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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Zohydro ER 30 mg capsule once every 12 hours. In terms of dosage, the American Society of Interventional Pain Physicians (ASIPP) state that 40 morphine milligram equivalents (MMEs) is low dose, 41 to 90 MME is a moderate dose, and greater than 91 MME is high dose. In this case, the patient has chronic pain from lumbar stenosis and left lumbar radiculopathy per the providers notes. She has lumbar scoliosis with degenerative disc disease affecting L4-5 level. The patient is a candidate for spine surgery, but has been unable to move forward with surgery, as she is the primary caregiver in her home. She is currently actively participating in a home exercise program including yoga, which reportedly is helpful in managing her pain. The patient is currently taking Norco for breakthrough pain and her provider is using Zohydro to reduce her reliance on the short-acting pain medication. The provider documented that the Controlled Substance Utilization Review and Evaluation System (CURES) report and urine drug screens have been consistent with therapy and the patient has no documented events of aberrant drug behavior. Based upon the above listed guidelines, the patient is successfully managing her pain while also being weaned off her pain medications by her provider. She is effectively using non-pharmacologic modalities to treat her pain in addition to opioid medication and there are no signs of behavioral problems. Given these findings, the requested Zohydro ER 30 mg capsule once every 12 hours 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with Crohns disease of the small and large intestine with complications. The provider noted the patient has failed treatment with sulfasalazine, hydrocortisone enemas, metronidazole, thiopurines, and infliximab. The physical examination was notable for right lower quadrant abdominal tenderness. The patient reported significant fatigue and two to three formed bowel movements per day with hematochezia the prior day. The patient was being treated with Stelara 90 mg every eight weeks and methotrexate. Laboratory results dated revealed a Stelara level of 4.0 ug/mL, and there were no anti-Stelara antibodies. The patient has requested authorization and coverage for Stelara 90 mg every four weeks. The Health Plan denied the request and reported the requested medication regimen is not medically necessary for the treatment of this patient. At issue in this case is whether Stelara 90 mg every four weeks is medically necessary for the treatment of the patients medical condition. Researchers demonstrated the safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate to severe Crohns disease that were resistant to anti-tumor necrosis factor (TNF) therapy. Studies performed showed a retrospective open-label study. The authors reported, The results of our study provide further evidence that subcutaneous ustekinumab treatment is associated with a sustained clinical response in the majority of anti-TNF resistant Crohns disease patients. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, Stelara 90 mg every four weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 in gastroenterology 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 ketamine infusions for three to four days every three months, plexus neurolysis and sympathetic block with ultrasound guidance, and plexus neurolysis and sympathetic blocks with ultrasound guidance every three to six months. The American Society of Regional Anesthesia and Pain Medicine state that, evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. Researchers found that there is a lack of evidence in the peer-reviewed medical literature to support ketamine infusions for the treatment of complex regional pain syndrome (CRPS). In this case, the patient has undergone multiple ketamine infusions with marginal benefit for management of her CRPS. The records document fewer than the three- and six-week cutoff offered by the most recent expert consensus panel on the treatment. The patient reported six days of relief with the inpatient infusions and two weeks with the outpatient infusions. The medical literature and specific results in this patients clinical scenario do not support the medical necessity of additional ketamine infusions. Thus, ketamine infusions for three to four days every three months are not medically necessary for treatment of this patient. In addition, the requested plexus neurolysis and sympathetic block with ultrasound guidance and plexus neurolysis and sympathetic blocks with ultrasound guidance every three to six months are not medically necessary for treatment of this patient. The evidence for this treatment modality is limited and there is a paucity of data in the literature to support brachial plexus neurolysis for CRPS. Moreover, this patient has a spinal cord stimulator implant in place with reported benefit. All told, ketamine infusions for three to four days every three months, plexus neurolysis and sympathetic block with ultrasound guidance, and plexus neurolysis and sympathetic blocks with ultrasound guidance every three to six months are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication and 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage 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. As noted by ASAM guidelines the duration of treatment always depends on an individuals progress in acquiring basic living skills and how long a person stays in a 24-hour treatment setting depends on his ability to apply and demonstrate coping and recovery skills. This patient has not yet attained the skills needed to maintain recovery. The patient is at high risk of acute or subacute withdrawal as evidenced by visible hand tremor, agitation, and severe cravings rated as 8/10. Continued use places the patient health at serious risk as evidenced by his liver status. He is taking Clonidine 0.1 mg and he required a benzodiazepine taper at the beginning of his admission. The patients mental status is sufficient to permit participation in treatment and he has been unable to control his substance use without 24-hour support. He requires a 24-hour milieu treatment to support his recovery and formulate a relapse prevention plan. The patient described that his feelings of resentment fuel his desire to drink alcohol. The patient is experiencing intense cravings, which place him at high risk for relapse due to his psychosocial stressors and poor coping without treatment in a supportive 24-hour setting. The patients recovery environment is a major trigger for his substance abuse and would not facilitate his goal to achieve and maintain sobriety. All told, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cryoablation of bone and lymph node metastases (CPT 20983). Tumor ablative therapies for palliation of disease complications are within the standard of care for the treatment of symptoms related to metastatic malignancies. This approach includes cryoablation, which has well characterized treatment protocols, standard equipment and technical characteristics. Cryoablation has been demonstrated to provide a safe and effective treatment option for both soft tissue and bony lesions in this clinical setting. Use of cryotherapy has been effective for the palliation of skeletal metastases as well. This patient has nerve pain due to hepatocellular carcinoma with involvement of the right fourth rib at the junction with the sternum. His pain has been refractory to conservative management. Given the support in the medical literature, the requested cryoablation of bone and lymph node metastases (CPT 20983) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested cryoablation of bone and lymph node metastases (CPT 20983) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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: Physician reviewer 1 is board certified in oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma injection to the right elbow. Routine use of platelet-rich plasma in clinical practice is not recommended given the lack of high-quality clinical evidence supporting its efficacy (Krogh, et al.). Moraes and colleagues concluded that there is insufficient evidence to support platelet-rich plasma for treating musculoskeletal soft tissue injuries. In this case, the patient has chronic right elbow lateral epicondylitis. The current literature fails to provide high quality evidence that platelet-rich plasma injections are effective for the treatment of lateral epicondylitis or any other musculoskeletal condition. Therefore, the requested platelet-rich plasma injection to the right elbow is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested platelet-rich plasma injection to the right elbow is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of breast implants without an en bloc by a plastic surgeon who utilizes microsurgery techniques and total capsulectomy; or in the alternative, removal of breast implants generally with total capsulectomy. The patients symptoms include insomnia and brain fog, fatigue, joint pain and left breast pain, as well as numbness in the extremities. However, the records provided for review do not include complaints referring to physical complications of her breast augmentation. Magnetic resonance imaging (MRI) showed intact bilateral subglandular silicone implants. The left implant showed a fold and a trace of peri-implant fluid on the left, suggestive of a left capsular contracture. There is no history of the breast augmentation or physical examination describing capsular contracture. Researchers stated that, autoimmune/inflammatory syndrome by adjuvants (ASIA), allergies, autoimmune diseases, immune deficiencies and lymphomas occur in patients with silicone breast implants. However, Balk and colleagues noted that the evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. This patient presents with generalized complaints. Based on the available documentation, an association of the patients symptoms with the presence of silicone gel implants has not been established. The patient requests authorization for removal of her breast implants with capsulectomies. The medical information reviewed and peer-reviewed medical literature do not support removal of the patients silicone gel breast implants, with or without capsulectomies. Accordingly, the requested removal of breast implants without an en bloc by a plastic surgeon who utilizes microsurgery techniques and total capsulectomy or removal of breast implants generally with total capsulectomy is 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with right knee osteoarthritis. The provider noted the patient has been treated with viscosupplementation injections, a corticosteroid injection, and knee bracing. The provider also noted a right knee x-ray revealed severe patellofemoral compartment degenerative changes. The patient reported right knee pain. The provider noted that the patient had been successfully treated with Synvisc injections in 2018. The patient has requested authorization and coverage for a Synvisc One injection in the right knee. The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether a Synvisc One injection in the right knee is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients 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. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of good response to prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, including corticosteroid injections and bracing, with the alternative being a total knee arthroplasty. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc One injection in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with right knee osteoarthritis. The patient noted that a previous right knee viscosupplementation injection provided increased tolerance for activities of daily living and improved sleep. The patient reported right knee pain. The patient has been treated with a home exercise program, an unloader brace, and medication, including ibuprofen and a topical cream. The patient received a right knee cortisone injection. The patient has requested authorization and coverage for Orthovisc injections in the right knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections in the right knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of benefit from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, including nonsteroidal anti-inflammatory drugs, physical therapy, home exercise program, topical analgesics, unloader brace, and corticosteroid injections, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections in the right knee 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: An enrollee has requested authorization and coverage for Humira (adalimumab).Humira is a TNF alpha blocking medication that was approved for the treatment of chronic plaque psoriasis in 2008 by the U.S. Food and Drug Administration. It is widely used and is safe and efficacious. Humira (adalimumab) is given a rating of A by the recently published National Psoriasis Foundation/American Academy of Dermatology guidelines for use as monotherapy. In the treatment of psoriasis, methotrexate was shown to have a four times greater risk of adverse events than Humira in the CHAMPION study. In this case, the patient has been diagnosed with chronic plaque psoriasis affecting his skin and genital area, and treatment with topical creams and UV therapy has not provided relief. The patient also has elevated liver enzymes and a fatty liver, which make methotrexate a poor choice as an initial treatment due to methotrexates risk of liver toxicity. Under these circumstances, Humira (adalimumab) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the 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.