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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for the medication Stelara. The enrollee has psoriasis of the scalp, ears, arms, and legs. She has been treated with Taclonex, Enbrel, methotrexate, and Excimer laser. Her dermatologist noted she had severe involvement of the scalp, scaling of the ears, and scattered scaly papules on the arms and legs. The records show the enrollee has extreme anxiety with needles and would greatly benefit from biologics that require less frequent injections. The dermatology office reports that, due to the possibility of tumor necrosis factor-induced psoriasis, Humira is not preferred. Literature shows pediatric persons with psoriasis showed an excellent response to Stelara. Initial doses of the medication are administered at weeks 0 and 4, and then maintenance dosing is administered every 12 weeks. This regimen makes Stelara appealing for pediatric populations.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 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 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 Xelajanz (tofacitinib), 5 mg tablet. The enrollee has alopecia areata. She was diagnosed at age nine. At an office visit with her dermatologist, she reported she had lost almost 80 percent of her hair. She has received Kenalog injections, Rogaine, and topical medications. Her occipital and temporal areas are the most difficult to regrow. The recommendation was for treatment with Xeljanz (tofacitinib). The provider reports that, due to the lack of alternatives that are safe and effective, and the trial and failure of steroid injections, treatment with tofacitinib is being requested. This enrollee has tried and failed conservative therapy. Alopecia areata is not a cosmetic disorder. It is an autoimmune disorder that affects the hair or nails and glandular structures. This is a disease process. It is associated with depression, anxiety and social isolation, which are significant psychosocial conditions. Xeljanz has been found safe, effective and durable for the treatment of alopecia areata. Literature reports alopecia areata affects people of all ages. There is currently no cure, and a highly effective therapy for severe disease has been elusive. A clinical trial of tofacitinib for the treatment of severe alopecia areata showed, of the 66 subjects treated, 64 percent of subjects responded to treatment.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 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 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 bilateral cervical/thoracic facet joint blocks (CPT 64490). Manchikanti and colleagues concluded that the evidence for therapeutic cervical facet joint interventions is fair for conventional cervical radiofrequency neurotomy and cervical medial branch blocks. Klessinger found that persistent postsurgical neck pain is a common problem for which there are limited therapy recommendations. The authors supported use of therapeutic medial branch blocks. This patient presents with a history of chronic cervical spine pain. She is status post C4-6 fusion with increased pain since surgery. Functional limitations are noted in the patients ability to perform activities of daily living (ADLs). Clinical examination findings have documented restricted range of motion and positive facet provocative testing. There is reported imaging evidence of severe right-sided facet arthritis. She has tried and failed over six months of comprehensive conservative treatment including activity modification, medications, physical therapy, and an epidural steroid injection. Current evidence-based medical literature support the use of diagnostic medical branch blocks in this patients clinical scenario. She has ongoing cervical spine complaints consistent with facet-mediated pain with no apparent radicular component. Given these findings, the requested bilateral cervical/thoracic facet joint blocks (CPT 64490) 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Supartz injections in the right knee. 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 history of chronic right knee pain due to mild osteoarthritis. The pain is mostly anterior and has been present for several months. The patient experienced a temporary response to a corticosteroid injection into the knee and non-steroidal anti-inflammatory drugs (NSAIDs) were not adequately effective. The provider found a mild to moderate joint effusion and restriction of range of motion of the right knee on examination. An MRI scan revealed grade II chondral surface irregularity of the medial femoral condyle, bone edema of the tibial plateau, and chondral fissuring of the patella. Given the support in the medical literature, the requested Supartz injection in the right knee 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: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, 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.Based on CALOCUS criteria, this patient does not meet the criteria for RTC level of care. The patient has been at significant risk of harm to others (score 3) as evidenced by the patients past and current passive suicidal ideation, without evidence of active suicidal ideation. The patient has demonstrated moderate functional impairment (score 3) due to intermittent food refusals and superficial self-harm, with limited gains made in a structured treatment setting. The patient has no significant comorbidities (score 1) given the absence of medical or substance use issues. The patients recovery environment is mildly stressful (score 2) as evidenced by her recent transfer from a different RTC facility, and continued discomfort associated with expectations around eating. The patients recovery environment is supportive (score 2) given her parents efforts to take the patient on outings from the RTC and their cooperation with treatment. The patient has shown limited response to treatment (score 3) based on continued food refusal despite extended RTC level of care and multiple prior inpatient hospitalizations. The patient has been incompletely engaged in treatment (score 3) considering her poor insight and judgment, self-harm, and continued food refusals. This gives the patient a composite score of 17, which meets the criteria for high intensity community based services, such as intensive outpatient program (IOP) level of care. Given these findings, the RTC services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that services at issue were not and 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 with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for methadone. The current guidelines do not support the use of long acting opioid therapy for chronic non-cancer pain. According to the Centers for Disease Control and Prevention (CDC) guidelines, methadone is not recommended as a first-line opioid for the treatment of non-cancer pain. The Federation of State Medical Boards (FSMB) guidelines state that the 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. This patient has chronic neck and back pain with a history of Chiari malformation treated with surgical repair several years ago. Treatment has included high dose methadone for chronic pain. The patient was tapered off methadone and she was transitioned to Percocet. She states that Percocet has not been as effective for managing her pain as methadone. Her physical examination and MRI of cervical spine are unremarkable for any acute changes. She has a history of chronic depression and suicidal ideation, which has been exacerbated due to the recent loss of her pet. The presence of psychiatric comorbidities place the patient at higher risk for self-harm. As the risks of treatment outweigh the potential benefit, the requested methadone 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 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 acupuncture. Authors noted that, the existing evidence suggests that most acupuncture therapies combined with other therapies, are effective in decreasing pain and in improving physical function. Similarly, researchers concluded that a course of acupuncture treatment is a reasonable option for a patient with chronic pain. This patients records document that she completed at least six sessions with substantial benefit in terms of ability to sleep and perform ADLs. Additional acupuncture could address the patients medical condition with further functional improvement. Due to the chronicity of this injury, the use of passive care should be limited. Self-management strategies like an independent exercise program, self-imposed restrictions, and proper biomechanics are supported by the peer-reviewed medical literature to stimulate self-reliance. Given these findings, an additional six sessions of acupuncture are medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for one hour of speech therapy three times a week, one hour of occupational therapy three times a week, and one hour of physical therapy three times a week. The documentation does not support that this patient requires the skills of a qualified provider of speech, physical, and occupational therapy services. The documentation indicates that the patients functional status is at a baseline and has been chronic. The providers notes from speech, occupational, and physical therapy indicate that the patients functional level does not require skilled therapy services. The patient has maintained her level of mobility through daily active range of motion (AROM) and transfers. The patient has tube feedings and has not had an updated modified barium swallow study to assess if there has been a change in her swallowing status. Her chronic cognitive impairments prove to be a barrier in progressing as well, as they limit her ability to motor plan and sequence higher levels of mobility and self-care. She has maintained her current level of functional ability with minimal fluctuations. No further skilled inpatient speech, occupational, or physical therapy needs have been indicated per the medical progress notes. All told, the requested one hour of speech therapy three times a week, one hour of occupational therapy three times a week, and one hour of physical therapy three times a week, are 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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 acute hospitalization level of care, subacute hospitalization level of care, a chest computed tomography (CT) with contrast, and abdominal CT with contrast. The records provided for review document that this patient has undergone an extensive work-up and evaluation with multiple specialists for her ongoing symptoms of intermittent, small-volume emesis, and atypical chest pain. The patient has been hemodynamically stable with intermittent vomiting. The patient does not have any medical conditions that require acute or subacute hospital level of care services. Accordingly, the requested acute hospitalization level of care, or subacute hospitalization level of care, is not medically necessary for treatment of this patient. The patient has chest pain that has been described as atypical in nature. Diagnostic tests have included x-rays, echocardiogram, and electrocardiogram with cardiac enzymes. A CT with contrast of the chest was requested to rule out an aneurism or the aorta as the source of the patients recurrent chest pain. The clinical presentation of the patients chest pain is not consistent with an aortic syndrome that would include an aortic aneurysm, aortic dissection, or an aortic ulcer. According to the providers progress notes, the patient continues to be medically stable and is at her new baseline. The patient does not have any active medical issues that require diagnostic imaging. She is tolerating enteral feeding via her PEG tube and there is no indication of infection. There is no indication that her symptoms of emesis will resolve as she is being treated with Reglan for gastroparesis and has a PEG tube for nutrition. There is no indication that she is malnourished as her albumin is 3.4 and her weight has been stable for at least two months. The emesis is likely due to excessive saliva production and poor control over oropharyngeal secretions. The most recent laboratory studies are negative for significant electrolyte abnormalities. Given these findings, the requested abdominal CT with contrast is not medically necessary for this patient. All told, the requested acute hospitalization level of care, subacute hospitalization level of care, a chest CT with contrast, and abdominal CT with contrast, are not medically necessary for 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 internal medicine with expertise in skilled nursing facilities 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 a Positron Emission Tomography (PET) scan.The submitted documentation does not support that the requested services are medically necessary. Chronic lymphatic leukemia (CLL) is an indolent lymphoma and is not considered a fluorine 18 fluorodeoxyglucose (FDG) avid disease, and PET scanning is therefore not generally indicated. A PET scan is sometimes utilized in CLL if transformation to a more aggressive lymphoma is suspected. In this case, the patient has CLL and has received treatment due to thrombocytopenia. There is no documentation, however, that the patient has signs or symptoms to suggest transformation. Under these circumstances, a Positron Emission Tomography (PET) scan is not medically necessary to treat 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 denials should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in hematology and medical oncology, 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 sildenafil 20 mg tablets taken three times a day for 90 days for a total of 270 tablets. This patients records support a diagnosis of limited cutaneous scleroderma associated with CREST syndrome with calcinosis, esophageal dysmotility, telangiectasias and Raynauds syndrome, but not systemic sclerosis. The records report that she did not respond to nifedipine and antiplatelet therapy. However, the patient does not have documented pulmonary artery hypertension, for which sildenafil would be indicated. In addition, she has been responsive to current medications and also has not tried and failed other standard therapies such as Prazosin or Cozaar. Vitiello and colleagues noted that the initial approach in treatment is vasoconstriction can be reduced by avoiding precipitating factors, such as cold, stress, and nicotine. The use of topical antibiotics and occlusive dressings (hydrocolloid) can promote healing, but the choice of dressings depends on the presence or absence of underlying infection. The author reported that treatment might include calcium channel blockers angiotensin II receptor blockers such as Losartan, a blocker such as Prazosin and selective serotonin reuptake inhibitor such as Prozac. Based on the available records, the patient has not exhausted all other possible therapies and is thus, not considered refractory. All told, the requested sildenafil 20 mg tablets taken three times a day for 90 days for a total of 270 tablets 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.