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

Nature of Statutory Criteria/ Case Summary: This is patient with diagnoses of gastritis, osteopenia, and chronic bilateral hip and back pain from degenerative disc disease.The patients primary care physician (PCP) noted she was having trouble sleeping and having to limit her activity due to her chronic pain in the hips, back and other joints. Celebrex 200 mg capsules were recommended as other non-steroidal anti-inflammatories are contraindicated due to her history of gastritis confirmed by endoscopy in 2018. Another provider reported that ibuprofen taken over the prior two months was not effective for her chronic pain and recommended Celebrex. At issue is whether the requested medication, Celebrex (celecoxib) 200 mg is medically necessary to treat the patients medical condition. Based on the medical record showing the lack of benefit with ibuprofen, the potential risk of GI complications, the relief of her chronic pain with Celebrex without GI complications, and the need to manage the patients chronic pain, Celebrex is appropriate for the patient. 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 in physical medicine & rehabilitation, sports and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for weekly psychotherapy sessions. The records provided for review document that the patient presented to her provider with significant depression, increased crying spells, debilitating anxiety with regard to work, and resultant overall decreased function at home and at work. She described feelings of inadequacy and guilt over taking care of herself, which manifested after many years of suppression. The patient reported a family history of mental illness and resistance to use of medication. Despite her history, the patient agreed to a trial of Wellbutrin. The patients dosage was later increased with good benefit. By March 2020, the provider noted that the patient demonstrated significant recovery from disabling depression and the patient was considering returning to work. Dunlop reports that, pharmacotherapy and high-intensity psychotherapy (interpersonal therapy, [cognitive behavior therapy] CBT) should be provided for patients with moderate to severe depression. The author noted that the treatment plan is typically structured into three phases, with three different goals. Acute phase treatment, typically six to 12 weeks, is focused on reducing symptoms, improving functioning, and achieving remission from the major depressive episode. Following this treatment phase, the continuation phase treatment occurs after acute response (preferably remission) has been achieved, and it lasts four to nine months to prevent relapse back into the major depressive episode. Based on the available documentation, the medication management and psychotherapy provided from October 2019 through March 2020 included services in the acute and continuation phases and restored her to a previous level of functioning both occupationally and socially. Without the outpatient therapy, as described previously, she would have been at risk of the known disabilities associated with untreated depression. Given these findings, the weekly psychotherapy sessions 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 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 for neuropsychological testing. The use of imaging studies alone may not be helpful in determining clinical functioning. Neuropsychological testing is a key diagnostic tool for assessing people with mild cognitive impairment and can provide data on different cognitive domains as well as neuropsychiatric and behavioral features. Baseline neurological testing can establish the rate of impairment. A neuropsychological evaluation may also be helpful in addressing concerns about functional capacities and in determining a patients capacity to make decisions about health care or finances, and in understanding and coping with cognitive problems. In this case, the patients cognitive dysfunction prevented her from functioning at work, and she required an initial neuropsychological evaluation to determine level of her disability. Based on the results of the findings, the patient underwent treatment, including psychotherapy. The patient required repeated neuropsychological testing to obtain a proper assessment of whether the treatment was effective or not, if she would be able to return to work, and if she remained fully disabled. Therefore, neuropsychological testing was medically necessary for the evaluation 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 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 parent of an enrollee has requested authorization and coverage for Epidiolex 100 mg/mL, dosed at 150 mg twice a day.Scientists have explained that cannabidiol (CBD) is one of the cannabinoids with non-psychotropic action, extracted from Cannabis sativa. CBD is a terpenophenol, and it has received a great scientific interest thanks to its medical applications. This compound showed efficacy as anti-seizure, antipsychotic, neuroprotective, antidepressant and anxiolytic. The neuroprotective activity appears linked to its excellent anti-inflammatory and antioxidant properties. Researchers state that the results of scientific studies obtained so far on the use of CBD in clinical applications could represent hope for patients who are resistant to all conventional anti-epileptic drugs. Researchers have noted that almost a third of patients with epilepsy have a treatment-resistant form, which is associated with severe morbidity and increased mortality. The requested medication in this case, Epidiolex, is a pharmaceutical formulation of highly purified CBD in oral solution, 100 mg/ml, usually administered at 2-10 mg/kg/day. It has been demonstrated to be an effective long-term treatment option in Lennox Gastaut syndrome and Dravet syndrome, two forms of intractable generalized epilepsy syndromes in children, and is approved by the FDA for those conditions.In this case, the patient has had an EEG, with video EEG telemetry, and MRI of the brain, and she has a diagnosis of Lennox-Gastaut syndrome with refractory focal and generalized seizures. The patient has been on multiple previous anticonvulsants, including levetiracetam, lamotrigine and clonazepam, none of which resulted in adequate seizure control. The patient has achieved and maintained a positive clinical response with Epidiolex as evidenced by a decreased seizure frequency (less than 1 seizure per month, compared with one to two seizures per week before Epidiolex) and duration (seizures now last seven to ten minutes, are less intense, and now stop spontaneously, whereas previously the patient required rectal Diastat to abort a prolonged seizure). Under these circumstances, the requested medication, Epidiolex 100 mg/mL, dosed at 150 mg twice a day, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested reimbursement for air ambulance transportation services. Convulsive status epilepticus (CSE) is the most common life-threatening childhood neurological emergency. Despite guideline recommendations for continuous electro-encephalographic monitoring (cEEG) use, cEEG may be underutilized in the intensive care units of smaller nonacademic affiliated hospitals, and there is discordance in its availability. Delays in treatment of pediatric patients with refractory convulsive status epilepticus (rSE)  are associated with intermittent rSE and out-of-hospital rSE onset. In this case, lack of stepwise escalation of anti-epileptic therapies with appropriate electroencephalographic monitoring in a pediatric patient with refractory status epilepticus necessitated transfer to a tertiary care center. Given that status epilepticus when refractory can lead to potentially persistent neurologic injury, the current medical literature indicates that transfer to a higher level of care center was medically necessary and the standard of care for this patient. Therefore, air ambulance transportation services were medically necessary for the 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 neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: This is a patient who has a history of osteoarthritis (OA) and bilateral knee pain. The patients records from a physical medicine specialist, note the left knee with no effusion, normal motion and tenderness to the lateral and medial joint line of the left knee, and viscosupplementation (hyaluronic acid under brand names such as Orthovisc) being recommended. The orthopedic surgeon reports that the patient has benefited from viscosupplementation after oral medication was unsuccessful in relieving her knee pain. The patient also reports benefit from prior knee injections. At issue is whether the requested Gelsyn-3 injection series in the left knee (J7328) is medically necessary to treat the patients medical condition. The reviewer stated that literature reports that viscosupplementation injections to the knees can be helpful for pain reduction in patients like this one, with OA. Studies have shown that this may help delay the need for a total knee replacement surgery. Although additional records to note the patients response to the latest injection(s) were not provided for review, it is apparent from the medical records that this patient has received benefit from viscosupplementation. Literature review notes that hyaluronic acid injections may delay the need for knee surgery and may be of value.  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 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 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 Xeljanz 5 mg twice daily. This patients alopecia areata has not improved with first-line steroid injections. Over the last six months, his hair loss has rapidly progressed to include more than 50% of his scalp and his beard. For rapidly progressing alopecia areata, oral Xeljanz 5 mg twice daily is an excellent choice for the next step on the treatment ladder. A substantial volume of peer-reviewed literature supports treatment with Xeljanz in this patients clinical setting. Liu and colleagues studied Xeljanz in 90 patients with severe alopecia areata and found a clinical response in 77% of patients with no serious adverse events. Similarly, Cheng and colleagues demonstrated success in alopecia areata patients with Xeljanz. Jabbari and colleagues studied Xeljanz in moderate to severe patch-type alopecia areata. The authors noted that only one of 12 patients did not respond with regrowth. Since standard therapies have not substantially improved this patients condition, treatment with Xeljanz is indicated. Therefore, the requested Xeljanz 5 mg twice daily 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 Xeljanz 5 mg twice daily 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 medication is 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 dermatology with subspecialty certification in dermatopathology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology with subspecialty certification in dermatopathology 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: This is a patient with right knee osteoarthritis (OA), cardiac disease (coronary artery disease, congestive heart failure and cardiomyopathy), and gastric reflux. The patient cannot tolerate anti-inflammatory medications due to his cardiac disease. At issue is whether the requested Orthovisc Injections in the right knee (J7321) are medically necessary to treat the enrollees medical condition. The patient received some benefit from PT and reports currently riding a bicycle up to 30 miles a day. The literature recommendations for the use of viscosupplementation (Orthovisc) have recently changed. Previously, scientific literature had recommended viscosupplementation for the treatment of OA if all other conservative treatment failed prior to surgery. However, that is no longer the current clinical practice guidelines (CPG) based on the evidence-based research, which no longer recommends using viscosupplementation for symptomatic OA of the knee.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 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 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 Dificid (fidaxomicin tablet 200 mg), ten tablets per five days. For treatment of Clostridioides difficile infections, the Infectious Diseases Society of America (IDSA) guidelines recommend Dificid (fidaxomicin) at a dose of 200 mg twice daily for ten days, both for initial treatment of the infection, and for recurrence if vancomycin has been tried and failed. The current medical evidence supports the safety and efficacy of fidaxomicin for the treatment of Clostridioides difficile infections. In this case, the patient has a confirmed Clostridioides difficile infection. The infection has not responded to vancomycin, and the patient continues to experience persistent diarrhea. The patient saw improvement with a partial course of Dificid. The current medical literature supports the use of Dificid for an additional five days to complete the recommended course to treat this patients Clostridioides difficile infection. Therefore, Dificid (fidaxomicin tablet 200 mg), ten tablets per five days 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 internal medicine with sub-specialty certification 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 hyperbaric treatment. Indications for hyperbaric oxygen as an adjunct treatment include necrotizing infections, chronic refractory osteomyelitis, failed flaps, and acute peripheral ischemia. There is insufficient evidence for the use of hyperbaric oxygen to treat a non-healing wound, without additional supporting indications. In this patients case, the records and results of cultures do not support indications for the use of hyperbaric oxygen as a treatment. There is no documentation of a failed flap, necrotizing infection, or osteomyelitis. Rather, the use of negative pressure therapy and local wound care, or a plastic surgeon consultation may be appropriate. Therefore, hyperbaric treatment is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested treatment 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 family medicine with sub-specialty certification in undersea and hyperbaric 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 hydrocodone/acetaminophen 5/325mg (Norco  60 tablets/30 day supply).Centers for Disease Control and Prevention (CDC) guidelines for the prescribing of opioids for chronic pain state that clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. The 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. Federation of State Medical Boards guidelines for the chronic use of opioid analgesics state that continuation, modification or termination of opioid therapy for pain is contingent upon a clinicians evaluation of evidence of the patients progress toward treatment objectives and the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion.In this case, the submitted documentation reflects that the patient has peripheral neuropathy and has been treated with Cymbalta and gabapentin along with Norco. The patient has, however, had two inconsistent urine drug screen results which were both negative for the prescribed opioid and were positive for THC, which was not being prescribed. The records suggest that the patient has violated the terms of her opioid agreement. Based on current CDC guidelines and those published by the Federation of State Medical Boards, the patient is no longer deemed a good candidate for opioid therapy. Under these circumstances, the treating provider has acted in a manner which is consistent with current guidelines and best practices recommendations by discontinuing opioid therapy and offering non opioid treatment alternatives. Accordingly, the requested hydrocodone/acetaminophen 5/325mg (Norco-60 tablets/30 day supply), is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat 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 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.