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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee requested authorization and coverage for Botox injections.Findings:  Three physician reviewers found Botox injections have been successfully used in adults and adolescents for the treatment of chronic migraine. In the pediatric age group, migraine headaches may be treated with off-label medications. The medical literature supports Botox injections for the treatment of pediatric patients with chronic migraine. In this patients case, she has been refractory to multiple medications. She has also experienced negative side effects from prior medications. There is support for Botox injections in this patients case. In sum, Botox injections are likely to be superior over other treatment options. 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 and 3 are board certified in neurology with special qualification in child neurology and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation medicine. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the Hybrid Maze procedure and percutaneous transcatheter closure of the left atrial appendage with endocardial implant. Based on the current literature and review of multiple studies, the Hybrid Maze procedure results in reduced arrhythmia recurrence and fewer re-interventions when compared with catheter ablation to treat atrial fibrillation. Researchers reported long-term success with the Hybrid Maze procedure at four-year follow-up. Although there are surgical risks involved with the procedure this patient would likely benefit from this procedure given age and symptomatic arrhythmia episodes despite multiple catheter ablations and antiarrhythmic medications. Therefore, the requested Hybrid Maze procedure and percutaneous transcatheter closure of the left atrial appendage with endocardial implant are supported as 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 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:  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xtampza, Percocet, and Soma. The Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioid medications assist providers in making decisions regarding initiating, adjusting and discontinuing of opioid therapy. The guidelines do not provide a hard limit to the prescribing of opioid medications for chronic pain patients. To clarify these issues, the CDC recently announced that providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Federation of State Medical Boards (FSMB) guidelines state continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. The FSMB noted that opioid dosage should be maintained as low as possible and continue[d] only if clear and objective outcomes are being met. In this case, the patient has multiple pain generators in the lumbar spine, cervical spine, and knee. The patient has documentation of pathology in these areas. Her pain management regimen has included chronic opioid therapy. Treatment with non-opioid therapies have failed to produce adequate pain control. Previous attempts to taper her medications have led to a clinically significant decrease in functionality and inhibition of the performance of her activities of daily living. The records document the patient has shown a clinically meaningful improvement in pain and function that outweighs risks to patient safety to support continued opioid treatment. Further, the records state the patient has been compliant with her regimen of Xtampza and Percocet. Thus, Xtampza and Percocet are medically necessary for treatment of this patient. However, there is a paucity of evidence supporting the safety and effectiveness of Soma. Researchers found that studies demonstrate the efficacy of skeletal muscle relaxers for up to 14 days after symptom onset, and the evidence for long-term use is lacking. Given the lack of peer-reviewed medical literature demonstrating benefits for chronic low back or neck pain, Soma is not indicated. Therefore, Soma is not medically necessary for the treatment of this patients chronic low back and neck pain.Final Result: The reviewer determined that a portion of the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Taltz. Taltz is a monoclonal antibody that inhibits interleukin 17a. The U.S. Food and Drug Administration has approved Taltz for patients with moderate to severe plaque psoriasis. A recent joint statement of the American College of Rheumatology and the National Psoriasis Foundation provided a Class A recommendation for the use of Taltz as monotherapy for patients with plaque psoriasis with associated psoriatic arthritis. In this patients case, the records document plaque psoriasis with associated arthritis. He has failed topical and oral small molecular (OSM) treatment. In this case, an interleukin 17a inhibitor is the appropriate next line of therapy. This patient has plaque psoriasis over his knees and elbows. Arthritic symptoms are noted in multiple joints. The medical evidence supports the requested medication in this clinical setting. Therefore, Taltz 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 dermatology 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 reimbursement for cooling and compression device rental. Recent medical literature does not support the post-operative use of cold compression over standard ice packs following shoulder arthroscopy. Colleagues reported on 40 randomized controlled trials comparing various modalities of postoperative pain control including cryotherapy. The authors concluded that interscalene nerve blocks were the most effective method to control postoperative pain after shoulder arthroscopy. Further studies have not found substantial advantages with cold compression over ice packs after arthroscopic surgery of the shoulder. Based on a review of recent medical literature, the rental of the cold compression device was not medically necessary for this patients post-operative care.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 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: An enrollee has requested authorization and coverage for conscious sedation. This patient is scheduled to undergo lumbar facet injections at L3-4 through L5-S1 to test for a possible future lumbar radiofrequency ablation procedure at these levels. The medical records indicate that sedation will be ordered for this procedure. In this case, the clinical notes do not document the need for sedation. Per the medical evidence, the majority of minor pain procedures do not require anesthesia care other than local anesthesia. Medical literature noted that significant anxiety may be an indication for conscious sedation. Medical literature also noted that procedures that require the patient to remain motionless for a prolonged period of time and/or remain in a painful position may require sedation or anesthesia services. In this patients case, the provider did not document an indication for conscious sedation, such as significant anxiety or pain with positioning. The medical evidence does not support the requested services in this clinical setting. Therefore, the requested conscious sedation is 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 anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Otezla 30 mg for psoriasis. A review of the record indicates the enrollee is diagnosed with psoriasis vulgaris with history of hypertension and gout.  He has 27% of body surface involvement, including his elbows, knees, head, and lower back.  Previous treatment was with Taclonex, Dovonex, and clobetasol.   Symptoms are itching and flaking that is considered severe and persistent despite aggressive treatment.  His physician prescribed treatment with Otezla. The enrollee does not want to use injectable medications, which his physician indicates will cause a significant barrier to adherence to the plan of care. Without Otezla, his physician is concerned he will have increased pain, suffering, and loss of function. A review of the record indicates no clinical reason, trial, failure, contraindication or adverse effect to safe and effective alternatives, such as Enbrel, Humira, and Cosentyx. The medical literature indicates biologic agents are considered the gold standard for moderate to severe psoriasis due to their favorable safety profiles and excellent efficacy. Among these biologic agents, are adalimumab (Humira) and infliximab (Cosentyx).  Biologics are highly effective treatments for moderate-severe psoriasis. Comparison of medication response rates at one year showed best results with secukinumab (Cosentyx) and worst with apremilast (Otezla). In those who received one year of continuous treatment, maintenance was best with adalimumab (Humira) and worst with apremilast (Otezla). Clinical data has demonstrated the efficacy of Humira (adalimumab). Adalimumab efficacy was well maintained over more than three years of continuous therapy for patients.   Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Dermatology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage of Symbicort inhaler for asthma with symptoms of shortness of breath, coughing spasms, and tightness in her throat. She also has environmental allergies for which she takes antihistamine medication and a nasal spray. The enrollee reports she has tried multiple inhalers, steroids, and antibiotics to control her asthma symptoms. Her allergist noted poorly controlled, moderate persistent asthma and a chronic cough as a result, and ordered Symbicort. Her primary care provider noted her asthma was stable with Symbicort and Albuterol, as needed. The enrollee returned with an upper respiratory infection and reported that she had tried to refill her Symbicort, but the pharmacist gave her Dulara, which she had failed. A new authorization for Symbicort was submitted and denied. A physician response to insurer inquiry regarding trial and failure of Breo, Advair and Dulera indicates enrollee advised to try formulary alternative but member is adamant about getting Symbicort. A review of the records shows no notations of contraindications, adverse events or potential drug interaction with formulary alternatives, such as Breo and Advair. There is no documentation of an inadequate treatment response after a trial of formulary alternatives. A review of the records indicates there is insufficient evidence of the enrollees failed trial of alternatives, such as Breo and Advair. . Researchers indicate that the combination of an inhaled corticosteroid and a long acting beta-2-agonist is considered a preferred therapy. They note combination therapy offers the best prevention of severe asthma exacerbation. The requested medication, Symbicort, is a combined inhaled corticosteroid and a long acting beta-2-agonist that has worked well for the enrollee. However, other available options include a combination inhaled corticosteroid, such as Advair. There are no  adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long term efficacy and safety of Symbicort over the preferred formulary medications for the treatment of this enrollees medical condition.  Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Pulmonology 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: The patient has requested Synvisc One injections. Findings: The physician reviewer found that medical evidence supports that Synvisc One injections are medically necessary. The patient has had an excellent response to past viscosupplementation injections with nine months of pain relief following each series of injections. A review of current medical literature pertaining to viscosupplementation reveals mixed results. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. Current research reports that intra-articular hyaluronic acid (IAHA) provides a moderate symptomatic benefit for patients with knee osteoarthritis, without major safety concerns. IAHA may offer one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee OA health outcomes, overall gain in quality-adjusted life years and substantial delays in time to total knee replacement. In this case, there is evidence of benefit from prior injections. Moreover, the options are limited, with the alternative being a total knee arthroplasty. Medical evidence supports the services at issue in this clinical setting. Therefore, Synvisc One injections 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for suction-assisted lipectomy procedure of bilateral hips and legs. The patient has congenital lymphedema with Aegenes syndrome. This condition is complicated due to severe obesity with a body mass index (BMI) of just under 54. Weight loss may improve lymphatic dysfunction, but might not reverse the condition. He has massive bilateral leg and foot swelling, which is non-pitting. Conservative therapy has not been successful. Classical liposuction for the treatment of lower extremity lymphedema has not been shown to be beneficial in the long-term. The literature states that the approach outlined by researchers is different. Researchers reported that suction-assisted protein lipectomy (SAPL) has been shown to reduce large amounts of volume excess with a one-year average reported reductions in volume excess in the legs of 86%. The authors reported that the SAPL is effective in reducing limb volume in patients with lower extremity lymphedema who have used maximal conservative therapy preoperatively and postoperatively. The key differentiation is whether the lymphedema is pitting or non-pitting. Pitting lymphedema is an early stage, is not pathognomonic of protein accumulation, and is not appropriate for SAPL. Non-pitting edema is protein containing, will not be responsive to conservative therapy, and is appropriate to consider for SAPL. This patient has non-pitting edema, which has been resistant to standard conservative therapy. Based on peer-reviewed medical literature and the medical information available for review, the requested suction-assisted lipectomy procedure of the bilateral hips and legs 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 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:  One reviewer is board certified in plastic surgery and is actively practicing. One Reviewer is board certified in plastic surgery and is actively practicing.  One Reviewer is board certified in plastic surgery 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

An enrollee has requested reimbursement for residential treatment center services. This patient was admitted with a history of cannabis use as well as recent suicidal ideation. The progress notes indicate that the patient was not exhibiting withdrawal symptoms during the disputed timeframe. The patient did not report significant medical issues. He did not engage in self-harm behaviors during the admission. The patient expressed motivation for treatment. He demonstrated an understanding of struggles with substance use and was insightful in therapy sessions. The records indicate that the patients overall function was good. There was no indication of problems with activities of daily living. 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 and appropriate level of care for adults. In terms of risk of harm, the records support a score of 2 due to a lack of current suicidal ideation with any active intent or plan. With regards to functional status, the records support a score of 2 due to overall good functional level in treatment but consideration of family relationship issues when in the community and using substances. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and history of cannabis use that appeared to be under adequate control and was not adversely affecting treatment to a significant degree. In terms of level of stress of the recovery environment, the records support a score of 2 due to a stable living environment. With regards to level of support of the recovery environment, the records support a score of 2 due to supportive resources who were willing to provide aid in times of need. In terms of treatment and recovery history, the records support a score of 3 due to current motivation for treatment but no past significant sobriety with consideration of minimal past substance use or mental health treatment. With regards to engagement and recovery status, the records support a score of 2 due to cooperation in treatment. Thus, the patient has a composite score of 15. This score correlates with high intensity community-based services. Therefore, residential treatment center services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at 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 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.