Persius/hicric huggingface dataset:
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 30 mg. With regard to the treatment of chronic low back pain with opioid therapy, a review concluded that there is evidence of short-term efficacy (moderate for pain and small for function) of opioids to treat chronic low back pain (CLBP) compared with placebo. The effectiveness and safety of long-term opioid therapy for treatment of CLBP remains unproven. Similarly, a review by Shaheed and colleagues also determined that for patients with chronic low back pain who tolerate the medicine, opioid analgesics provide modest short-term pain relief but the effect is not likely to be clinically important within guideline recommended doses. Evidence on long-term efficacy is lacking. An outcome study on the effects of opioid therapy for lumbar disc herniation established that patients who were treated with opioids had significantly worse baseline pain and quality of life. At final follow-up, there was no long term difference in outcome associated with opioid pain medication use. This patients provider noted that the patient has been treated with soma and oxycodone. The patients current treatment plan includes long-term use of oxycodone. However, the records provided for review do not support the long-term use of oxycodone. Further, the records do not document a trial and failure, or contraindication to treatment with the Health Plans formulary alternatives. With regard to biochemical equivalence, pooled head-to-head comparisons of opioids provide no rationale for preferring one opioid and/or administration route over another in the therapy of patients with chronic non cancer pain. For these reasons, the requested oxycodone 30 mg is not medically necessary for the treatment of this patients chronic low back pain.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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The patient with osteoarthritis of the left knee tried steroid injections, lifestyle changes, Motrin, Celebrex, a brace, ice, heat, natural remedies, stretching, acupuncture, chiropractic care and bee therapy.  Hyaluronan injections to the knee were requested. Based on the current medical studies, hyaluronic acid is no longer recommended for patients with symptomatic osteoarthritis. There was not enough improvement noted to support it use.Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients condition.  Therefore, the health plans denial was upheld.Credentials/Qualifications: The physician reviewer is board certified in Orthopedic Surgery and is actively practicing.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The patient has requested reimbursement for thawing cryopreserved embryo and assisted embryo hatching MicroTQ services. The American College of Obstetricians and Gynecologists (ACOG) reports that oocyte cryopreservation, with appropriate counseling, is recommended for patients facing infertility due to chemotherapy or other gonadotoxic therapies. However, the ACOG states that there are not yet sufficient data to recommend oocyte cryopreservation for the sole purpose of circumventing reproductive aging in healthy women. The medical records for this patient indicate that cryopreservation of fertilized embryos was performed with the intention to prolong fertility until later in life. The records provided for review do not document a medical indication for oocyte cryopreservation due to chemotherapy or other gonadotoxic therapies. For these reasons, the thawing cryopreserved embryo and assisted embryo hatching MicroTQ were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the services at issue were not 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology 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 is a 57-year-old female diagnosed with chronic hepatitis C genotype 3. Laboratory results revealed a viral load of 933,310 IU/mL. A FibroScan showed liver stiffness of 6.1 kPa, consistent with F0-F1 fibrosis. The provider noted the patient is treatment naive. At issue in this case is whether Mavyret for eight weeks is medically necessary for the treatment of the patients medical condition. According to the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The AASLD/IDSA guidelines recommend that all patients should be treated, regardless of fibrosis stage and non-cirrhotic treatment-naive genotype 3 patients should be treated with Mavyret for eight weeks. The ENDURANCE-3 trial showed a 95% cure rate with eight or 12 weeks of treatment with Mavyret and a low relapse rate in treatment naive, non-cirrhotic patients with chronic hepatitis C genotype three infection. Further, the AASLD/IDSA guidelines report reduced survival rates with delayed treatment. Therefore, Mavyret for eight weeks is medically necessary for the 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 subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for DecisionDx-Melanoma testing. The Health Plan has denied the service at issue as investigational for evaluation of the enrollees melanoma.Findings:  Two out of three physician reviewers found that this patient has an early stage melanoma. The National Comprehensive Care Network (NCCN) Guidelines state that while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of a clinical trial. Should the patient have high-risk results, treatment and surveillance recommendations would unlikely be altered. One physician reviewer found that the risk classification provided by this test can be used to better estimate an individuals risk for recurrence and therefore aid in determining the most appropriate surveillance methodology and frequency.Final Result: The reviewers determined that the service at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The Health Plan denied the services at issue as not medically necessary.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.Regarding the six LOCUS dimensions, the patient has a low risk of harm. The records document that he has not expressed any suicidal or homicidal ideation or intent (score 1). Regarding functional status, he is minimally impaired and has maintained activities of daily living and employment (score 1). His comorbidities include alcohol use disorder (score 2). The patients recovery environment is minimally stressful with a stable housing situation (score 1) and the patients family is supportive (score 1). The patient has had a significant response to treatment, given his absence of depressive symptoms and sobriety (score 1). Moreover, he participates in therapy and attends Alcoholics Anonymous and Gamblers Anonymous meetings (score 1). For a LOCUS composite score of 8, the recommended level of care is basic services which consistent of outpatient treatment with a therapist and psychiatrist.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients behavioral health 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 is a 56-year-old female with Parkinsons disease (PD). The patient was diagnosed with PD. She was started on carbidopa/levodopa (Sinemet) 25/100mg three times a day. Per a letter from her provider, she was unable to tolerate a full dose of the drug due to side effects. She then tried one-half tablet three times per day, but this was not effective for symptom control. She was then started on a treatment course of one-half tablet every three hours. Per the provider, this dosing schedule was only partially effective. The record indicated that while the patient had an improvement on Sinemet IR, there was also noted to be a degree of fluctuation in her symptomatic control.  The patient was started on a trial of Rytary ER. The patient has subsequently reported improvement in control of her motor symptoms. Laboratory results revealed a glomerular filtration rate (GFR) of 54 and a creatinine of 1.14 indicating mild kidney disease. The patient has requested authorization and coverage for Rytary ER 23.75mg 95mg capsules. At issue in this case is whether Rytary ER 23.75mg 95mg capsules are medically necessary for the treatment of this patient. In general, the treatment of PD involves a flexible trial-and-error approach. Current guidance statements from the International Parkinson and Movement Disorder Society indicate that therapy with levodopa/peripheral decarboxylase inhibitor agents is effective. However, these same guidelines do not readily recommend the use of one particular formulation of levodopa over another.  In clinical practice, the newest extended release formulation of carbidopa/levodopa is generally reserved for use in patients with more advanced forms of the disease who have not responded to multiple initial therapies from different classes. In this case, based on the medical records provided for review, the patient is newly diagnosed and cannot be said to have an advanced form of the disease. The use of the requested medication would not be consistent with other treatment approaches of initial motor symptoms of PD given the symptomology and the period of time since diagnosis. The patients mild kidney disease would not preclude the use of other medications. Therefore, Rytary ER 23.75mg 95mg capsules are not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for intensive outpatient program (IOP) services received. The Health Plan has denied the services at issue as not medically necessary.The American Society of Addiction Medicine (ASAM) criteria describe the continuum of treatment for patients seeking recovery from alcohol dependence. In reviewing the ASAM criteria, the patient had minimal medical complications or withdrawal symptoms. He had mild behavioral complications, he was cooperative and ready for change yet required the structure and monitoring given his high relapse potential. His recovery environment was moderately supportive, but he had no partner or close family involvement. He admitted that people in his support system used alcohol. Based on the ASAM criteria, the patient met the criteria for IOP during the period at issue. 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 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 Otezla 30 mg. Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.The submitted documentation supports the medical necessity of the requested medication. This enrollee has tried and failed therapy with methotrexate. Otezla is non-immunosuppressive and has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of psoriasis and psoriatic arthritis. In this enrollees case, the requested medication is being used for its FDA-approved indication. The enrollee is wheelchair-bound and has a history of fistulas in the past, making him at higher risk of infection. Since the biologics are immunosuppressive, the use of Otezla is favored over the Health Plans preferred agents. The medical evidence supports the requested medication in this clinical setting. Therefore, Otezla 30 mg 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 enrollees 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

Nature of Statutory Criteria/Case Summary: The patient presented to the emergency department (ED) via ambulance. He complained of waking up with epigastric discomfort with nausea, weakness, and diaphoresis. While in the ED, vital signs were stable and diagnostic testing was significant for negative findings. This patient underwent EKG, cardiac enzyme testing, CT angiogram of the coronary arteries, and an echocardiogram. All of these were unremarkable. This patients vital signs were normal on arrival. He was not experiencing unstable symptoms at the time of his admission. This patients symptoms did not meet criteria for the inpatient stay.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 emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a cortisone injection. Epidural injections with corticosteroids have a clinically established role in the short-term management of low back pain when the pain is associated with symptoms of nerve root irritation, or there is low back pain due to disc extrusions or contained herniations, and the pain is unresponsive to conservative treatment, including to pharmacotherapy, exercise and physical therapy. In this case, the patient has reported chronic back pain with associated numbness and weakness of the right lower extremity since September 2018. A lumbar spine MRI showed disc herniations with annular tears involving L4-5 and L5-S1 along with mild canal stenosis at these levels. The patient was initially managed conservatively with medications, physical therapy modalities, and a chronic pain program. However, the patient has failed to respond to these modalities. The lack of concordance of her symptoms with MRI findings does not constitute grounds for dismissing a diagnosis of lumbar radiculopathy. In 2013, the American Society of Interventional Pain Physicians concluded that for for lumbar disc herniation with radiculitisthe evidence is considered good for short-term and long-term relief with local anesthetics with steroids. Evidence is superior in contained disc herniation. Similarly, the North American Spine society determined that transforaminal epidural steroid injection is recommended to provide short-term (2-4 weeks) pain relief in a proportion of patients with lumbar disc herniations with radiculopathy. Further, researchers found that epidural steroid injections with or without local anesthetics may be used as part of a multimodal treatment regimen to provide pain relief in selected patients with radicular pain or radiculopathy. Based on the medical records reviewed and the current medical literature, the requested cortisone injection is medically necessary for treatment of this patients symptoms consistent with lumbar radiculopathy.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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The patient with bulima nervosa, depression and anxiety requested Intensive Outpatient Program Services. The medical literature indicated that continued intensive outpatient program stay is generally needed until IOP is no longer necessary due to adequate patient stabilization improvement as indicated by weight stable, increasing or any issues manageable at a lower level care; purging and other behavior is manageable at a lower level of care; the status acceptable; medical needs absent or manageable at a lower level care. This patient had tried and failed treatment before.  Increasing weight, purging and other behaviors were not manageable at a lower level of care.Final Result: The reviewer determined that the service at issue was medically necessary for treatment of the patients condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in Psychiatry and is actively practicing.