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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with hemoccult positive stool. The patient underwent a colonoscopy with polyp removal. The patients height was 69 inches, his weight was 195.8 pounds, resulting in a body mass index of 28.9. He was given an American Society of Anesthesiologists (ASA) score of two. The patient has requested reimbursement for monitored anesthesia care (MAC - CPT 00811) that was provided. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether monitored anesthesia care (MAC - CPT 00811) that was provided was medically necessary for the treatment of the patients medical condition. The American Society for Gastrointestinal Endoscopy Guidelines for Sedation and Anesthesia in Gastrointestinal (GI) Endoscopy noted, We recommend that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. Researchers concluded, The overall risk of complications after colonoscopy increases when individuals receive anesthesia services. The widespread adoption of anesthesia services with colonoscopy should be considered within the context of all potential risks. In this case, the patient underwent a routine colonoscopy with polyp removal. The patient did not have any documented cardiac, pulmonary, kidney or liver disease. There was no previous history of difficulties with anesthesia or sedation. There was no history of alcohol or substance abuse. The patient was given an ASA score of two, which indicates a low likelihood of complications from anesthesia. The medical evidence does not support the services at issue in this clinical setting. Therefore, monitored anesthesia care (MAC - CPT 00811) that was provided was not medically necessary for the treatment of this patient. 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 anesthesiology 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 and prospective authorization and coverage for  Duexis 800 mg-26.6 mg tablets. The guidelines from the American College of Gastroenterology (ACG) regarding non-steroidal anti-inflammatory drugs (NSAIDs) in patients at high risk for gastrointestinal toxicity recommend co-therapy with misoprostol, histamine type-2 receptor antagonists or proton-pump inhibitors (PPIs) and/or the use of cyclooxygenase-2 selective inhibitors. The records provided for review document the presence of shoulder pain with confirmation of a partial rotator cuff tear. The patient has undergone cortisone injections in the shoulder without significant benefit as well as physical therapy with improvement in range of motion. However, she has found Duexis to be more helpful than single agents. However, the peer-reviewed medical literature has not demonstrated that use of a one-pill agent is superior to a two-pill combination of the same agents. Currently, there is a lack of data in the medical literature demonstrates that using Duexis is superior to using ibuprofen 800 mg with famotidine 80 mg in combination as single agents. For these reasons, Duexis 800 mg-26.6 mg tablets were not and are not medically necessary for 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 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

The patients parent has requested authorization and coverage for speech therapy two times per week for 60 minutes. This patient has autism and the records indicate that he has made considerable progress using an adaptive communication program known as language acquisition through motor planning (LAMP) on his tablet. Young patients with autism can experience a differential response to standard approaches with speech therapy and exhibit considerable progress using augmentative or assisted approaches to speech and language. Given this patients progress, noted by his caregivers and provider, continued speech therapy services are appropriate. Given this support, the requested speech therapy two times per week for 60 minutes is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for Norco 5-325 mg. U.S. Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for non-cancer pain state that nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. CDC guidelines state that clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation.  American Society of Interventional Pain Physicians (ASIPP) guidelines for prescribing opioids state that to establish medical necessity for opioid therapy, it is essential to have a physical diagnosis and information on inadequacy of multiple modalities of treatments including conservative, various other alternatives, and consultations if necessary. In this case the patient has chronic low back pain without radiation into the lower extremities. There are no findings of focal neurological deficits on exam in the submitted documentation, and the patients lumbar MRI and X-rays have not revealed any significant narrowing of the spinal canal or nerve root foramen. The patient has tried and failed medication management with anti-inflammatories, anti-depressants and lidocaine patches. The patient has made clear that he is not interested in trying any other non-opioid agents at this point. Other treatments including home stretching and yoga have also been tried with limited benefit. The treating providers did not feel the patient was a good surgical candidate due to a lack of an obvious therapeutic target. The CDC guidelines state that initiating or continuing opioid therapy is contingent on whether the prescriber feels the benefits outweigh the risks, which is not present in this case. The provider has suggested that the patient continue with non-opioid based therapy, consistent with CDC guidelines. In addition, ASIPP guidelines state that a physical diagnosis be established, while in this case, the patient has non-specific back pain, MRI does not show significant pathology that would correlate with the patients reported pain, and physical exam has not shown any obvious neurological deficit. Under these circumstances, there is nothing identified in the medical records that would warrant escalation to chronic opioid therapy. Accordingly, the requested Norco 5-325 mg is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollees parent has requested authorization and coverage for immunoassay for analyte other quantitative laboratory testing. This patient presents with a history of severe tree nut allergies and anaphylaxis. The patient was planned to undergo induction of food tolerance program. The two major recent practice parameters published by the National Institute of Allergy and Infectious Diseases (NIAID) and American Academy of Allergy, Asthma and Immunology (AAAAI) and American College of Allergy, Asthma and Immunology (ACAAI) Joint Task Force do not support IgG food testing as a validated form of testing. Testing with IgG and IgG4 laboratory tests have shown equivocal outcomes with false-positive test results in non-food allergic patients. For these reasons, the immunoassay analyte quantitative laboratory testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 allergy and immunology 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

The patient has requested reimbursement for air and associated ground ambulance transportation services. The records provided for review document that this patient received acute hospital care in a different state following an injury he sustained. The patient required critical care services and cervical spine surgery. By transport, he was medically stable and ready for inpatient rehabilitation. The patient did not require air ambulance transportation back to his home state at that time. Participation by family members or other members of the patients support system during the rehabilitation process would have been preferable, but it was not a medically necessary for successful inpatient rehabilitation. For these reasons, the air and associated ground ambulance transportation services provided were not medically necessary for 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 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 Nucynta 50 mg four times a day. Studies reported that Nucynta monotherapy was as effective as combination therapy with Nucynta and pregabalin in patients with severe, chronic low back pain with a neuropathic component. A review of Nucynta analyzed five years of data concerning the use of Nucynta for chronic pain and concluded that, head-to-head studies with World Health Organization (WHO) III opioids such as oxycodone controlled release and oxycodone/naloxone PR showed at least comparable pain relief in the treatment of moderate-to-severe musculoskeletal pain. Moreover, the authors noted that, rotation from poorly tolerated WHO III opioids to Nucynta provided effective pain relief and better symptom control for musculoskeletal pain compared to previous medication. In this case, the patient has chronic back and leg pain due to previous back surgeries. She has a diagnosis of lumbar post laminectomy syndrome. She has tried several different opioid pain medications and has allergies to morphine, Dilaudid, and Fentanyl. Most recently, she had tried Tylenol #4 and buprenorphine with gastrointestinal side effects. The patient reported using Nucynta in the past with much less gastrointestinal distress. Evidence from the recent reviews show that Nucynta does possess an improved gastrointestinal side effect profile. The studies also show that it has similar efficacy as traditional opioid medications such as oxycodone with the additional benefit of improved control of neuropathic pain. The records show that the patient has been compliant with her providers treatment plan, which has included epidural steroid injections. Furthermore, the provider noted that Nucynta has allowed the patient to function at work. For these reasons, the requested Nucynta 50 mg four times a day 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 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: An enrollee has requested authorization and coverage for ceftriaxone (Rocephin) 2 Grams IV daily for 4 weeks.The submitted documentation does not support that the requested medication is medically necessary. In this case, the patient does not meet U.S. Centers for Disease Control and Prevention (CDC) criteria for having Lyme disease, because she does not have a positive screening test nor does she have positive IgM and IgG western blots. Moreover, there are no symptoms described that are consistent with central nervous system Lyme disease, and the patients cerebrospinal fluid findings were normal. Accordingly, the patient does not meet diagnostic criteria for Lyme disease. Solitary positive IgM testing (i.e., without a positive IgG) is usually a false positive result. Therefore, the requested medication, ceftriaxone (Rocephin) 2 Grams IV daily for 4 weeks, is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in infectious disease, 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: An enrollee has requested reimbursement for mesenchymal stem cell transplant (CPT 17999). The records provided for review document that this patients diagnosis is post-traumatic osteoarthritis of the right ankle. The patient previously underwent right ankle reconstruction surgery for tibia and fibula fracture with subsequent hardware removal. There is a paucity of peer-reviewed medical literature supporting the long-term safety and efficacy of stem cell transplant in lieu of standard therapies in this patients clinical scenario. Issues regarding the type of stem cell, the number of cells, and the proper combination of growth factors or mechanical stimuli to induce differentiation remain unclear. One systematic review found limited benefit with stem cell treatment for tendon disorders. For adipose-derived stem cells, most tissue engineering techniques are novel and are not supported for routine clinical use. Given these findings, the requested mesenchymal stem cell transplant (CPT 17999) is not 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 mesenchymal stem cell transplant (CPT 17999) is not 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 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for dual diagnosis residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. Applying the ASAM guidelines, the patient is at risk for subacute protracted withdrawal. The records document physical and psychological symptoms including sweating, tremor, agitation, and anxiety. These symptoms, combined with intense cravings and poor coping strategies, place him at high risk of relapse outside of a structured setting. Continued substance use places a serious risk to the patients health, as evidenced by a recent car accident, abscesses related to intravenous drug use, and related risky sexual behaviors. The patients mental status is sufficient to permit participation. However, he is unable to control his substance use without 24-hour support, unable to control his impulses and is at imminent risk of relapse if discharged. He does not possess the impulse control required to cope with his emotions and gain new healthy coping strategies to maintain sobriety. The patient has demonstrated opposition to addressing his substance use disorder. He requires structured therapy and the 24-hour milieu due to his impaired perspective and inability to make sound decisions. The patient has been unable to identify his relapse triggers without guidance by staff and reports severe use cravings. He has social stressors involving his mother and not seeing his daughter, which have been prior triggers to relapse. The patient lacks a healthy, supportive family network. Given these findings, dual diagnosis RTC level of care services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in addiction 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 enrollee is requesting authorization and coverage for lumbar spine magnetic resonance imaging. The enrollee has a history of back pain. A spinal x-ray showed multilevel spondylolisthesis of L3, disc narrowing/degeneration, and facet spondylosis. A progress note showed the physician ordered piroxicam, 10 milligrams, once a day for 30 days, naproxen, 375 milligrams, every twelve hours for 30 days, and he placed an order for a lumbar spine magnetic resonance imaging scan. The enrollee reports that she has experienced severe medical complication with the lower back lumbar area, which has caused further complications, such as uncontrollable bowel movements. The enrollee reports she has visited chiropractors and used other alternative means of treatment to relieve her pain. This enrollee has experienced back pain for almost a year. Despite home exercise, activity modification, and the use of non-steroidal anti-inflammatory medications, including naproxen and piroxicam, she has experienced severe pain in the back and left knee, and more recently in the right foot. Given the persistent symptoms of pain and radiculopathy, and the abnormality seen on the x-ray, the lumbar spine magnetic resonance imaging scan is medically necessary for the enrollee's medical condition.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurosurgery 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.