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

The patient has requested authorization and coverage for Gel One knee injections for both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a documented history of lasting relief from viscosupplementation of both knees with complete pain relief for six months. For these reasons, the requested Gel One knee injections for both knees are 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for general anesthesia received with a colonoscopy and endoscopy.The patient was undergoing a routine colonoscopy and endoscopy. The patient did not have any heart, lung, kidney or liver disease. There was no documentation of a history of alcohol or substance abuse. There was no detailed description of previous history of difficulties with anesthesia or sedation with past procedures documented. The treating providers note that monitored anesthesia care was needed due to difficulty of sedation failed to provide a specific explanation or concern. The treating providers letters and medical records do not identify or provide any details regarding the patients reported difficulty of sedation. In addition, the anesthesiologists record does not include an ASA classification or difficult airway score, so there is no evidence of medical necessity based on these grounds. Under these circumstances, the general anesthesia received with a colonoscopy and endoscopy was not medically necessary for the patient.Final Result: The reviewer determined that the services at issue were not medically necessary for the patient. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Lyrica. The U.S. Food and Drug Administration (FDA) noted that the generic formulation of a medication is created to be the same as an already marketed brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use. The FDA continued to state that, these similarities help to demonstrate bioequivalence, which means that a generic medicine works in the same way and provides the same clinical benefit as its brand-name version. In this case, the patient has a diagnosis of fibromyalgia, which is an FDA approved indication for Lyrica. The patient was treated with generic Lyrica, which was associated with cognitive impairment and depressed mood. The patient reported that his pain was not under adequate control with generic Lyrica. The patient state that treatment with brand name Lyrica has been more effective in managing his pain. The reported side effects from the generic Lyrica are known to occur with the brand name Lyrica and are not unique to the generic formulations. Based on the available documentation, the requested brand name Lyrica is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested brand name medication 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Butrans patch. This patient has chronic abdominal pain and is currently under the care of a pain management specialist for his abdominal pain and intercostal neuralgia. He has been treated with Percocet and Norco for pain control, but these were ineffective. His provider as prescribed the Butrans patch due to its more favorable side effect profile, 24-hour formulation, and because it bypasses the gastrointestinal system. A recent peer-reviewed medical literature validates the efficacy of buprenorphine for use in chronic pain population and current consensus guidelines support using buprenorphine as first line treatment over traditional full opioid agonists due to better safety profile, tolerability, and non-inferior analgesic effects. This therapy is consistent with the current Centers for Disease Control (CDC) guidelines on opioid therapy, which advocate starting patients on the lowest effective dose of opioids as part of a multi-modal pain management strategy. This patients provider is managing this patient in a manner consistent with current practice guidelines and has selected the transdermal formulation, which is appropriate for this patient with gastrointestinal intolerances. For these reasons, the requested Butrans patch is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for positron emission tomography (PET) scans. This patient has had stable non-small cell lung cancer (NSCLC) for a few years. Although a PET scan with computed tomography (CT) for attenuation showed a suspicious right axillary node, this was resolved on repeat imaging. The National Comprehensive Cancer Network (NCCN) guidelines recommend assessment of treatment response with CT of known sites of disease every 6-12 weeks. However, surveillance or restaging PET scans are not within the standard of care. PET may be useful for assessing CT imaging results suggesting the presence of malignant neoplasms that may actually be due radiation fibrosis, atelectasis, or other benign condition. The use of PET scan for surveillance is not likely to be more beneficial than a CT scan. Therefore, the PET scan (CPT 78815) already performed and a future PET scan (CPT 78815) was not and is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the PET scans (CPT 78815) were not and are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not and are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for embryo storage services (CPT 89342). Based on the available clinical documentation, the patient has a history of infertility, Hashimotos thyroiditis, and uterine leiomyoma. The patient underwent in vitro fertilization (IVF) procedures. Embryo storage services are a component of IVF treatment. The patient has a history of uterine fibroids on imaging. Her most recent hysteroscopic assessment revealed a normal intrauterine cavity indicating no submucosal component to her fibroids. There is a lack of data in the peer-reviewed medical literature supporting an indication for IVF in this clinical setting. Embryo storage services are not a standard therapy in the treatment of uterine fibroids. All told, the embryo storage services (CPT 89342) provided were not 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 embryo storage services (CPT 89342) provided were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Simponi Aria infusions. The patient is seropositive rheumatoid arthritis with an elevated C-reactive protein, and episodic flares of joint pain in the wrists and knees. She is on methotrexate. The patient was on Remicade (infliximab) infusions and experienced hives. The provider is recommending the use of golimumab (Simponi Aria) intravenous infusions as an alternative to Remicade in order to bypass concerns about allergic reactions (hives or urticarial). The provider notes that this patient is needle phobic (has a fear of self-injecting), has chronic wrist pain with dexterity issues making it difficult to self-inject, and is at risk of power blackouts making storage of subcutaneous medications, such as Humira and Enbrel unsafe. As noted by Singh and colleagues, there is no significant difference in potential benefit from the three anti-tumor necrosis factor agents that are used for rheumatoid arthritis (Humira, Enbrel and Remicade), versus the anti-tumor necrosis factor agent being requested by the provider (Simponi Aria). Simponi Aria is an intravenous medication, as well as subcutaneous, and Humira and Enbrel are subcutaneous. The patient has already been on Remicade in the past with a possible reaction. The remaining options for this patient include subcutaneous Humira, Enbrel and Simponi or intravenous Simponi. Given the patients combination of wrist problems, needle phobia and unreliable storage (power blackouts), subcutaneous injections are not reasonable. Therefore, intravenous Simponi Aria is medically necessary for this 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 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 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 psychiatric intensive outpatient program (IOP) 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. Applying LOCUS guidelines, this patient met the criteria for psychiatric IOP services. The patient was at some risk of harm (score 2) as she exhibited passive suicidal ideation with periodic flare-ups of active suicidal ideation with intention and plan. The patient has a history of an overdose attempt necessitating critical care and psychiatric hospitalization in 2019. The patient reported that she stockpiled medications at home so she could overdose. The patient demonstrated serious functional impairment (score 4) due to ongoing significant anxiety and depression symptoms necessitating active medication management while at the IOP. The patient dropped out of college due to mental health concerns. The patient has significant comorbidities (score 3) involving trauma, anxiety, depression, and possible bipolar disorder. The patients recovery environment was moderately stressful (score 3) as she lived with her father and the provider noted that the patient had parent-child relational challenges. The patients recovery environment provided limited support (score 3) as the records document the patient had emotional distance with her family and frequent feelings of isolation. The patient has exhibited poor response to treatment (score 4) given her history of three hospitalizations and chronic suicidal ideation despite intensive therapies and medication management since age 16. The patient was constructive in treatment (score 2) as she was engaged in therapy. The records state that the patient made gradual incremental improvement with periodic setbacks. This gives the patient a composite score of 22, which is consistent with medically monitored non-residential services, such as IOP. Given this support, the psychiatric IOP services 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cimzia 200 mg syringe every other week for four months. Researchers reported that TNF inhibitors are well-established, effective drugs in the treatment of ankylosing spondylitis symptoms. The provider reported that the patient has failed treatment with Humira. However, the patients records do not document treatment failure or contraindication to anti-tumor necrosis factor (TNF) agents including Enbrel and Cosentyx, which are first-line therapies for the treatment of HLAB27 positive ankylosing spondylitis. In addition, the documentation does not report that the patients condition has failed to improve with maximally dosed non-steroidal anti-inflammatory drugs (NSAIDs). All told, Cimzia 200 mg syringe every other week for four months is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication 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 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

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given the findings, the RTC level of care services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance-guided high intensity focused ultrasound ablation (MRgFUS) (CPT 0398T). Researchers reported that MRgFUS provides significant improvement in four different quality-of-life measures for patients with disabling essential tremor. The authors concluded that patients sustained a 68% improvement in tremor scores in the hand contralateral to the thalamotomy. In addition, Gallay and colleagues showed that MRgFUS is an effective treatment option for therapy-resistant essential tremor. MRgFUS has been demonstrated to provide positive results in patients with tremors that have failed to respond to typical first-line therapies. This patient is a good candidate for MRgFUS given his failure of propranolol and primidone. For these reasons, the requested MRgFUS (CPT 0398T) 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 MRgFUS (CPT 0398T) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology 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.