancer syndromes. The guidelines focus on syndromes associated with an increased risk of breast and/or ovarian cancer. Literature indicates women with the BRCA 1 or BRCA 2 mutation have an increased risk of developing ovarian cancer and fallopian tube cancer. This mutation also indicates an increased risk of other cancer types, such as male breast cancer, prostate cancer, pancreatic cancer, gastrointestinal cancers, and melanoma. Current professional society guidelines recommend BRCA 1 and 2 testing for those diagnosed with breast cancer at age 50 or younger and have one close relative with prostate cancer. The enrollee meets these criteria. The test is an accepted standard of care.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 clinical genetics 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

The parent of an enrollee has requested reimbursement for intensive outpatient program (IOP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for children needing mental health treatment. The patients score correlates with a treatment intensity level of care of Level Five, or Medically Monitored Residence Based Services. Consistent with CALOCUS, it is possible to provide Level Five services in a child or adolescents home, if wraparound planning and resources can provide the needed service intensity in the less restrictive environment. In this case, the wraparound services offered by the IOP met this level of care. Therefore, the intensive outpatient program (IOP) services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement and prospective authorization and coverage for theta burst transcranial magnetic stimulation (TMS) services. Researchers concluded that about 20-30% of patients continue to experience pervasive depressive symptoms despite adequate trials of medication and psychotherapy. The authors noted that effective second-line therapies including TMS are viable options for treatment resistant depression. Moreover, the authors found that TMS protocols with repetitive TMS and theta burst stimulation have been shown to be effective, safe and tolerable. In one study on theta burst TMS, medical literature reported five of six patients qualified as responders, and four patients achieved full remission. In this case, the patient was previously treated with and either failed or was intolerant to multiple treatments for major depression. He continued to experience debilitating symptoms but showed a positive response to theta burst TMS. Given these findings, the theta burst TMS 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 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

Findings:  Medical literature supports that the requested device is medically necessary. Studies concluded that the adjunctive use of pulsed electromagnetic field (PEMF) for fifth metatarsal fracture non-unions produced a significant increase in local placental growth factor. PEMF also produced trends toward higher levels of multiple other factors and faster average time to radiographic union compared to unstimulated controls. Their study included patients who had been diagnosed with a fifth metatarsal fracture with delayed or non-union, with no progressive signs of healing for a minimum of three months. Shi and colleagues concluded that long-bone fracture patients treated with an early application of PEMF achieved a significantly increased rate of union and an overall reduced suffering time compared with patients that receive PEMF after six months or more of delayed union.In this case, the submitted documentation reflects that the patient has persistent right foot pain and has been diagnosed with a non-displaced right fifth metatarsal fracture non-union following a traumatic injury to the right foot. She has been immobilized in a CAM walker. Serial follow-up x-rays have documented no significant fracture healing. Current evidence based medical literature supports the use of this type of bone stimulation for fifth metatarsal fracture non-unions as safe and effective. Therefore, the requested electromagnetic bone growth stimulator device is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested device 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Orthovisc injections in the left knee. The enrollee has left knee and low back pain. He describes his knee pain as a constant sharp, shooting, aching sensation; often associated with morning stiffness. The provider has discussed left knee replacement, but the enrollee wants to trial knee injections prior to proceeding with surgery. He reports better management of his pain with his current medications of oxycodone, 30 milligrams five times per day, and oxymorphone, 40 milligrams three times per day. A pain management progress note described the examination of the left knee as demonstrating full range of motion, crepitus, and a grossly stable medial joint line; tender to palpation. The provider is requesting Monovisc for this enrollee. Literature describes clinical studies which show hyaluronic acid injections are effective for pain relief in knee osteoarthritis. Hyaluronic acid injections improve both pain and function, and minimize the use the use of anti-inflammatory treatment and corticosteroids. Individuals tolerate the injection well, with a low rate of complications. Researchers studied previous systematic reviews of hyaluronic acid injections, and discovered the benefit of hyaluronic acid injections is underestimated analyzed conventionally methods. When accounting for control group effects studies show hyaluronic acid injections may be beneficial for a large number of those with knee osteoarthritis. A recent progress note shows the enrollee had Orthovisc injections twice prior, and the enrollee reported a greater than 65 percent relief of his pain for approximately six months following the injection. Since the enrollee has achieved symptom relief with prior treatments, it would be appropriate and necessary to repeat the hyaluronic acid injections.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 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for allogenic islet cell transplant. The literature comparing islet cell transplantation to pancreas transplant demonstrates that islet cell transplantation is associated with excellent long-term results. Studies found that pancreatic islet cell transplant has moved from a curiosity to a realistic treatment option for selected patients with type 1 diabetes mellitus with hypoglycemic unawareness. This patient has a longstanding history of diabetes with episodic symptomatic hypoglycemia. The requested islet cell transplant is a next reasonable step in treatment for this patient, especially since he is on immunosuppressive therapy and is status post two prior pancreas transplants. Given these findings, the requested allogenic islet cell transplantation is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested allogenic islet cell transplantation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services 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 surgery 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: The patient has requested authorization and coverage for admission to a 60-day residential treatment center (RTC) program, or admission to a 30-day RTC program, or caregiver services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) 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. Applying the LOCUS guideline, this patient meets the criteria for the requested 60-day RTC program. The patient is at extreme risk of harm (score 5) as he engages in behaviors that endanger himself and others. The records document destructive behaviors including making Molotov cocktails. The patient has demonstrated moderate functional impairment (score 3) with inability to perform activities of daily living (ADLs). The patient has no significant comorbidities (score 1) in addition to schizophrenia. The patients recovery environment is moderately stressful (score 3) given the patients anger and aggression toward his family members. The patients recovery environment is supportive (score 2) but inadequate as it is unable to provide the requisite structure, limits, and professional input to appropriately address the patients issues. The patient has shown poor response to treatment (score 5) despite multiple admissions. The patient has been inaccessible (score 5) as he has been unable to form therapeutic working relationships with his providers. This gives the patient a composite score of 24, which is consistent with medically monitored residence based services, such as RTC. Given the severity of the patients illness, admission to a 60-day RTC program is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with type 2 diabetes with peripheral neuropathy. The patient reported that she had received pregabalin. She requested brand name Lyrica. The patients medication records show that she received brand name Lyrica from at least February 2019 through June 2019. The patient noted that pregabalin caused blurred vision, dizziness and insomnia. Per the patient, pregabalin did not provide pain relief. The patient has requested authorization and coverage for brand name Lyrica. 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 brand name Lyrica is medically necessary for treatment of the patients medical condition. In this case, the patient received brand name Lyrica and subsequently received the generic pregabalin. The patient reported experiencing side effects and not tolerating this preparation. Although the bioactive fraction of the medication is bioequivalent, she might be experiencing side effects from the inert components, which might be different from the brand name Lyrica. The medical evidence supports the requested medication in this clinical setting. Therefore, brand name Lyrica 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 internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism 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.