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

Findings:  The physician reviewer found that this enrollee has a history of rheumatoid arthritis. Previous therapy has included Arava and Remicade. Treatment with Remicade was stopped due to a lack of efficacy and because of side effects. The patient complained of pain, and physical examination identified proximal interphalangeal (PIP) joint swelling on the right and metacarpophalangeal (MCP) joint swelling on the left. The patient is noted to have been taking Xeljanz samples, which have been effective. The 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis (the 2015 ACR Guideline) recommends methotrexate (MTX) +/- Tumor Necrosis Factor inhibitor (TNFi) as the next treatment for patients who have failed MTX alone. The 2015 ACR Guideline states that there are potential longer-term safety concerns related to tofacitinib (Xeljanz) that need more study, partly related to the shorter experience using tofacitinib. Although the quality of evidence is low, the 2015 ACR Guideline recommends TNFi with or without MTX over tofacitinib. There are also multiple studies demonstrating efficacy and safety with TNFi in treating moderate to severe rheumatoid arthritis, and there is evidence that a second TNFi is effective in those who have tried and failed a previous TNFi or who have had adverse reactions to other TNFi. There are currently no studies looking at the failure of a first TNFi agent and a different biologic agent. Given safety data and efficacy rates, the 2015 ACR Guideline recommends a 2nd TNFi with or without MTX of non-TNF biologic agent over tofacitinib (Xeljanz). In this case, the patients medical records fail to demonstrate that he has had a failure of 2 TNFi, as recommended by the 2015 ACR Guideline. The patients records also fail to demonstrate a contraindication to a 2nd TNFi. Under these circumstances, Xeljanz XR 11 mg is not medically necessary for treatment of the patients medical condition.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 internal medicine, with subspecialty certification in rheumatology 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

Findings:  The physician reviewer found that this enrollee has a history of headaches. The patient has had prior trials of topiramate, indomethacin and nortriptyline for headache prophylaxis. Office visit notes indicate that the patient had stopped the medication Pamelor (nortriptyline). The patient had been advised by the provider to wean down to 10mg/day, but the patient self-discontinued the medication. The patient reported an increase in headaches following discontinuation of the medication. The patient reported that she had 8 migraines and 4-8 tension type headaches. This was said to show an improvement from the prior month during which she had experienced 3 migraines per week. The patient has been prescribed Aimovig by her treating neurologist, who has noted, that she has experienced improvement in her migraine headaches since starting the medication. The submitted documentation does not support that the requested medication is medically necessary. The medication Aimovig was the first FDA approved agent of a new class of medications developed for migraine headaches known as calcitonin gene-related peptide (CGRP) inhibitors. To date, there is a lack of published evidence available to permit conclusions that the requested medication Aimovig would be more effective than oral agents that have been historically used in the prophylaxis of migraine. A recent report concluded that there is inconclusive evidence for the use of Aimovig compared to other established oral agents for the prevention of migraine. Under these circumstances, the medical literature does not support  that Aimovig would provide the patient with a greater treatment benefit than other available medications that have been historically used in the prophylaxis of migraine. Therefore, the medication Aimovig is not medically necessary for treatment of the patients medical condition. 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 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: An enrollee has requested authorization and coverage for a continuous positive airway pressure (CPAP) device. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees obstructive sleep apnea. A review of the submitted records indicates that the enrollee has been diagnosed with obstructive sleep apnea (OSA). Records reflect that the enrollee had a sleep study evaluation and that this study identified the enrollees diagnosis of obstructive sleep apnea. The enrollees sleep medicine specialist has recommended a CPAP device for the enrollee.The submitted documentation supports the medical necessity of the requested device. Current guidelines of both the American Academy of Sleep Medicine (AASM) and the American College of Physicians recommend the use of CPAP as the first line to therapy for OSA. In this case, the patient had a history of snoring and insomnia and she was found to have an REI of 5.3 (greater than 5) on a home sleep test. Therefore, she would have a diagnosis of OSA based on current diagnostic criteria. Although the patient does not present with comorbid conditions, her clinical presentation, history, and sleep study results, as reported in the submitted documentation, meet the diagnostic criteria for OSA. Considering that CPAP is considered the first-line treatment for patients with OSA, and this patient meets the diagnostic criteria for OSA, the provision of a CPAP device and related accessories is within the generally accepted standards of clinical practice. Thus, the requested CPAP device is supported as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology, with subspecialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for prescribed Otezla. The Health Plan has denied this request indicating that the requested medication is not medically necessary. The submitted documentation does not support the medical necessity of the requested medication. The submitted documentation notes the patient has been treated with other medications. However, the medical records fail to indicate a contraindication, adverse effect or failed treatment trial for any of the preferred treatments.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. There are standard first-line therapies available for treatment of this patients psoriasis, the requested Otezla is not supported as medically necessary. Therefore, the Health Plans denial should be upheld. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) provided and prospective authorization and coverage for future TMS services (two to three times per week). The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health conditions. The submitted documentation fails to demonstrate the medical necessity of the services at issue.  Researchers described a treatment protocol of five days per week, four to six weeks in duration.  Based upon the clinical documentation, the patient was unable to comply with five treatments per week due to mobility issues. The initial treatment period describes a total of eleven treatments, which is below the recommended frequency of treatments. Further treatments beyond this initial period do not have evidence based support as recommendations state that continuation of treatment is indicated in patients that complete a standard acute course of treatment. The protocol employed during the treatment period is not supported by current evidence.  Future TMS treatments that follow a treatment course of two to three times per week would not be supported by existing protocols due to the lack of an initial treatment course. Therefore, transcranial magnetic stimulation (TMS) provided and future TMS services (two to three times per week) were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: An enrollee patient has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association guidelines recommend residential treatment for patients who do not meet the clinical criteria for hospitalization, but whose lives and social interactions have come to focus predominantly on substance use and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. This patient required treatment at the residential level of care in order to develop her recovery skills. The purpose of detoxification was to stabilize the patient. In this clinical setting, residential treatment was an essential component following detoxification to allow for the patient to maintain sobriety and reduce the risk of relapse. Residential treatment was in accordance with generally accepted standards of medical practice and clinically apprporiate for the treatment of this patient. Therefore, residential treatment center services provided were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for emergency services provided. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services.The submitted documentation do not demonstrate that the services were provided for treatment of an emergency medical condition. The patient was not experiencing a life threatening emergency and chiropractic care is not considered emergency care. The chiropractic notes indicate the patient was in mild intermittent pain upon prolonged sitting. There is no medical documentation of any life threatening aspects of his condition. Emergency medicine is care for patients with acute illnesses or illnesses that require immediate medical attention that require immediate care. Therefore, the chiropractic care provided were not provided for emergency medical services. Final Result: The reviewer determined that the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified chiropractor and with specialization in oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An patient has requested authorization and coverage for a power wheelchair. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees late-onset cerebellar ataxia. The submitted documentation supports the medical necessity of the requested equipment. In this case, the patient has idiopathic progressive neuropathy and cerebellar ataxia with a history of repeated falls and impairment of gait and mobility. The patient is unable to self propel a manual wheelchair. He is unable to perform pressure reliefs and is at risk for pressure ulcers. He resides in a subacute facility and would be expected to receive assistance in terms of performing transfers to and from a wheelchair. The current medical evidence supports the requested equipment in this clinical setting. Therefore, the requested power wheelchair 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 physical medicine and rehabilitation 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: A patient has requested authorization and coverage for labiaplasty. The Health Plan has denied this request indicating that the requested surgery was not medically necessary for treatment of the enrollees labial hypertrophy and are not reconstructive in nature. The submitted documentation supports the medical necessity of the requested surgery. The patient complaints include dyspareunia, pain with activity, and pain with wearing clothes. Physical examination revealed asymmetric labia hypertrophy. As noted in the medical literature, there are functional concerns related to labial hypertrophy which can be improved with surgery. Labial hypertrophy is an abnormal enlargement of the labia, which constitutes an abnormal structure of the body. This can be considered a developmental disorder that led to enlargement.  The planned surgery is being performed to improve function and would provide more than a minimal improvement in appearance. All told, the requested labioplasty is supported as medically necessary and reconstructive in nature for treatment of this patients symptomatic labial hypertrophy.Final Result: The reviewer determined that the requested surgical procedure 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 plastic surgery and 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 positron emission tomography (PET) scan (CPT code 78813). The submitted documentation fails to demonstrate the medical necessity of the requested services. Normal surveillance for tumor recurrence for patients after surgery/radiation therapy for prostate cancer includes serial serum prostate-specific antigen (PSA) levels and digital rectal examinations. Appropriate surveillance for recurrent thyroid cancer includes monitoring of serum thyroglobulin levels and neck ultrasound. According to the American College of Radiology appropriateness criteria, PET/CT is usually not appropriate for prostate cancer follow-up with clinical concern for recurrence. In the absence of rising PSA levels, the search for the presence of recurrent disease is usually not warranted, imaging or otherwise. The National Comprehensive Cancer Network recommends surveillance of thyroid cancer status post thyroidectomy by means of monitoring thyroglobulin levels, physical examination and periodic neck ultrasound. In the setting of rising thyroglobulin levels, further imaging is warranted. However, PET/CT is not indicated in routine post-treatment surveillance with normal thyroglobulin levels. In this case, the routine surveillance of this patients prostate and thyroid cancer has not yielded any increased suspicion for recurrence. Imaging examinations of the pelvis have been stable for over two years, therefore making the diagnosis of osseous metastases unlikely. Therefore, PET scan is not an appropriate examination in this case. Thus, the requested PET scan (CPT code 78813) is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) level of treatment, three days a week. The American Psychiatric Association (APA) guidelines for patients with major depressive disorder notes that admission to an intensive day program, may also be indicated for severely ill patients who lack adequate social support outside of a hospital setting, who have complicating psychiatric or general medical conditions, or who have not responded adequately to outpatient treatment. This patients records document that she has a severe illness with complicating psychiatric conditions. In addition, the patients condition has not responded adequately to outpatient treatment. The provider reports the patient has demonstrated improvement in her condition, which supports IOP level of care as the appropriate modality for her but improvement. However, the patient remains at risk to herself in terms of suicidal thoughts and self-neglect. Thus, her improvement is only partial and requires consolidation. Continued treatment at IOP level is consistent with standards of good medical practice and the APA treatment guidelines. Thus, the IOP level of treatment, three days a week were and are medically necessary for treatment of this patients behavioral health issues. 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 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 a referral to a gastroenterologist. In this case, the enrollee has had protracted symptoms despite lifestyle changes and several medications. Symptoms including hematemesis have persisted, and her primary care physician and emergency department physicians have not found an etiology for her symptoms. Her symptoms warrant evaluation for complications of gastroesophageal reflux disease such as esophagitis or esophageal ulcer, gastritis or peptic ulcer disease, and other causes for hematemesis such as angiodysplasia. Diagnosis of these conditions is not possible without endoscopy. Per the American Society of Gastrointestinal Endoscopys Standards of Practice Committee, evaluation by a gastroenterologist is needed to determine whether endoscopy is appropriate and to perform endoscopy if needed.  Therefore, the request for consultation with a gastroenterologist is supported as medically necessary for evaluation of this enrollees symptoms.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with a subspecialty certificate 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.