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 a Praluent pen 75 mg/mL (alirocumab). The U.S. Food and Drug Administration (FDA) approves the use of Praluent (generic name alirocumab), a proprotein convertase subtilisin-kexin type 9 (PCSK9), for the treatment of adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease, who require additional lowering of low-density lipoprotein cholesterol (LDL-C). Robinson and colleagues note that PCSK9 inhibitors have been shown to reduce LDL-C levels in patients who are receiving statin therapy. Cannon and colleagues note that in patients with acute coronary symptoms, when added to statin therapy, ezetimibe resulted in incremental lowering of LDL cholesterol levels and improved cardiovascular outcomes. In this case, while the patient has some coronary risk, the documentation does not support a diagnosis of heterozygous familial hypercholesterolemia with elevated LDL-C levels that significantly exceed 180 mg/dL, or a or a strong family history of coronary disease. Physical examination did not document findings such as arcus cornealis below the age of 45, or tendon xanthomatas. The records do not reflect angina, ischemic electrocardiogram change, or ischemia on stress testing. The documents do not reflect trials of specific statin medications, such as pitavastatin and Fluvastatin, which may have lower side effect profiles. While the provider noted that the patient was not sufficiently controlled on ezetimibe, the documentation does not reflect that the patient was unable to tolerate this medication, which has been shown to improve outcome in patients with a variety of responses. Given that the current medical literature does not support the of PCSK9 inhibitors in this primary prevention setting, the requested medication is not medically indicated. Therefore, a Praluent pen 75 mg/mL (alirocumab) is not medically necessary for the treatment of this patient.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 internal medicine with sub-specialty certification in cardiovascular 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Gel One injection for the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, a Gel One injection for the right knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 patient has requested reimbursement for all or any of the residential treatment center (RTC) level of care provided. 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. With regard to risk of harm, the records support a score of 3. The patient had a history of suicidal ideation and past attempts with Advil, however the records did not indicate current suicidal ideation or intent. In terms of functional status, the records support a score of 3. The documentation noted ongoing difficulties in interpersonal relationships and ability to function in employment. With regard to comorbidity, the records support a score of 3. The patient reported past issues with substance use but reported being sober at the time of admission. In terms of level of stress of the recovery environment, the records support a score of 3. The patient reported an aversion to returning home due past trauma. However, the records did not identify significant stressors or stress factors to be addressed in the treatment plan.With regard to level of support of the recovery environment, the records support a score of 2 as the patient had a supportive family.In terms of resiliency and treatment history, the records support a score of 4. The patient had equivocal response to past treatment, due to extended abstinence from substance use, but persistent mood and anxiety symptoms. With regard to treatment acceptance an engagement, the records support a score of 2. The patient was well engaged in present treatment, recognized and understood her illness, and demonstrated a desire for recovery. Thus the patient has a total score of 20. In this case, the recommended level of care was medically monitored non-residential services. Therefore, all of the RTC level of care provided was 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 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

An enrollee has requested authorization and coverage for rhinoplasty which includes septoplasty procedures (CPT 30420 and CPT 30520).Rhinoplasty is a surgical procedure to smooth out the nasal deformities and to fix nasal breathing problems. Improving nasal valve angle has been shown to improve nasal breathing. In this case, the patient was involved in a motor vehicle accident that resulted in suffering nasal obstruction. The submitted records document that the patient has a septal deviation, and the submitted photographs of the patient demonstrate valve collapse with inspiration. The submitted records reflect that a Cottle maneuver improved the patients nasal breathing, thereby indicating nasal valve collapse. Under these circumstances, a septoplasty will be necessary to correct the septal deviation that was also caused by the accident. Accordingly, the requested rhinoplasty which includes septoplasty procedures (CPT 30420 and CPT 30520) is medically necessary for the patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the patient requires surgery to correct or repair nasal obstruction and septal deviation, which are trauma that were caused in this instance by a motor vehicle accident. The requested surgery will improve the patients nasal breathing, thereby improving function. The submitted photographs of the patient also demonstrate valve collapse with inspiration, and the requested surgery will thereby provide more than a minimal improvement in the appearance of the patient. Therefore, the requested rhinoplasty which includes septoplasty procedures (CPT 30420 and CPT 30520) is reconstructive in nature for treatment of the patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for use of a power wheelchair with tilt option (GRP 2).The submitted documentation does not establish that the patient has upper body musculoskeletal, cardiovascular, respiratory or other impairments that would preclude effective propulsion of an optimally configured manual wheelchair for accomplishing mobility-related activities of daily living. There are no objective indications of any pathology or other medical condition beyond a reduced subjective tolerance for propelling a manual wheelchair. This does not constitute an impairment or functional limitation with respect to this activity.The submitted records also do not establish that the patient has upper body impairments that would preclude effective pressure relief maneuvers in an appropriately fitted manual wheelchair in conjunction with an appropriate pressure relieving seat cushion. Compliance is the key to pressure injury prevention when the physical capacity to perform the appropriate maneuvers is intact. Lack of compliance can result in pressure ulcer development with or without tools such as power tilt-in-space. A study of the effects of wheelchair cushions and pressure relief maneuvers on ischial interface pressure and blood flow in people with spinal cord injury. They found that regardless of the cushion being used, pressure relief maneuvers resulted in very large reductions in interface pressures and significant increases in buttock blood flow. Poor subjective tolerance of or compliance with performing pressure relieving maneuvers does not constitute an impairment or functional limitation with respect to this activity.The patients most recently documented mobility evaluation is a physical therapy evaluation that indicated that the patient has the physical capacity to propel a manual wheelchair and to perform adequate pressure relieving maneuvers using his own body power. No impairment precluding these functional activities and tasks was noted on this evaluation. Under these circumstances, the requested use of a power wheelchair with tilt option (GRP 2) is not medically necessary for the patient to perform one or more mobility related Activities of Daily Living or Instrumental Activities of Daily Living in or out of the home, including access to the community.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection in both knees. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections in 2019. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc One injection in both knees are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly speech therapy. Based on the available documentation, this patient with autism and Down syndrome has participated in speech therapy for several years with slow progress. In July 2020, the provider reported that the patient has met one of six goals, significant progress in two of six goals, and progress in the remaining three goals. According to the National Down Syndrome Society (NDSS), patients with Down syndrome frequently have difficulty with grammar, tenses and word endings and use shorter sentences to communicate. In the medical literature, researchers noted that language disorder is a cardinal challenge for children with Down syndrome and these patients have the potential to respond to language intervention. A study noted that the achievement of speech intelligibility by patients with Down syndrome facilitates their participation in society. Given this patients slow progress with speech therapy thus far, continued weekly speech therapy is consistent with current medical literature recommendations. Moreover, the requested weekly speech therapy is medically necessary to decrease disability due to speech and language impairment and promote health and efficiency by decreasing her frustration with her difficulty in communication with others. For these reasons, the requested weekly speech therapy 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly speech therapy. Based on the available documentation, this patient with autism and Down syndrome has participated in speech therapy for several years with slow progress. In July 2020, the provider reported that the patient has met one of six goals, significant progress in two of six goals, and progress in the remaining three goals. According to the National Down Syndrome Society (NDSS), patients with Down syndrome frequently have difficulty with grammar, tenses and word endings and use shorter sentences to communicate. In the medical literature, researchers noted that language disorder is a cardinal challenge for children with Down syndrome and these patients have the potential to respond to language intervention. Another study noted that the achievement of speech intelligibility by patients with Down syndrome facilitates their participation in society. Given this patients slow progress with speech therapy thus far, continued weekly speech therapy is consistent with current medical literature recommendations. Therefore, the requested weekly speech therapy 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) skilled services by a registered nurse for management and evaluation of the plan of care (CPT code G0162), 1 unit at 15 minutes each, and (2) direct skilled nursing services of a registered nurse in the home health or hospice setting (CPT code G0299), 3 units at each 15 minutes. Green notes that patients with dementia have unique safety needs due to cognitive and behavioral changes associated with dementia. The author further notes that safety interventions for persons with dementia who remain in their home environment should be considered to mitigate the risks associated with falling, kitchen use and food safety, medication safety, and wandering and personal safety. Despite these measures, constant supervision and caregiver assistance for safety may still be needed. Maayan and colleagues note that caring for someone with dementia can be emotionally and physically demanding. In this case, the patient has profound cognitive deficits. The records do not reflect skilled therapy needs or that the patient is capable of being rehabilitated. She requires indefinite assistance with basic care and mobility. Given that these services are custodial in nature, the requested services are not medically indicated. Therefore, (1) skilled services by a registered nurse for management and evaluation of the plan of care (CPT code G0162), 1 unit at 15 minutes each, and (2) direct skilled nursing services of a registered nurse in the home health or hospice setting (CPT code G0299), 3 units at each 15 minutes are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dosage of the medication Klonopin (clonazepam), 5.0 mg twice daily and 2.5 mg to 5.0 mg at bedtime. Breilmann and colleagues note that while benzodiazepines are frequently used in the treatment of panic disorder, guidelines recommend antidepressants, mainly selective serotonin reuptake inhibitors (SSRIs), as first-line treatment for panic disorder, particularly due to their lower incidence of dependence and withdrawal reaction when compared to benzodiazepines. The American Psychiatric Association (APA) practice guidelines for the treatment of panic disorder recommend psychosocial treatment, with the strongest evidence available for cognitive behavioral therapy. In this case, the patient has reported life stress and the records reflect symptoms that appear consistent with affective dysregulation consistent with borderline personality disorder. She is being treated with numerous medications without improvement to her anxiety and affective dysregulation. The documentation does not reflect that the patients provider has recommended a higher dosage of clonazepam. Given that benzodiazepine treatment is meant for the short-term treatment acute panic attacks, and at a low dose chronically for residual anxiety if SSRI treatment is insufficient, and that a dosage higher than that approved by the U.S. Food and Drug Administration (FDA) may carry the risk of would have significant morbidity and chance of mortality, the requested medication regimen is not medically indicated. Therefore, dosage of the medication Klonopin (clonazepam), 5.0 mg twice daily and 2.5 mg to 5.0 mg at bedtime is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 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 right subacromial ultrasound-guided right bursa injection (CPT 20610 and 76942).Injections under ultrasound guidance have become increasingly popular because of the accuracy and efficacy of the injections. Liao and colleagues performed a retrospective study to identify the treatment response to ultrasound-guided musculoskeletal interventions. Among the 605 injections included in their analysis, there was a positive response in 81% of the interventions, with positive response ranging from 70% to 88% in different groups. As such, ultrasound guidance is effective in musculoskeletal injections and facilitates the accuracy of the injection. In this case, the patient has Complex Regional Pain Syndrome type I and reports severe burning pain in the shoulder at this time. The patient is currently being treated with opioid analgesics, however, this medication is not providing effective pain relief. The provider has determined that the patients pain source is the subacromial bursa. A prior injection into the subacromial bursa with ultrasound guidance gave 50 percent relief. Under these circumstances, the requested right subacromial ultrasound-guided right bursa injection (CPT 20610 and 76942) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's 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.