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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for an additional five hours per week (for a total of 25 hours per week) of Applied Behavior Analysis (ABA). The Council of Autism Service Providers guidelines on ABA treatment of autism spectrum disorder note that focused ABA plans are appropriate for individuals who (a) need treatment only for a limited number of key functional skills or (b) have such acute problem behavior that its treatment should be the priority. In this case, the records note 15 goals and an acute presentation of challenging behavior including nearly six tantrums daily. The guidelines further note that treatment dosage, or intensity of services, will vary among patients and should reflect the goals of treatment, specific patient needs, and response to treatment. In this case, the patient is making progress at the requested intensity. This intensity should continue until the transition plan criteria is met and a reduction to fewer hours is warranted. Papatola and Lustig report that ABA services should be consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research, and that they should be rendered in the least intensive setting that is appropriate for the delivery of health care. Given that the treatment plan includes all essential elements and meets the core components of ABA guidelines, the requested service is medically indicated. In this patients case, the requested services are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, an additional five hours per week (for a total of 25 hours per week) of applied behavior analysis (ABA) 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 licensed B.C.B.A, board certified in psychology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage/reimbursement for (1) Evenity injections (210 mg), and (2) Evenity injections (210 mg) administered every four weeks. The U.S. Food and Drug Administration (FDA) approves the use of Evenity (generic name romosozumab), for the treatment of osteoporosis in postmenopausal women at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or in patients who have failed or are intolerant to other available osteoporosis therapy. Studies in current medical literature on the use of romozosumab for the treatment of osteoporosis primarily concentrate on postmenopausal women with severe osteoporosis, with T-scores greater than -3.5 or with fragility fractures. Given that romosozumab is not considered initial therapy for most patients with osteoporosis, and as the records do not demonstrate a history of fracture, the services at issue were not and are not medically necessary. Therefore, (1) Evenity injections (210 mg), and (2) Evenity injections (210 mg) administered every four weeks were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a cryotherapy machine/device (Kodiak combo cold therapy unit) by Pacific Medical Inc. Cold applications are well understood as helping to decrease pain following shoulder replacement surgery. However, researchers report that there does not appear to be a significant benefit to the use of compressive cryotherapy over standard ice wrapping in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression. Given that current medical literature does not support the use of a motorized unit versus the self-application of cold packs, the equipment at issue was not medically indicated. Therefore, the cryotherapy machine/device (Kodiak combo cold therapy unit) by Pacific Medical Inc. was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for FoundationOne CDx genetic testing. In addition to likely providing prognostic information, there are data to support the utility of next generation sequencing to predict candidates for specific mutation-driven treatment. Specifically, patients with inflammatory and metastatic breast cancers have been shown to benefit from next generation sequencing to identify markers that may be targeted for treatment or for enrollment in clinical trials. For this patient, testing for mutations with tumor or liquid biopsy was appropriate to identify whether the patient is a candidate for treatment with alpelisib. Testing for BRCA mutations, mismatch repair (MMR), microsatellite instability (MSI) was indicated to help identify possible targeted therapies. Based on the medical literature, the use of next generation sequencing with FoundationOne was reasonable in this patients clinical setting. Therefore, the FoundationOne CDx genetic testing was medically necessary for this patient. 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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy Solution auto injection 1.7 mg/0.75 mL. The records provided for review document that this patient presents with a history of borderline obesity, hypertension, and mixed connective tissue disease. The patients provider reports that the patient has responded well to treatment with Wegovy over two months. The provider has recommended continued treatment with Wegovy. While lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. There are currently multiple pharmacologic therapies which are available for weight management (Gadde, et al.). Wegovy is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs. Medications in the GLP-1 class can improve glycemic control, reduce body weight, and decrease cardiovascular risk (Knudson and Lau). Multiple studies have demonstrated that Wegovy has the ability to promote weight loss via reduced appetite and energy intake and delayed gastric emptying (Corness). Given these findings, the requested Wegovy Solution auto injection 1.7 mg/0.75 mL is medically necessary for 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 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: The patient has requested authorization and coverage for Belbuca (buprenorphine). The providers notes state that the current treatment goal is to treat the patients pain in a more effective manner without drastically escalating the daily morphine equivalents. The provider has recommended continued use of the Belbuca patch. Researchers reported on a meta-analysis and review of 33 studies assessing the safety and efficacy of buprenorphine in the treatment of patients with chronic pain. The authors concluded that buprenorphine is an atypical opioid that demonstrates efficacy similar to full mu-opioid receptor agonists in managing chronic pain while exhibiting a favorable tolerability profile, including the reduced likelihood of abuse potential and respiratory depression. A recent expert consensus guideline on chronic pain management found that buprenorphine should be considered before some opioids in patients with a favorable risk-to-benefit profile on the basis of metabolic factors, abuse potential, and tolerability. Overall, the most recent peer-reviewed medical literature supports the efficacy of buprenorphine for use in patients with chronic pain and current consensus guidelines support using buprenorphine as first-line treatment over traditional full opioid agonists due to an improved safety profile, tolerability, and non-inferior analgesic effects. Based on this support, the requested Belbuca (buprenorphine) is medically necessary for 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 anesthesiology with subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Dupixent Pen. Dupixent is FDA approved and supported in the medical literature as an add-on treatment of moderate to severe asthma in adults with an eosinophilic/allergic phenotype or with corticosteroid dependent asthma. In this case, the patient carries a diagnosis of asthma, which is an allergic phenotype based on an elevated IgE level. Records reflect that the patient's asthma has been poorly controlled, requiring two hospitalization and multiple rounds of systemic steroids in the recent past. Under these circumstances, Dupixent is appropriate for the management of the patients condition. Accordingly, the requested medication Dupixent  Pen is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat 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 pulmonary diseases, 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for expedited scheduling of the corrective spine surgery. Bydon and colleagues report, A trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options may include physical therapy, epidural steroid injection, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion. Chan and colleagues note, Patients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-selected patients who fail conservative management strategies, surgical management is appropriate. Resnick and colleagues explain, As a result of the decompression, the inherent instability associated with the spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar fusion is considered appropriate to stabilize the spine and prevent delayed deterioration. In this case, the patient being treated for lumbar spondylolisthesis and presented with low back and left lower extremity L5 pain. The patient reported pain in the setting of L5-S1 isthmic spondylolisthesis with some left whole-body weakness and dropping things with left hand. An examination revealed strength at 5/5 on the bilateral lower extremities and intact sensation at L2-S1 bilaterally. Gait was intact. A computed tomography (CT) scan demonstrated grade 1 anterolisthesis of L5 on S1 with bilateral pars defects noted with bilateral moderate neural foraminal narrowing, along with loss of disc height at L5-S1. X-rays did not show any interval change in grade 1 anterolisthesis of L5 on S1 in flexion and extension. The records noted that the patient was a former smoker. X-rays did not demonstrate instability on flexion/extension. The submitted records did not document red-flag findings such as a loss of control of bowel or bladder function, genital region numbness, progressive weakness, or intractable pain, and there was no documentation from the provider supporting the need for expedited scheduling of the surgery. Therefore, the requested expedited scheduling of the corrective spine surgery is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient skilled nursing facility (SNF) services and physical therapy, occupational therapy, and speech therapy services provided at Broadway by the Sea. Functional impairments due to acquired brain insults such as stroke can be severe to profound. One researcher notes that rehabilitation is an important aspect of the continuum of care in strokes, and that successful rehabilitation involves understanding the natural history of stroke recovery and a multidisciplinary approach to identify and treat common poststroke sequelae. A researcher notes that patients may improve spontaneously within the first three months and then more slowly in the coming year. Rehabilitation services are rendered first in the inpatient setting, followed by rehabilitation in the community setting if still indicated, based on impairments and the potential for achieving practical, functional goals. Rehabilitation efforts are indicated at a level of intensity commensurate with deficits until care can be safely and effectively transitioned to a less intensive level of care. In this case, the patient sustained an ischemic stroke in the distribution of the right middle cerebral artery, resulting in severe to profound deficits affecting multiple domains, including motor speech, swallowing, self-care and basic mobility.  She made slow but steady gains with multidisciplinary rehabilitation, with clinically significant gains in dressing, substantive gains in transfers, major gains in ambulation, and major gains in swallowing ability.  Given that these gains could not have been achieved in a safe and efficient  manner without the aid of therapists, the services at issue were medically indicated. Therefore, inpatient SNF services and physical therapy, occupational therapy, and speech therapy services provided at Broadway by the Sea were medically necessary for the treatment of this patient.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 physical medicine and rehabilitation 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 Lacosamide 450 mg/day. Findings:  The physician reviewer found that Lacosamide can be taken as monotherapy or adjunct therapy for focal-onset seizures in patients ages four years and up (Subbarao, et al). According to the practice guideline update summary from the American Epilepsy Society and subcommittee of the American Academy of Neurology (AAN), lacosamide is likely effective in treatment-resistant adult focal epilepsy and should be considered to decrease seizure frequency in this patient population (Kanner, et al.). Peer-reviewed medical literature includes publications comparing lacosamide to placebo in 1 Class I and 2 Class II studies. Kanner and colleagues reported that lacosamide at doses of 400 and 600 mg/day showed significantly higher responder rates and greater median reduction of seizures than placebo. Similarly, Chung and colleagues found that lacosamide 600 mg/day yielded a greater reduction in secondarily generalized tonic-clonic seizures. In this case, the patient has intractable epilepsy refractory to multiple medications. Based on the current medical literature and recommendations, lacosamide is appropriate for this patient to decrease seizure frequency in treatment-resistant epilepsy. In addition, lacosamide at doses up to 600 mg/day has been demonstrated to yield a greater reduction in seizures. Given this support, the requested lacosamide 450 mg/day is medically necessary for 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the SPRINT peripheral nerve stimulation (PNS) system. Findings:  The physician reviewer found that the records provided for review document that the patient presents with right foot and ankle pain. The records document that the patient is status post right superficial peroneal nerve block with two hours of relief with anesthetic, but she failed to obtain adequate relief with the steroid. The patients provider has recommended treatment with PNS. The SPRINT PNS system is a minimally invasive, nondestructive treatment modality that has been shown to provide relief of neuropathic pain of the lower extremities and trunk (Hanyu-Deutmeyer and Pritzlaff). In patients who have failed to improve with conservative care including a multimodal treatment approach, PNS may be an effective and minimally invasive treatment option (Deer, et al.). A diagnostic right superificial peroneal nerve block with local anesthetic reportedly yielded two hours of relief, but the patients relief was not sustained with the steroid. PNS of the right peroneal nerve is appropriate as the next treatment option to provide this patient with more sustained pain relief. Given this support, the requested SPRINT PNS system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested SPRINT PNS system 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 reviewer 1 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine and is 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.