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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Botox injections. This enrollee has chronic low back pain as the result of several car accidents. He has had injections and surgery but his symptoms are still present. He currently uses pain medications, including Tylenol and OxyContin. His physician is requesting Botox injections. Botox injection has been shown to help with piriformis muscle syndrome. Studies show pain improvement persists twelve weeks after injection.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 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 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 occipital nerve injection (CPT code 64405). Greater occipital nerve blocks are an effective treatment alternative for patients who have headaches secondary to greater occipital neuralgia, which can be worsened secondary to myofascial neck pain. There are multiple studies demonstrating the benefits of greater occipital nerve blocks for patients with migraine who have failed standard therapies. Studies found that compared to control interventions, greater occipital nerve blocks provide substantial relief of pain and reduce the number of headache days and medication consumption. In this case, the patients migraines have been refractory to treatment with ibuprofen, Imitrex, Maxalt, and Zembrace SymTouch. The patients provider recommended treatment with greater occipital nerve blocks. Given the current support in the medical literature, the requested occipital nerve injection (CPT code 64405) 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 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 HP Acthar gel 80 Unit/mL (2 x 5 mL vials), injected twice per week. Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation. Psoriasis has a high negative impact on the quality of life, especially in patients with moderate or severe disease. Long-term use of traditional systemic therapies is frequently unacceptable due to side effects and limited efficacy. Although there are numerous agents available, for patients with refractory disease that continue to experience tender and/or swollen joints, pain, and disease activity, HP Acthar gel may be indicated. Repository corticotropin injection (HP Acthar gel) produces steroid-independent, anti-inflammatory and immunomodulatory effects in patients with rheumatic disorders, such as psoriatic arthritis. Current studies have demonstrated that repository corticotropin injection is a safe and effective option for patients with refractory psoriatic arthritis who failed therapy with multiple previous treatments. The records provided for review document that this patient has failed treatment with topical steroids, Otezla, and prednisone. Given these findings, the requested HP Acthar gel 80 Unit/mL (2 x 5 mL vials), injected twice per week is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology 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 a panniculectomy. The enrollee underwent gastric bypass surgery four years ago; with a 90-pound weight loss. The enrollee has noticed odor and irritation at her navel for the past two years. She has treated the area with cleaning and ointments, but the odor and redness is still present. Her physician recommended plastic surgery. Studies show this type of surgery is not cosmetic, but a needed surgery to fix the problems of odor and redness.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 plastic 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement for residential treatment center (RTC) services.  Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient did not meet the requirements for dimensions 1 and 2. However, she meets the remaining criteria. For dimension 3, the patient demonstrated depression and anxiety with a history of attempted suicide. The patient showed readiness to change for dimension 4, as she was willing, but after one week, she was unable to acquire the coping strategies needed to overcome her more than 20-year history of depression, anxiety and alcohol misuse. For dimension 5, the patients 20-year struggle with addiction and comorbid depression places her at high risk for relapse. In addition, the patient is noted to self-medicate with alcohol, which elevated her risk for relapse. The patients recovery environment satisfied the criterion for dimension 6, as she would have been isolated during the day while her husband was at work and her children were at school. The patient required a safe and stable living environment in order to develop her recovery skills. The patient qualified for ASAM Level III treatment, similar to what patient received at the RTC facility. Given the severity of the patients illness, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

The patients parent has requested authorization and coverage for Norditropin Flexpro or Nutropin AQ. Based on the medical records provided, this patient had no growth between 2016 and 2017, which suggests poor growth velocity. The patient had a bone age of 14 years at the chronologic age of 15 years five months, which gave him an estimated predicted adult height of 171.5 cm. This estimated predicted adult height is significantly below his midparental target height of 182 cm. He had a testicular volume of 4 mL prior to treatment with growth hormone (GH), which indicates delayed puberty could have contributed to his poor growth. However, the complete absence of any growth for five months suggests this patient has idiopathic short stature only partially attributed to his pubertal status. This patient had a good response to GH treatment, which suggests that his short stature is responding to Norditropin Flexpro GH therapy. Continuing GH therapy with Norditropin Flexpro is consistent with the current Pediatric Endocrine Society guidelines. Therefore, the requested Norditropin Flexpro is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certification in pediatric endocrinology 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 lumbar microlaminectomy.In this case, there is objective evidence of lumbar stenosis and neural compression noted in the patients MRI report. MRI of the lumbar spine noted moderate to severe central canal stenosis at L3-4 and mild central canal stenosis at L4-5. Central stenosis due to broad-based disc herniation and ligamentum flavum thickening, as well as bilateral foraminal stenosis were noted at the L3-4 and L4-5 levels. In addition, the patient has a long history of low back pain in which nonoperative treatment has failed to provide relief. At this time, the patient reports numbness when sitting or standing, and his pain level has increased. Under these circumstances, the requested lumbar microlaminectomy is medically necessary for treatment of the patients medical condition.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 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:  The enrollee is requesting authorization and coverage for HP Acthar Gel 40 units, 2 times per week for 4 weeks, then titrate to 80 units, 2 times per week for 5 months. The enrollee has stage 4 chronic kidney disease. At an office visit, her provider indicated the amount of interstitial fibrosis and tubular atrophy was working against her success rate. The providers recommendation was for the enrollee to continue angiotensin II receptor blockers The pharmacist reports the enrollees condition has worsened; despite maximum evidence-based, non-immunosuppressive therapy. She is spilling a high level of protein in her urine; at a rate of 7.3 grams per day. Normal urinary protein is less than 150 milligrams per day. The enrollees kidney biopsy displayed immunoglobulin A nephropathy, with 50 percent global sclerosis and 40 percent interstitial fibrosis and tubular atrophy. A recent study did not support the use of Acthar gel for those with immunoglobulin A nephropathy, as the study size was limited to five participants; one of whom terminated due to the adverse side effect of weight gain. Studies provide stronger support for immunosuppressants, such as leflunomide, for treating immunoglobulin A nephropathy. Studies showed immunosuppressive therapy can significantly reduce proteinuria and end stage renal disease risk in enrollees with immunoglobulin A nephropathy. While meta-analysis are available to support immunosuppressant use for refractory immunoglobulin A nephropathy, the same level of high evidence for Acthar gel in the treatment of immunoglobulin A nephropathy was not available. Additionally, the article which supports the use of Acthar gel for treatment of immunoglobulin A nephropathy notes that Acthar gel is indicated after the individual has failed more than two prior immunosuppressive or cytotoxic therapies. Medical records do not show the enrollee has trialed immunosuppressive or cytotoxic therapies.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 nephrology and internal 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 similar medical condition.
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 30 sessions of transcranial magnetic stimulation (TMS), or a lesser amount of TMS services. Based on the current available data and U.S. Food and Drug Administration (FDA) approval, controlled clinical trials have not demonstrated that NeuroStar TMS therapy is safe and effective in patients younger than 22 years of age. In a recent review, Croarkin and colleagues concluded that there is a paucity of systematic data demonstrating the safety of TMS in children and adolescents. In this case, the patient has experienced long-term, debilitating symptoms that have persisted despite multiple medication trials and behavioral treatments, including long-term RTC level of care treatment. However, the current peer-reviewed medical literature and FDA do not support treatment with TMS given the patients age. All told, 30 sessions of TMS, or a lesser amount of TMS, 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 board certified in psychiatry with subspecialty certification in child and adolescent 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gammunex-C Immune Globulin Therapy.Findings:  Three of three physician reviewers found that there is sufficient support for the requested services in this clinical setting. Intravenous immunoglobulin therapy is FDA approved for the immune-mediated peripheral nerve disorders Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. Immunoglobulin therapy has been used increasingly with significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia, which are most often small fiber (autonomic and/or sensory) polyneuropathies. Small fiber neuropathy is the most common cause of neuropathic pain in peripheral neuropathies. Patients experience excruciating pain, and currently available anti-neuropathic and other pain drugs do not relieve the pain substantially. Several open-label studies have suggested an immunological basis in small fiber neuropathy and have reported efficacy of treatment with intravenous immunoglobulin. In this case, the patient has been diagnosed with small fiber polyneuropathy and is reported to have debilitating neurological symptoms, neuropathic pain, debilitating paresthesia, and sensory and autonomic dysfunction that are progressing. The patient has tried other types of medical therapies without improvement. Under these circumstances, Gammunex-C Immune Globulin Therapy is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: Three of three reviewers determined that the requested services are likely to be more beneficial than any other available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for the Stretta procedure. The enrollee has gastroesophageal reflux disease with esophagitis; partially controlled with proton pump inhibitors. He also has a hiatal hernia. An esophagogastroduodenoscopy revealed grade III esophagitis in the lower third of the esophagus and gastroesophageal junction, compatible with gastroesophageal reflux disease, and an irregular Z line in the gastroesophageal junction and erythema in the antrum; compatible with mild gastritis. His gastroenterologist is requesting a flexible, transoral esophagogastroduodenoscopy; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease (Stretta procedure). The physician believes this is a reasonable next step, as the enrollees gastroesophageal reflux disease is only partially controlled with medications. A professional society guideline on the role of endoscopy in the management of gastroesophageal reflux disease indicates the Stretta procedure received initial regulatory agency approval in 2000.  The Stretta procedure uses radiofrequency energy delivered to the distal esophagus, which can relieve gastroesophageal reflux disease symptoms for up to 10 years in the majority of individuals. Literature described more than 30 peer-reviewed studies which documented the safety and efficacy of the Stretta procedure.  Durable treatment outcomes, lasting at least 48 months, were documented in multiple studies.  The procedure is as an alternative to fundoplication in individuals with chronic heartburn. Since the enrollee has remained symptomatic on proton pump inhibitor therapy, he is a good candidate for the procedure.  The Stretta procedure is a safe and effective procedure for those with gastroesophageal reflux disease.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in internal medicine and gastroenterology and are actively practicing.  All three 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

The enrollee is requesting reimbursement for partial hospitalization program (PHP) services and intensive outpatient program (IOP) services. He was admitted to the partial hospitalization program to address symptoms of depression and anxiety. The enrollee was compliant with regards to session attendance and sharing what was on his mind. The discharge report indicated there was a good possibility the enrollees functioning would continue to deteriorate. The enrollee was transferred to the intensive outpatient program. The Level of Care Utilization System (LOCUS), a level of care assessment tool to support accurate level of care recommendations was used in this review. The enrollees composite LOCUS score correlates with low intensity community-based services without frequent contact. Medical evidence supports the services at issue in this clinical setting.Final Result: The reviewer determined that the requested service were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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 computed tomography (CT) angiography of the head and CT angiography of the neck. CT angiogram of the head and neck can be utilized to evaluate for stenosis, occlusion, vasculitis, aneurysm or additional structural abnormalities in the vessels of the head and neck. In the setting of neurologic deficit with suspicion for stroke, CT angiogram of the head and neck is supported by the American College of Radiology. In this case, the patient is at high risk for cerebrovascular disease given his history of hypertension and type 2 diabetes. The patient presented to his provider with complaints of increasing extremity weakness. The provider documented clinical suspicion for stroke or significant cerebrovascular disease. CT angiogram of the head and neck is medically necessary to evaluate for cerebrovascular disease in 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 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.