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 Ubrelvy (ubrogepant). The records provided for review document that this patient presents with a history of migraines. Treatment has included multiple prophylactic and abortive medications such as nortriptyline, propranolol, sumatriptan, and valproic acid. The patients provider has recommended treatment with Ubrelvy. The U.S. Food and Drug Administration (FDA) has approved Ubrelvy for the treatment of patients with migraine. Studies found Ubrelvy has been shown to be effective and safe in the treatment of patients with migraine. The use of Ubrelvy is indicated for the disease process in this patient, is consistent with accepted standards of medical practice, and is therefore medically necessary. All told, the requested Ubrelvy (ubrogepant) 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 neurology with subspecialty certification in vascular neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone-acetaminophen #96 tablets per 30-day period. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has chronic low back pain due to severe spinal stenosis. The records do not note any aberrant or drug seeking behavior, and a Controlled Substance Utilization Review & Evaluation System (CURES) consolidated report does not note any irregularities. The patient has been prescribed the requested medication while awaiting imaging and neurosurgery evaluations with a plan to wean off the medication following treatment and improvement in pain. Given that this patient is being treated in a manner consistent with current medical literature, the requested medication is medically indicated. Therefore, oxycodone-acetaminophen #96 tablets per 30-day period are 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 anesthesiology with sub-specialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment (DME) custom oral device (CPT E0486). Findings:  The physician reviewer found that records provided for review document that this patient failed treatment with continuous positive airway pressure (CPAP) as first-line of treatment due to intolerance. The patient is symptomatic, and her provider has recommended treatment with a custom oral device. Oral mandibular advancement devices are U.S. Food and Drug Administration (FDA) approved for the treatment of patients with mild to moderate OSA. Per the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM), treatment with oral appliance therapy is supported for the treatment of patients with moderate OSA (Ramar, et al.) Given the moderate severity of this patients OSA with an apnea/hypopnea index (AHI) of 22.3 events per hour, treatment with a custom oral device is consistent with the recommendations in the medical literature and current guidelines. Therefore, the requested DME custom oral device (CPT E0486) is medically necessary for treatment of this patient. 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 internal medicine 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injection series in both knees.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 current 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, there is a history of significant relief from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Therefore, Orthovisc injections series in both knees are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 image-guided sacroiliac joint injection. Researchers completed a systematic review of sacroiliac joint injections for low back pain. The authors concluded that, No single physical examination maneuver predicts response to diagnostic injections. When at least three physical examination findings are present, sensitivity, and specificity increases significantly. In relation to the evidence supporting the procedure, authors stated that, Two randomized controlled trials and multiple observational studies supported the effectiveness of therapeutic sacroiliac joint injections. Another study evaluated the diagnosis and treatment for sacroiliac joint pain and found that Diagnosis was made with three or more positive provocation tests, with the highest sensitivity being Faber (91.4%) and lowest probability was Gaenslen test. In this case, the patient presents with pain over the sacroiliac joint region bilaterally. Treatment has included radiofrequency ablation of the lumbar facet joint with good relief in the area. Recent physical examination included positive tenderness to palpation over the sacroiliac joints bilaterally as well as positive findings on three provocation tests of the sacroiliac joint. The patient has not demonstrated any focal neurological deficits and previous straight leg tests were negative. Medication use is limited due to sensitivity and physical therapy was attempted prior to the provider recommending sacroiliac joint injections. Based on the medical records for review and current medical literature, the requested image-guided sacroiliac joint injection 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vein embolization and sclerotherapy. Pelvic congestion syndrome has been suggested to include symptoms such as pelvic pain, heavy menstrual bleeding, vaginal and vulvar varicosities, and painful intercourse. Diagnosis is corroborated by the radiological finding of dilated ovarian and other pelvic veins. The records provided for review document that imaging findings were consistent with severe gonadal vein reflux and dilated pelvic varicosities, including vulvar varicosities. A computed tomography (CT) of the abdomen and pelvis revealed prominent bilateral gonadal veins, with prominent bilateral adnexal, periuterine and perivaginal veins, prominent superficial veins in the left upper thigh, and sclerotic changes on the iliac side of the sacroiliac joint. The patients provider has recommended treatment with vein embolization and sclerotherapy. Recent studies suggest that ovarian and pelvic vein embolization can be performed with a high safety rate, excellent radiological success, and good clinical improvement at two-year follow-up (Hansrani, et al.; Gloviczki, et al.; Daniels, et al.). Given this support, the requested vein embolization and sclerotherapy are 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 vein embolization and sclerotherapy are 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 reviewers 1, 2, and 3 are board certified in surgery with subspecialty certification in general vascular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an air ambulance transfer from Linden Oaks Behavioral Health-Main Inpatient Campus in Naperville, Illinois, to the Acute Center for Eating Disorders in Denver, Colorado. Medical researchers describe anorexia nervosa as a serious psychiatric disease and that the choice of acute impatient care is driven by the patients severity of symptoms and level of risk. The researchers note that anorexia nervosa is the most severe eating disorder with a protracted course of illness and the highest mortality rate among all psychiatric illnesses. While there are no clear standards regarding ambulance or air ambulance transport for these patients, current medical literature reflects how brittle the medical stability of these patients is. In this case, the patient was medically unstable due to an eating disorder. He had a history of seizure from hyponatremia. The patient was referred by his provider at Linden Oaks Hospital to the Acute Center for Eating Disorders for medical stabilization. While his vital signs remained stable during the air ambulance transfer, the patient became nauseous upon landing and was treated with Zofran. Upon admission to the Acute Center for Eating Disorders, the patient was placed on one-on-one observation for fall risk. In this clinical setting, due to the patients medical instability requiring additional monitoring during transport and the high risk of morbidity and mortality in patients with severe anorexia nervosa, the service at issue was medically indicated. Therefore, the air ambulance transfer from Linden Oaks Behavioral Health-Main Inpatient Campus in Naperville, Illinois, to the Acute Center for Eating Disorders in Denver, Colorado, was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Sprint peripheral nerve stimulation (PNS) procedure, 2 leads (CPT 64555 x 2 units). Deer and colleagues report that PNS is a minimally invasive, nondestructive, motor-sparing alternative to repeat radiofrequency ablation and more invasive surgical procedures. In this case, the patient has undergone comprehensive, multimodal treatment, including interventional pain procedures such as radiofrequency ablation and steroid injections, other modalities such as physical therapy, massage, acupuncture, and chiropractic treatment. Despite conservative treatment including pharmacological therapies, the patient continues to report chronic back pain. Given that interventional and multimodal treatment options have not provided sustained relief in this patients case, the requested service is a clinically indicated treatment option with evidence of efficacy in current medical literature. Therefore, a Sprint peripheral nerve stimulation (PNS) procedure, 2 leads (CPT 64555 x 2 units) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Sprint peripheral nerve stimulation (PNS) procedure, 2 leads (CPT 64555 x 2 units), 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 service 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 reviewers 1 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Eversense continuous glucose monitor (CPT 0448T) with sensor implantation every 90 days. In a comparative accuracy study of continuous glucose monitoring (CGM) devices in the home-use setting, Jafri and colleagues found that the Senseonics Eversense CGM device was better than the Dexcom G5 and Abbott Freestyle Libre Pro devices when comparing point-of-care plasma-glucose values. Joseph notes that a majority of studied patients described a positive experience managing their diabetes with the Eversense CGM System and requested implantation of a new sensor 90 or 180 days later. Sanchez and colleagues reported that real-world data from the Eversence CGM system showed promising glycemic results, sensor accuracy, and safety. CGM devices may help improve control and decrease the frequency of low blood sugars in patients with type 1 diabetes over patients using a glucometer alone. In a letter, the patient reported that she was allergic to adhesives and that she experienced good control with the Eversense implantable CGM. In this clinical setting, the patient would likely not realize the same level of control with a glucometer alone. Therefore, the requested Eversense continuous glucose monitor (CPT 0448T) with sensor implantation every 90 days is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Eversense continuous glucose monitor (CPT 0448T) with sensor implantation every 90 days 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 equipment 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 reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: 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) (ASAM 3.5) services. For dimension 1, the patient was admitted voluntarily due to feeling depressed and unhappy with ongoing substance usage and needing help with withdrawal management. For dimension 2, they had a history of seizures and infections related to substance use. The patients biomedical problems, if any, are stable and do not require medical or nurse monitoring, and the patient is capable of self-administering prescribed medications. For dimension 3, the patient was diagnosed with ADHD, major depressive disorder, and borderline personality disorder. The patient demonstrated repeated inability to control their impulses to use alcohol and other drugs and was in imminent danger of relapse, with attendant likelihood of harm to self, others, or property. The resulting level of dysfunction was so severe that it precludes the patients participation in treatment in the absence of the 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was admitted to RTC voluntarily due to feeling depressed about their drug usage and inability to stop using. The patient endorsed use of fentanyl, Xanax, and amphetamine daily for extensive years except for time spent in structured treatment. For dimension 5, the patient had undergone multiple prior treatment episodes. They underwent detoxification and continued on suboxone to help with opioid cravings. They had a history of multiple opioid overdoses. The patient experienced addiction symptoms such as drug craving, insufficient ability to postpone immediate gratification, and other drug-seeking behaviors. For dimension 6, the patient was single. They were previously homeless and estranged from family except for phone calls with their mother. They did not have a sober support network. The patients social network was comprised of drug dealers and substance users. Given these findings, the patient meets the six ASAM dimensions to support RTC services. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and are not primarily for the convenience of the patient or provider. All told, the RTC (ASAM 3.5) level of care 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 subspecialty certification 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.