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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services provided at Second Nature Entrada. Findings:  The physician reviewer found that there is lack of support in the literature for the medical necessity of the services at issue. From the documentation provided, there is a lack of evidence to indicate that standard therapy was trialed for this patient prior to treatment at the therapeutic wilderness program. The submitted records do not document failures of community-based services or evidence-based treatments. Additionally, there are not enough studies to support that wilderness therapy is an effective treatment for opioid use disorder, oppositional disorder, anxiety, and cluster B personality traits. Studies found that wilderness therapy research is significantly lacking in controlled studies. Another study noted that while some studies report benefits of wilderness therapy, caution should be exercised in the interpretation of these results. As such, the services provided at Second Nature Entrada were not medically necessary for the 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 with expertise in child psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco for treatment of her chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The management of acute pain in patients already on buprenorphine is challenging.  Using non-opiate medications, regional blocks and transcutaneous electrical nerve stimulation, as well as increasing the buprenorphine dose, is the standard approach. Adding a fixed combination opiate in this situation will not overcome the buprenorphine binding at the opiate receptor, and very high doses would be required. Gevirtz and colleagues reviewed this issue and found pain control required very large doses of potent opiates, such as fentanyl or hydromorphone. The current medical evidence does not support the requested medication in this clinical setting.  All told, Norco 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 in anesthesiology with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the continuous positive airway pressure (CPAP) replacement supplies provided for treatment of the enrollees obstructive sleep apnea.Findings: The physician reviewer found that CPAP is recommended as the first-line treatment for use in OSA. Epstein and colleagues recommend that patients with OSA should have ongoing, long-term management for their chronic disorder. The authors noted further that patients on chronic therapy should have regular, ongoing follow-up to monitor adherence to therapy, side effects, development of medical complications related to OSA, and continued resolution of symptoms. In this setting, the American Academy of Sleep Medicine (AASM) recommends at least annual follow-up visits at which time a patients use of CPAP should be evaluated including review of usage date to monitor compliance. However, it is not within the generally accepted standards of clinical practice to provide replacement CPAP supplies to patients whom a provider has not recently seen in the office or to those patients who are non-compliant with therapy. In this case, the clinical documentation provided for review was limited to the sleep study from 2011. There is no report that the patient has been seen to follow-up on his OSA as recommended by AASM practice guidelines. Given the lack of clinical records demonstrating that the patient continues to benefit from CPAP treatment, the CPAP replacement supplies provided were not medically necessary for treatment of this patients medical condition.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 neurology with sub-specialty certification in sleep 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 parent of an enrollee has requested authorization and coverage for a walker with seat and pelvic support. Findings:  The physician reviewer found that, as is, the goal with all treatment for cerebral palsy, surgery aims to provide children the greatest chance of living as independently as possible. This patient has been in a power wheelchair and his providers report that he is able to ambulate independently within the home and community settings using a walker with seat and pelvic support. He is noted to be using the walker consistently for 45-60 minutes a day and following through on his physical therapy appointments. The patients orthopedic surgeon, pediatrician and physical therapist have reported on the patients ability to use the walker within the home and community, as well as frequency of use with consistent improvement. Studies reported that preoperative functional level can be exceeded and sustained beyond 24 months following surgery. The health benefits of standing and walking as opposed to sitting have been well-documented in the literature. As such, this patient is likely to continue making progress with use of the walker. For these reasons, the requested walker with seat and pelvic support is supported as medically necessary for treatment of this patients cerebral palsy status post lower extremity surgery. Final Result: The reviewer determined that the requested device 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 pediatrics and 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: An enrollee has requested reimbursement and prospective authorization and coverage for high frequency chest wall oscillation device. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the device at issue in this clinical setting. Patients who are diagnosed with bronchiectasis often have mucus plugging and pulmonary infections. However, while high frequency chest wall oscillation devices for chest physical therapy have been available for many years, their efficacy over routine chest physical therapy have not been established. There is a lack of multicenter, randomized, controlled, and long term clinical outcome studies documenting the safety and efficacy of this device in patients diagnosed with pulmonary disease. There is a lack of objectively documented studies to indicate that the device at issue decreases the progression of any disease, decreases the number of pulmonary admissions or decreases the length of stay of an admission in any disease. The subjective improvement of a patients condition should not be a substitution for randomized, controlled, clinical trials to prove its safety and efficacy. While the patients symptoms may have improved with this device, there is a lack of documentation that the device at issue would improve the long term functional outcome of this patients condition.  Final Result: The reviewer determined that the device 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 pulmonary 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued acupuncture services for treatment of the enrollees pain. Findings: The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the requested services.  This patient has been treated with acupuncture services.  No objective, measurable improvement in function or activities of daily living was documented.  According to the provider, the patients pain and stiffness improved 30%.  However, she continued to have a high pain score of 9/10 per the providers letter.  Additionally, the clinical notes do not document the instruction of an independent exercise program to stimulate self-reliance. Although the peer-reviewed literature supports the use of acupuncture for the treatment of chronic neck pain, after an initial trial, the benefits obtained with such care needs to be assessed in order to evaluate future acupuncture for medical necessity.  Per the records, goals for the additional care were not identified.  All told, continued acupuncture services 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 oriental 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for parenchymal tissue ablation of the liver using NanoKnife technology for treatment of the enrollees epithelioid hemangioendothelioma. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  At this time, there is insufficient published evidence to assess the safety or impact of the requested services on health outcomes or patient management. There is limited long-term survival and recurrence data regarding the use of the NanoKnife technology in this clinical setting. The patient is currently stable, with no change in the liver lesions over multiple CT scans.  He also has normal liver function tests.  All told, the requested parenchymal tissue ablation of the liver using NanoKnife technology is 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 interventional radiology and diagnostic radiology 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 a referral to a neurosurgeon for treatment of the enrollees low back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has chronic back pain. Based on the records, she has no neurologic symptoms and no symptoms of neurogenic claudication. MRI showed no evidence of nerve root compression. The current medical evidence supports neurosurgical referral for urgent conditions such as tumor, fracture, cauda equina syndrome, and bowel-bladder incontinence. The records do not document these urgent conditions in this patients case. Based on the records, she does not have a surgical condition. The requested neurosurgical referral is not supported in this clinical setting. 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 neurological 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:  An enrollee has requested authorization and coverage to be prescribed both Tri-Mix and Quad-Mix. Findings:  The physician reviewer found that there is a lack of medical literature supporting the concurrent use of both Tri-Mix and Quad-Mix in patients with ED. Both Tri-Mix and Quad-Mix are compounded medications which are injected intracavernously to treat erectile dysfunction. Tri-Mix is a combination of three medications and Quad-Mix has one additional medication than Tri-Mix. Given the lack of support in the peer-reviewed literature, the request to be prescribed both Tri-Mix and Quad-Mix is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested 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 urology 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 Butrans patch for treatment of the enrollee's pain.Findings:  The medical reviewer found that the submitted documentation supports the requested medication in this clinical setting.  This patient has tried multiple prior opiates, with only small decreases in pain scales.  She has had better results with Butrans patch.  According to the package insert, Butrans patch is indicated for chronic pain management as well as opiate maintenance therapy in patients with a history of opiate abuse.  This patient has tried multiple other medications, without adequate pain relief. She has also used other modalities, including physical therapy, behavioral therapy, and massage therapy. All told, Butrans patch 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 sub-specialty 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: The parent of an enrollee has requested authorization and coverage for 30 hours per week of direct applied behavioral analysis (ABA) therapy and three hours per week of supervision for treatment of the enrollees autism. Findings:  The physician reviewer found that several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes. Moreover, Ample research has shown that intensive applied behavior analysis (ABA) treatment produces robust outcomes for individuals with autism spectrum disorder (ASD). A study of 726 children (ages 1.5 to 12) to evaluate the relationship between treatment intensity and treatment outcomes. The study showed a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In this case, the patient has made progress with ABA therapy as evidenced by the behavioral data submitted, but he continues to have problematic behaviors which include vocal stereotypies, visual self-stimulating behaviors, self-injurious behaviors and pica. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 reimbursement for the Prolia injection. Findings:  Three physician reviewers found that the Prolia injection provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient is intolerant to treatment with Fosamax. Treatment for Prolia is clinically indicated for treatment of the patients osteoporosis and intolerance to Fosamax. Based on the clinical documentation submitted and peer-reviewed literature, the service at issue was likely to be a more beneficial treatment than standard medical therapy in this clinical setting. Final Result: 3 of 3 reviewers determined that the service at issue was 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: All three Physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: An enrollee has requested authorization and coverage for methadone for treatment of the enrollees pain. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested medication quantity. Per the records, the patient was stable on 120 mg per day of methadone. She was able to perform her activities of daily living, and this dosage of methadone controlled her pain to a significant degree. Dowell and colleagues noted established patients already prescribed high dosages of opioids (greater than or equal to 90 MME per day), including patients transferring from other clinicians, should be offered the opportunity to reevaluate their continued use of opioids at high dosages in light of recent evidence regarding the association of opioid dosage and overdose risk. For patients who agree to taper opioids to lower dosages, clinicians should collaborate with the patient on a tapering plan. This statement does not mandate immediate reduction in dosage. Nuckols and colleagues found that while high dose methadone has higher risks, following guidelines can mitigate that risk.  The authors noted guidelines also agree that opioid risk assessment tools, written treatment agreements, and urine drug testing can mitigate risks. Most recommendations are supported by observational data or expert consensus.  A maintenance agreement and urine toxicology were obtained in this patient, and she was compliant.  There is no indication of diversion or of not following directions. The patient should be maintained on methadone 120 mg per day and given the opportunity to begin a gradual taper.  The dosage of methadone 120 mg per day is medically necessary. All told, a portion of the requested medication quantity is medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested medication quantity is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty 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.