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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient meets the criteria for RTC services. For dimension 1, the patient has been at serious risk of harm (score 4) due to expression of suicidal ideation prior to RTC admission. The records document that the patients friend brought the patient to the hospital given concern about the patient harming herself. The patient also experienced a recent alcohol relapse with loss of self-control and harmful behaviors with no demonstrated ability to abstain from use. There is support of clear compromise of ability to care adequately for oneself. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given her recent struggles with alcohol relapse and fulfilling job responsibilities. The patient was also noted to have a conflictual relationship with her father. The patient has only been able to maintain gains while participating in treatment in a structured setting. The records document recent gains and stabilization in function achieved while participating in treatment in a structured and protected setting. For dimension 3, the patient has significant comorbidities (score 3) considering her recent substance use with detrimental effects on presenting symptoms, worsening depression and anxiety and inciting suicidal ideation. Recent substance use has had clearly detrimental effects on the presenting disorder but has been temporarily arrested through use of a highly structured or protected setting. For dimension 4A, the patients recovery environment has been moderately stressful (score 3) due to ongoing conflicts with her father and her ex-husband. The records document significant discord and difficulties in family relationships and alienation from social interaction. For dimension 4B, the patients recovery environment is minimally supportive (score 4) since the patient has limited social support and has ongoing problems with her ex-husband. The patients father is housing and employing the patient, but he is frustrated with the patient. The patient is on bad terms with an unwilling to use supports available in a constructive manner.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for an additional four hours (three hours/units  96133; one hour/two units 96137) of neuropsychological testing (for a total of 13 hours testing)At issue is whether the additional four hours (three hours/units  96133; one hour/two units 96137) of neuropsychological testing (for a total of 13 hours testing) are medically necessary to treat the patients mental health or substance use disorder as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.The issue of neuropsychological testing for the diagnosis of ADHD has come up for debate in recent years, despite being the accepted modality for diagnosis previously. The medical literature indicates that it is no longer standard of care to refer for neuropsychological testing for a diagnosis of ADHD but instead, the diagnosis is meant to be made based on objective measures as well as clinical/psychiatric evaluation. In this case, the Health Plan has already authorized nine hours of testing. Despite the patient not yet receiving testing, his psychiatrist has already started Strattera for presumed ADHD based on clinical evaluation. The requested additional four hours (three hours/units  96133; one hour/two units 96137) of neuropsychological testing (for a total of 13 hours testing) are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, four additional hours (three hours/units  96133, one hour/two units  96137) of neuropsychological testing (for a total of 13 hours testing) 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for radiofrequency ablation (RFA) of the left and right first and second perforator veins (CPT 36475 x 2 and/or CPT 36476 x 2). The documentation provided for review does not support the medical necessity of the requested perforator vein treatments (Erben, et al.; Ozkan). Obi and colleagues noted that varicose vein surgery is predominantly characterized by endovenous treatment of axial vein reflux, phlebectomy of clusters, and substantial improvement in Venous Clinical Severity Scores. However, in this patients case, there is a lack of evidence of ulceration to support an indication for perforator vein treatment. In addition, there is a lack of report that evaluation with an arterial perfusion study was performed given the patients complaints of leg pain aggravated by walking. Furthermore, the records do not report that the patient has attempted an adequate trial of treatment with a lymphedema compression pump. Given these findings, the requested radiofrequency ablation (RFA) of the left and right first and second perforator veins (CPT 36475 x 2 and CPT 36476 x 2) 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 general surgery with subspecialty certification in vascular 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 requested authorization and coverage for lumbar/sacral facet joint block at bilateral L4-5. Researchers performed a systematic review of lumbar facet joint injections and medial branch blocks for the treatment of patients with chronic low back pain. The authors found promising data to support the efficacy of medial branch blocks for chronic low back pain deriving from facet joints osteoarthritis. The current American Society of Interventional Pain Physicians (ASIPP) guidelines for lumbar medial branch blocks and facet joint injections state that, The level of evidence is II in selecting patients for facet joint nerve blocks at least three months after onset and failure of conservative management, with strong strength of recommendation for physical examination and clinical assessment. In addition, ASIPP noted that, The level of evidence is II with moderate strength of recommendation for therapeutic lumbar facet joint nerve blocks with inclusion of three relevant randomized controlled trials, with long-term improvement. This patients records document the presence of chronic low back axial pain. There are lumbar MRI findings of degenerative disc and joint disease at the L4-5 level. Physical examination demonstrated positive facet joint challenge with normal neurological examination results. The patient has failed conservative care with physical therapy and non-steroidal anti-inflammatory drug (NSAID) therapy, and epidural steroid injections have become less effective over time. Based on current guidelines, lumbar medial branch blocks are indicated to confirm and treat this patients lumbar facet joint related back pain. Therefore, the requested lumbar/sacral facet joint block at bilateral L4-5 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for Ubrelvy 100 mg (10 tablets/30 days concurrently with Aimovig). Calcitonin gene-related peptide (CGRP) plays a crucial role in migraine pathophysiology and has been established as an important target for both preventive and acute treatments. Aimovig is an injectable monoclonal antibody targeting the CGRP receptor and approved by the FDA for the prevention of migraine. Ubrelvy is an oral CGRP inhibitor indicated for the acute treatment of migraine with or without aura in adults. The efficacy of Ubrelvy for the acute treatment of migraine has been demonstrated in two randomized, double-blind, placebo-controlled trials (Edvinsson, et al.; Mullin, et al.). In both studies, the percentage of patients achieving headache pain freedom two hours post dose was significantly greater among patients receiving Ubrelvy compared to treated with placebo. This patients records document a history of migraines that have not responded to multiple oral abortive and preventative medications. Given the current support demonstrating that the combination of the two classes of treatments are effective for acute migraine attacks as well as for migraine prevention, the requested treatment with Ubrelvy in combination with Aimovig is appropriate. For these reasons, the requested Ubrelvy 100 mg (10 tablets/30 days concurrently with Aimovig) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Ubrelvy 100 mg (10 tablets/30 days concurrently with Aimovig) 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for custom foot orthotics.Custom orthotics are fabricated to the patients foot from a mold of the patients foot in a corrected position. These devices support the medial column of the foot, support the plantar fascia, and alleviate stress and strain from the plantar fascia. Orthotics are also standard of care for the conservative treatment of neuroma.  Specialized forefoot pads may be applied to a custom orthotic in order to offload pressure from the metatarsal heads and the painful neuroma. Finally, dispersion pads may be applied to a custom orthotics in order to alleviate stress strain and pressure from the first MPJ. In this case, the patient has pain in her MPJ, plantar forefoot, and plantar fascia. Therefore, the requested custom foot orthotics are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Xeljanz. Findings:  The physician reviewer found that some excellent promise in the treatment of severe alopecia areata. According to the Alopecia Areata Consensus of experts, there was consensus on the effectiveness of monotherapy with oral corticosteroids, cyclosporine, and Janus kinase (JAK) inhibition therapy as well as combination therapy of oral corticosteroids together with cyclosporine or methotrexate when used as steroid-sparing. Moreover, Liu and colleagues concluded, Tofacitinib should be considered for the treatment of severe alopecia areata. Additionally, Chapman and colleagues state, Clinical trials and other studies have demonstrated the efficacy of JAK inhibitors in the treatment of a variety of dermatologic conditions. According to the medical literature, the use of Xeljanz (JAK inhibitor) has become the standard of care after patients fail or are no longer able to take steroids for safety reasons. Gilhar and colleagues state that the use of JAK inhibition in alopecia areata constitutes landmark progress in the treatment of this autoimmune disease. Therefore, the requested Xeljanz is medically necessary for treatment of the patients medical condition.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:  An enrollee has requested reimbursement for coronary angioplasty provided by Mayo Clinic Arizona on 1/08/21.The current medical evidence supports the service at issue in this clinical setting. Patel and colleagues indicate that diagnostic cardiac catheterization is considered appropriate in both symptomatic and asymptomatic patients with positive stress echocardiogram findings of stress-induced wall motion abnormality in two or more segments. In this case, the patient had exercise-induced hypokinesis of the anterior and septal segments, suggesting possible proximal left anterior descending artery obstructive disease. Therefore, the coronary angioplasty provided by Mayo Clinic Arizona on 1/08/21 was medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the service at issue was medically necessary for evaluation 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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has reimbursement for Supartz injections provided by Torrance Memorial Physicians and prospective authorization and coverage for future treatment with hyaluronan injection(s) (series of Supartz injections or Monovisc injection) in the left knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The conclusive evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, the patients options were limited, as she did not respond to other conservative treatment, including medication, bracing, and activity modification. Therefore, Supartz injections provided by Torrance Memorial Physicians and future treatment with hyaluronan injection(s) (series of Supartz injections or Monovisc injection) in the left knee were and are medically necessary for the 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 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 requested authorization and coverage for Admission to a skilled nursing facility (SNF) until the patient is mobile and able to care for herself. Based on  the available information, the SNF-level services provided from 10/11/21 forward are medically necessary for the management of this patients post-COVID-19 syndrome. The patient remains acutely deconditioned after a prolonged hospitalization for COVID-19 pneumonia and acute hypoxemic respiratory failure requiring mechanical ventilation with tracheostomy and PEG placement. The patients current condition remains an acute deterioration of her former baseline level of functioning. The admission to a SNF has not provided an adequate amount of time to allow for the patient to improve with physical therapy and occupational therapy. As noted in the medical literature, patients often requirement multiple months to fully recover after severe illness from COVID-19 (Bowles, et al.; Chopra, et al.). These findings support that continuation of SNF services with a focus on aggressive physical therapy and occupational therapy with the goal to regain mobility and independence in ADLs is appropriate for this patient. Therefore, the admission to a SNF until the patient is mobile and able to care for herself was and is 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 internal medicine with subspecialty certifications in pulmonary diseases and critical care 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.