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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Qsymia that was purchased and prospective authorization and coverage for Qsymia. The Health Plan has denied this request and reported that the medication at issue was not and is not medically necessary for the treatment of this patient. At issue in this case is whether Qsymia purchased and prospective Qsymia was and/or is medically necessary for the treatment of the patients medical condition. Patients with BMI greater than or equal to 25 can have obesity-related complications treatable by weight loss therap. Patients who have a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight loss medications. Qsymia is a medication approved by the U.S. Food and Drug Administration (FDA) to treat and manage obesity. In this case, the patients history of obesity and efforts in managing the disease illustrate the need to manage her obesity as a chronic disease. The patient reported that Qsymia has been beneficial. She has tried other medications and treatments for obesity. The medical evidence supports the medication at issue in this clinical setting. Therefore, the Qsymia that was purchased and prospective Qsymia was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication was and 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 sub-specialty 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

: The patient has requested authorization and coverage for Chantix tablet and cardiac rehabilitation. Based on the records provided for review, this patient underwent percutaneous coronary revascularization in May 2019. In this circumstance of coronary revascularization within the last six months, cardiac rehabilitation is considered the standard of care (Balady, et al.). In addition, the patient has ongoing smoking with documented inability to quit using multiple modalities other than Chantix medication. Since there is an improved smoking cessation rate using Chantix and the patient has failed other approaches to quitting smoking, Chantix tablet is indicated (Patel and Steinberg). All told, the requested Chantix tablet and cardiac rehabilitation are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication and services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Orthovisc injections (hyaluronic acid) in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of osteoarthritis of both knees, which interferes with her ability to perform activities of daily living. She had tried and failed conservative treatments. There is a history of excellent relief from viscosupplementation in the past with over one year of pain relief. Furthermore, the patients remaining treatment options are limited to a total knee arthroplasty. For these reasons, Orthovisc injections (hyaluronic acid) in both knees are 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 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

: The patient has requested authorization and coverage for Euflexxa injections in the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, there is a history of lasting benefit from prior injections over a period of three years. Each series of injections lasted six months or more. The patient has tried and failed other conservative treatments. Furthermore, the remaining treatment options are limited to total knee arthroplasty at a young age in the absence of imaging evidence of severe osteoarthritis. Therefore, the requested Euflexxa injections in the right knee are 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 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

The patient has requested authorization and coverage for The Centers for Disease Control and Prevention (CDC) guidelines state that clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The Federation of State Medical Boards guidelines state: Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion.In this case, the patient has been on chronic opioid therapy with Norco twice daily as needed for chronic pain related to failed right shoulder surgery and poorly healed forearm fracture with residual nerve damage. The records noted that the patients urine drug screen was positive for THC. The patient states that she has been using over-the-counter CBD oils as a balm for her pain. The patient has a psychiatric history notable for depression, anxiety, and a personality disorder. The physician reviewer found that conditions can increase the risk of inappropriate use and related side effects of opioid medications. In addition, the THC content in over-the-counter CBD products is variable. The CDC and the Federation of State Medical Board do not support the concurrent use of opioids with THC. Based on the available records for review and the current national guidelines, the requested hydrocodone/acetaminophen (Norco) 10/325 mg at one tablet twice daily is not medically necessary for treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for treatment with a wound care specialist. The critical aspects of the wound healing mechanism and host physiological status in patients with diabetes necessitate the selection of an appropriate treatment strategy based on the complexity and type of wound. In addition to systemic antibiotics and surgical intervention, wound care is considered an important component of diabetic foot ulcer management (Kavitha, et al.). This patient has significant foot ulcer with osteomyelitis and peripheral vascular disease. Wound clinic and specialist have access to advanced dressings, hyperbaric oxygen, and skills that are necessary to heal a wound in high-risk situations. Continuity of care by a wound specialist in a multidisciplinary context is standard of care for diabetic foot ulcers and leads to improved limb salvage (Flores, et al.). Although the patient has home health, a visiting nurse cannot perform continued wound care without direction from a physician. In addition, the patient requires weekly ulcer debridement, which must be performed by a wound specialist physician (Blume and Wu). The physician reviewer found that  the requested treatment with a wound care specialist is medically necessary for management of this patients diabetic foot ulcers. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Morphine sulfate ER 30 mg, four times daily and Dilaudid 4 mg, four times daily. The Centers for Disease Control and Prevention (CDC) state that when opioids are started, providers should prescribe the lowest effective dosage. The CDC also states that providers should use caution when prescribing opioids at any dosage. Providers should carefully reassess evidence of individual benefits and risks when considering increasing dosage to equivalent to 50 morphine milligram equivalents (MME) per day, and should avoid increasing dosage equivalent to 90 MME per day without a specific plan to titrate dosage (Dowell, et al.). In this case, the records available for review do not include objective treatment goals for pain and function consistent with the CDC guidelines. The patient was being treated with more than 90 MME per day and he is requesting to continue on this pain medication regimen, especially given the presence of sleep apnea. The physician reviewer found that the records do not include a specific medical evidence-based rationale to support this high of a daily MME. Further, there is no mention of behavior therapy documented despite much research to support its use (Lee, et al.). For these reasons, the requested morphine sulfate ER 30 mg, four times daily, and Dilaudid 4 mg, four times a day, are 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 15 hours per week of direct applied behavior analysis (ABA) services. To determine the medical necessity of ABA, A study provide guidelines. According to the authors, the definition entails: healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on the presenting information, this patient does not meet criteria (c) and (e). The provider has recommended a lesser intensity of service. However, in the attached authorization addendum, there is insufficient information beyond a reported average of interfering behavior including aggression 1.75, property destruction 1, and work refusal 1.3 times per session. The sessions are over two hours, which suggests that the patient is engaging in problem behaviors less than twice per hour. In addition, there is no other description of the patients current level of functioning or data to determine his progress. Given this dearth of information, there is not enough evidence that the patient requires any level of service delivery. Moreover, the provider recommended a fading of services to transition to parent directed services. This indicates that therapist directed sessions would be a more restrictive form of service delivery than appropriate. All told, the requested 15 hours per week of direct ABA services are not medically necessary for 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 a 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing (CPT 83704, 82172, and 83695). The utility of advanced lipoprotein analysis has been the subject of substantial research. Despite some data supporting the use of advanced lipid panel testing, this has not been adopted as a class I recommendation by the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines. Overall, the advanced lipoprotein panel has not been shown to be superior to standard testing with standard lipid panel in the current medical literature. This patients records document a history of hyperlipidemia and obesity. In this clinical setting, the standard of care remains risk factor profiling and basic lipid analysis. For these reasons, the advanced lipoprotein testing (CPT 83704, 82172, and 83695) was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Three physician reviewers found the advanced lipoprotein testing (CPT 83704, 82172, and 83695) was not likely to be more beneficial for evaluation of the patients 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 cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for a nuclear stress test. Based on the records provided for review, this patient presents with complaints of exertional dyspnea. The provider noted that the presence of diastolic dysfunction on echocardiogram (ECHO) prompted concern for cardiac amyloidosis. However, ECHO did not reveal left ventricular hypertrophy to support a diagnosis of cardiac amyloidosis. In addition, there is no documentation of low voltage on the patients electrocardiography. Based on the documentation provided for review, the requested nuclear stress test is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continuation of acute inpatient rehabilitation.The effect of time spent in rehabilitation following a stroke has been explored extensively in the medical literature, but without clear conclusions. The effect of increased time spent in rehabilitation on activities of daily living (ADLs) is also uncertain. In this case, the submitted documentation does not support that continuation of acute inpatient rehabilitation was medically necessary. The complexity of the patients nursing, medical and rehabilitation needs did not require continuation of his acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patients medical needs did not require continued intensive physician or nursing oversight that would have been present in an inpatient rehabilitation facility. While the patient could have benefitted from multiple additional therapies going forward, the submitted documentation does not reflect that the patients functional level required therapies on the intensive level of an inpatient rehabilitation facility program. In this instance, the patient had benefitted from care at the acute inpatient rehabilitation facility. While the submitted documentation reflects that the patient may have benefitted from continued therapies going forward, there is no evidence that a more intensive rehabilitation program was medically necessary. Accordingly, continuation of inpatient rehabilitation services was not medically necessary to treat the patients medical condition.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 physical medicine and rehabilitation, with subspecialty certification in neuromuscular 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:  The enrollee is requesting authorization and coverage for Nature Throid. The patient is a 57-year-old female. At an office visit, lab results showed she tested positive for thyroid antibodies, which her provider believed was due to episodic thyroid underactivity. During the visit, the patient indicated she wished to start natural thyroid hormones. She has been taking Nature Throid. The enrollee indicated her dosage has increased over a two-year period to 97.5mg. A lab report revealed her thyroid stimulating hormone was 0.39 (reference range 0.45 to 4.12) and thyroid peroxidase antibodies were 40 (reference range less than 35). A later report showed a T3 level of 2.2 (reference range 4.6 to 11.2) and thyroid peroxidase antibodies of 40. She indicates she requires a thyroid medication that includes both T3 and T4 because of her diagnosis of hypothyroid and Hashimotos thyroiditis. She is requesting coverage of Nature Thyroid. Review of the record indicates insufficient evidence of the patients trial and failure or contraindications to formulary alternatives, such as levothyroxine, levoxyl, liothyronine, Synthroid, Thyrolar and Unithroid. The medical literature describes a study that investigated the outcomes of a group of patients who were utilizing thyroid hormone extracts. The study reported adverse events. Ninety-one of these reports also showed alterations in thyrotropin values. Sixty-eight percent of the patients developed symptoms of altered thyroid-stimulating hormone, some of which were consistent with thyrotoxicosis. Two patients developed arrhythmias. Levothyroxine remains the standard of care among professional endocrine societies for treating thyroid deficiency. Dosage decisions for levothyroxine thyroid replacement require a thorough patient assessment and the review of many factors; such as age, the presence of cardiac disease, and the etiology of the patients hypothyroidism. Studies describe difficulty in dose adjustment of hormone extracts due to confusion in interpreting thyroid function test results while on thyroid extract. Standard of care and practice include replacement of T4 only, including treatment for Hashimoto Thyroiditis. The requested therapy with Nature Thyroid does not offer unique safety and efficacy advantages over other commercially available thyroid hormone preparations.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology, diabetes & 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 similar medical condition.