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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left atrial appendage closure with a Watchman device.Findings:  Two of the three physician reviewers found that in this patients case, the records document chronic atrial fibrillation, hypertension and a family history of stroke. She was treated with standard therapy with Xarelto and had a significant gastrointestinal bleed with persistent anemia. As a result, she has discontinued the anticoagulant, which places her at significant long-term risk of embolic stroke. The medical evidence indicates that the Watchman device provides protection from recurrent stroke in patients with significant contraindications to long-term anticoagulant therapy. There is sufficient support for the requested services in this patients case. In sum, left atrial appendage closure with a Watchman device is likely to be of greater benefit than other available 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, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 patients parent has requested authorization and coverage for residential treatment, wilderness therapy. Recent progress notes indicate the patients primary issues are mood related. His recent depression rating scale was in the moderate range. Recently, he has been intermittently compliant with his medications. He appears to be overall cooperative with treatment and is open and responsive to his current providers. The progress notes do not document any suicidal or homicidal thoughts. His activities of daily living appear intact as referenced by his attendance to his appointments and school. He does not appear to be experiencing any psychosis. He reports daily cannabis use and there is no indication he has any serious acute medical problems. Recent progress notes indicate a clinical recommendation for weekly therapy. The patients family has been involved in his treatment. Applying the Level of Care Utilization System (LOCUS), this patient does not meet the criteria for residential treatment, wilderness therapy services. The patient is currently at minimal risk of harm (score 1) due to a lack of current active or passive suicidal ideation. The patient has moderate impairment in his ability to function (score 3) as demonstrated by his inability to fulfill some responsibilities and interpersonal issues. The patient presents with minor medical, addictive and psychiatric co-morbidity (score 2) due to current cannabis use and no medical issues. The patients recovery environment is mildly stressful (score 2) due to some minor relational issues with family. His recovery environment is supportive (score 2) as he has access to supportive resources who are willing to provide aid. Further, the patient has demonstrated limited response to prior treatment (score 3) due to some treatment response in the past, but continued symptoms and occasional refusal to take medications. The patient has been cooperative in treatment but lacks insight into the need for treatment (score 3). This gives the patients presentation a composite score of 16.  A score of between 17-19 correlates with a treatment intensity level of two, which is described as low intensity community based services. According to the patients score on the LOCUS, residential treatment, wilderness therapy, is not medically necessary. 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 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

Nature of Statutory Criteria/Case Summary: The patient is a male who underwent a right total knee arthroplasty. The patient had persistent pain and a snapping popliteus tendon. He underwent revision surgery. At the time of surgery, the tibial component was noted to be loose and a revision tricompartmental arthroplasty and popliteus release was performed. The provider documented 48 hours of intravenous antibiotics, need for pain control after the pain block wore off, and initiation of physical therapy as the reasons for the inpatient hospitalization. Recent literature is mixed with respect to the incidence of complications of total knee arthroplasty in the outpatient versus inpatient treatment settings. According to Courtney and colleagues, outpatients experience higher rates of post-discharge complications. In this case, the reason for the extra day of hospitalization was for the patient to receive 48 hours of intravenous antibiotics, pain control after the pain block had worn off, and initiation of physical therapy. Based on the literature review, the inpatient hospitalization provided was medically necessary for post-operative management of this 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 viscosupplementation with Hyalgan injections. Findings  The physician reviewer found the submitted documentation supports that the requested medication is medically necessary. Current medical literature continues to support the use of viscosupplementation for osteoarthritis of the knees. There is good evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Evidence from studies of repeat courses of intra-articular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around two years. A systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis found that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. There is sufficient support for the requested services in this clinical setting as evidenced by the patients objective findings and history of significant benefit from prior injections. As such, the requested Hyalgan injections of the knees are medically necessary for treatment of this patients knee osteoarthritis.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: Case Summary An enrollee has been diagnosed with post-traumatic stress disorder (PTSD). The patient was reportedly experiencing problems coping with occupational stress. Crisis services were reiterated and the patient refused any new medication. Notes submitted through the visit date indicated that the patient is being treated with therapy twice weekly and is in a Seeking Safety group that is helpful. The enrollee has also signed up for an anger management class. The Health Plan has denied coverage for the requested individual therapy sessions.MD Analysis: In this case, one-hour individual therapy sessions three times a week are medically necessary to address this patients behavioral health issues. Applying the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS), the patient meets the criteria for one-hour individual therapy sessions three times per week. In terms of risk of harm, the records support a score of 2. With regards to functional status, the records support a score of 2 moderate. This is due to conflict with peers and quitting their job. Medical, addictive and psychiatric comorbidity, the records support a score of 2. This is due to overall medical stability with some mental health issues that are under control. In the terms of recovery environment, level of stress of the patients recovery environment, the records support a score of 3. This is due to a stable living environment but conflict with peers. With regard to recovery environment, level of support, treatment and recovery history, the records support a score of 3. This is due to mention in the records of problems with a roommate that contribute to her symptoms. For treatment and recovery history, the records support a score of 3. This is due to minimal past treatment response. In terms of engagement and recovery status, the records support a score of 3. This is due to fair cooperation in treatment, but failing to use available treatment resources. This gives the patients presentation a composite score of 18, which supports intensive outpatient services at a minimum of three days per week and are medically necessary. Final Result: The reviewer determined that the IOP 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 requested authorization and coverage for Natpara. The records provided for review document that this patient has postsurgical hypoparathyroidism and is currently on calcium, vitamin D, and vitamin D3 supplements to maintain her calcium levels in the normal range. The major side effects of calcium and vitamin D replacement in patients with hypoparathyroidism are hypercalcemia and hypercalciuria. Hypercalciuria is the earliest sign of toxicity and can develop in the absence of hypercalcemia. An increase in urinary calcium excretion is a predictable consequence of raising the serum calcium in patients with hypoparathyroidism. Natpara is considered a second-line therapy for patients with chronic hypoparathyroidism who are unable to maintain stable serum calcium on replacement therapy with high dose calcium and active forms of vitamin D. Natpara therapy does help in lowering the calcium and calcitriol requirements and also help lower calciuria. This patient does have chronic hypoparathyroidism and is on high dose calcium and calcitriol therapy. Given the support in the medical literature, the patient is likely to benefit from Natpara therapy as there is clinical documentation to show that she has unstable calcium levels and also has calciuria. Accordingly, the requested Natpara 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monovisc injections. In the current medical literature, researchers reported that in a multicenter double-blind randomized placebo-controlled trial, the Monovisc group had a significantly greater rate of patient success in 26 weeks compared to saline. Moreover, data has demonstrated that Monovisc is a safe and effective alternative for patients who are not candidates for a total or unicompartmental knee arthroplasty, as in this patients case. With regard to repeated courses of viscosupplementation, the researchers found that repeated courses of intra-articular injections of hyaluronic acid are safe and effective. Furthermore, additional courses of hyaluronic acid were demonstrated to maintain or further improve pain reduction without additional risk. Given these findings, the requested Monovisc injections are medically necessary for treatment of this patients bilateral primary osteoarthritis of the knees. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients representative has requested authorization and coverage for brand name Tegretol XR, Lamictal 200 mg, and Lamictal 25 mg. Several recent studies have examined the effectiveness of brand versus generic anti-epileptic medication regimens. Researchers reported on a randomized, double-blind, multiple-dose, bioequivalence study comparing generic lamotrigine to brand Lamictal in generic-brittle epilepsy patients. The researchers found that brand and generic bioequivalence was similar and no patient subpopulation reacted poorly to generic or brand formulations. In addition, the American Epilepsy Society recognizes that well-designed, prospective studies of generic antiepileptic drug substitutions have demonstrated bioequivalence of generic products. Further, results from these studies have shown no difference in bioequivalence when switching from a brand product to a generic product or between multiple generic products. This patients records do not include documentation of intolerance to the generic formulations of Tegretol and Lamictal. His parent reports that the patient has been stable on the brand name medications for over 40 years. However, based on the current medical literature, the generic formulations of the requested medications are the bioequivalent and likely to be as effective as the brand name alternatives. Thus, the requested Tegretol XR, Lamictal 200 mg, and Lamictal 25 mg are not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested brand name 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 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

An enrollee has requested authorization and coverage for subcutaneous immune globulin (SCIG). Common variable immunodeficiency is a disorder with impaired immunity, including B cell differentiation with hypogammaglobulinemia with varying degrees of loss of antibody. Typically, there are recurrent infections, chronic lung disease, gastrointestinal disease and autoimmune disorders. Treatment often includes immune globulin replacement. Although treatment with intravenous immune globulin may be necessary for those with substantial impairments in immune globulin production and no response to both protein and polysaccharide vaccines, for patients with higher levels of serum IgG and only minor impairments in response to some vaccines, intravenous immune globulin treatment can be deferred.In this patients case, testing revealed an inadequate response to the Pneumovax vaccine. The records noted less than half of the titers increased to the expected amount (greater than 1.3 mcg/mL). Additionally, the records noted recurrent bacterial and fungal infections of the respiratory tract. Although the patient does not have an IgG level less than 200 mg/dL, the records document an inability to respond to IgG antibody production after antigenic challenge against pneumococcal polysaccharide vaccine. The medical evidence supports the requested services in this clinical setting. Therefore, SCIG is 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 internal 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 reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. The medical literature indicates that rehabilitation post hospital discharge can be delivered in many settings. When there is concern about the patients inability to return home from the acute setting, SNF care may be indicated. SNF services are supervised by a physician, include physical therapy (PT) and occupational therapy (OT), and nursing is provided 24-hours a day. This patient was discharged from the acute care hospital to the SNF. Prior to admission to the SNF, she was independent living at home. On the date of admission to the SNF, she was completely dependent for standing, sitting, transfers, bathing, and her activities of daily living. She was noted to be participating with PT and required daily professional services for wound care, antibiotics, and monitoring. The treatment she has been provided could not have been administered at a lower level of care. Thus, the SNF services provided were and are medically necessary for treatment of this patients medical condition. 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 internal medicine with expertise in skilled nursing facility care 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

An enrollee who presents with a four-year history of growth over his left eye cornea, getting progressively worse. He was evaluated for an initial consultation. A nasal pterygium was found on examination, and best corrected visual acuity (BCVA) of 20/25 was measured in the left eye. A repeat visit revealed a left pterygium and BCVA of 20/25 in the left eye. Corneal topography showed irregular astigmatism associated with nasal pterygium of 2D cylinder in the left eye.  The astigmatism extended into the central four mm of central corneal surface. The patient was evaluated by a primary care physician who found a left eye pterygium extending onto the cornea and referred the patient to another specialist. The provider noted the patients BCVA was 20/30. However, his measurements of the pterygium at the slit lamp were only in the range. The second specialist declined surgical removal of the pterygium. No corneal topography was reportedly obtained by the second specialist to evaluate corneal astigmatism that maybe induced by astigmatism.   As noted in the medical literature, corneal topography is a reliable measurement of a lesion since it can be repeated and should be consistent from provider to provider. The first specialist who evaluated the patients corneal topography documented irregular astigmatism in the left eye, which corresponded to the pterygium location. This corneal topography finding is a more reliable assessment of the true size of a pterygium and its effect on the patients vision. A pterygium can cause irregular astigmatism and reduce the quality of vision even before it encroaches on the pupil. Considering this patients age, the risk of the recurrence is low, especially with the use of intra-operative mitomycin and post-operative prednisone drops. Removing the pterygium is indicated for this patient, as it is inducing irregular astigmatism that extends onto the central of cornea. Given these findings, the requested removal of pterygium is medically necessary for treatment of this 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 ophthalmology, 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.