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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center (RTC) services. The submitted documentation does not support that the services at issue were medically necessary. The American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay, moving from program-driven to clinically driven and outcomes-driven treatment. The ASAM criteria is a set of objective guidelines used by clinicians to assist with treatment planning and advocates for service intensity provided in the least intensive but safe treatment setting.In this case, the patient does not meet ASAM criteria for residential level of care. Although she was in withdrawals, they were on the low end of moderate with a clinical opiate withdrawal scale (COWS) score of 13, and a subsequent drop to 8. Mild withdrawals are treated on an outpatient basis. She was capable of controlling her substance use, as evidenced by her reported on and off use history and her ability to abstain for long periods of time. A Suboxone taper is generally considered an outpatient treatment that can be performed in a physician's office with monitoring.The patient was not a danger to self or others; she was not aggressive, violent, or gravely disabled. The patient was cognitively intact and accepting of her diagnoses. There were no severe emotional, behavioral, cognitive, or impulsive barriers to treatment at a lower level of care. The patient was medically and psychiatrically stable and did not need a 24-hour, 7-day structured setting to monitor medication management. There were no acute medical issues that required 24/7 medical or nursing care. Although relapse risk is inherent in this population, it is not a reason to keep a patient in this setting. All aspects of the patients treatment plan, including the as-needed medications and the Suboxone taper, could have safely been provided in an ambulatory setting in conjunction with supports such as the 12-step programs, a sponsor and outpatient counseling. Accordingly, residential treatment center (RTC) services at issue were not medically necessary to treat the patients medical condition.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 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 (Percocet), (Percocet) 7.5mg-325mg 90 tablets for 30 days. Findings:  The physician reviewer found that the current Centers for Disease Control and Prevention (CDC) guidelines state that if opioids are used for chronic pain that they should be used at the lowest possible dose, after or with alternative non pharmacologic or non-opioid therapy, and monitored closing with a pain contract and regular urine drug screens. In this case, the patient has a chronic pain condition that has been non-responsive to conservative measures. The patient is using a low dose of opioid (37.5 MED) which is lower than the 50 MED the CDC recommends as a ceiling dose. In addition, the patient has been tried on multiple other therapies. Further, the patient is currently on a non-steroidal anti-inflammatory drug (NSAID) and pregabalin. Lastly, the patient has a pain contract on file and has agreed to random compliance testing with no evidence of aberrant behavior. Overall, the requested opioid has been provided pursuant to the CDC guidelines. Given these findings, the Percocet 7.5mg-325mg 90 tablets for 30 days is medically necessary for management of this patients chronic pain. 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 a 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: An enrollee has requested reimbursement for the Acessa procedure. Acessa is a new U.S. Food and Drug Administration (FDA) approved procedure for the treatment of uterine fibroids. It is not a commonly adopted procedure and has not been shown to be more efficacious than existing therapies. In fact, few studies to date have been conducted on its adverse outcomes. At this time, due to its lack of nationwide adoption, the American College of Obstetricians and Gynecologists (ACOG) fails to comment on the subject of radiofrequency ablation of uterine fibroids. However, the Society of Obstetricians and Gynaecologists of Canada (SOGC) notes in their 2015 guidelines on the management of uterine leiomyomas that of the conservative interventional treatments currently available, uterine artery embolization has the longest track record and has been shown to be effective in properly selected patients. The SOGC note that newer focused energy delivery methods are promising but lack long-term data. The American College of Obstetricians and Gynecologists (ACOG) recommends that medical therapy is attempted prior to more invasive therapies.In this case, there is no documentation that the patient failed medical therapy or that medical therapy was contraindicated prior to surgical intervention. The submitted documentation does not reflect that this patient had failed or was contraindicated to receive an intrauterine device (IUD), the oral contraceptive pill (OCP) or gonadotropin-releasing hormone (GnRH) agonist therapy prior to the surgical intervention at issue. Under these circumstances, the Acessa procedure was not medically necessary to treat the patients medical condition.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 obstetrics and gynecology 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: The patient has requested authorization and coverage for implantation of the Bioness StimRouter System. Occipital neuralgia is a condition characterized by frequent and severe headaches with paroxysmal stabbing pain in the distribution of the greater or lesser occipital nerves. The pain is located in the occipital area and may spread. The treatment plan for occipital neuralgia depends upon many factors, such as the severity of the dysfunction and pain, the type and location of the pain, as well as ongoing medical conditions and ability to tolerate other medical therapies. Standard treatment may include medications to relieve pain and muscle spasms, localized injections, physical therapy, or massage. Over time, data has accumulated to support use of neuromodulation of the distal branches of C2-3 to treat refractory headache disorders. This is accomplished via implantation of subcutaneous electrodes to stimulate peripheral nerves in the occipital region. Although there is a lack of prospective clinical trials showing the safety and effectiveness, researchers concluded that occipital nerve stimulation is likely to be safe and effcicacious treatment for highly intractable chronic migraine patients even afterfollow-up of a median of over three years. This patient has failed treatment with lidocaine drip, mexiletine, gabapentin, nortriptyline, and lidocaine patches. Furthermore, the provider reports the patient experienced an excellent response to stimulation therapy for left occipital neuralgia. Given this support, the requested implantation of the Bioness StimRouter System is likely to be more beneficial for treatment of this patients occipital neuralgia than standard therapies. One reviewer found that the requested implantation of the Bioness StimRouter System is likely to be more beneficial for treatment of this patients medical condition than standard therapies. Final Result: Two of the three 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:  One reviewer is board certified in neurological surgery and is actively practicing. One Reviewer is board certified in neurological surgery and is actively practicing.  One Reviewer is board certified in neurological surgery and is actively practicing.  All three 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 has requested authorization and coverage for Xeljanz XR 11 mg. The American College of Rheumatology (ACR) guidelines recommend methotrexate with or without a tumor necrosis factor (TNF) inhibitor for patients who have failed methotrexate. In addition, the current guidelines recommend a second TNF inhibitor prior to treatment with Xeljanz. Although this patients records do not document trial and failure of a second TNF inhibitor or a non-TNF biologic agent, the patient has failed one TNF inhibitor with Humira, and has a history of a positive ANA. Although the positive ANA is not a contraindication to treatment with a TNF inhibitor, caution should be used in this clinical setting. Xeljanz does not have the same risk as a TNF inhibitor. Further, one study demonstrated that Xeljanz was beneficial in biologic naive and biologic non-responders. During her most recent evaluation, the patient continued to have evidence of active disease with evidence of response to the Xeljanz. Given the specifics of this case, the requested Xeljanz XR 11 mg is medically necessary for treatment of this patients rheumatoid arthritis. 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 internal medicine with subspecialty certifications in allergy and immunology, and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Euflexxa injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Studies reported on a systematic review of meta-analyses comparing hyaluronic acid injections with other non-operative treatment modalities for knee osteoarthritis. Studies found that intraarticular hyaluronic acid improves knee pain and function for up to 26 weeks. In addition, studies noted that the benefits of intraarticular hyaluronic acid on knee osteoarthritis may include mechanical viscosupplementation of the joint andthe re-establishment of joint homeostasis through induction of endogenous HA [hyaluronic acid] production, which continues long after the exogenous injection has left the joint. Moreover, hyaluronic acid injections have been shown to have a good safety profile. This patient has reported consistent relief with Euflexxa injections. Thus, the requested Euflexxa injections are medically necessary for treatment of this patients osteoarthritis. 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 enrollee has requested authorization and coverage for a Dexcom G6 Sensor. Continuous glucose monitoring system (CGMS) is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. As noted in the medical literature, CGMS can help identify fluctuations, maintain tight glycemic control, and prevent hyper and hypoglycemia. Use of CGMS can reveal high blood sugar levels between meals and show early morning spikes in blood sugar. CGMS has been shown to improve the hemoglobin A1C levels of diabetic patients. For this patient, CGMS has provided useful data for reducing glycemic variability and adjusting his insulin pump settings. For these reasons, CGMS devices have been confirmed to have high accuracy in glycemic values with a low complication rate. Given this support, the Dexcom G6 Sensor is medically necessary for treatment of this patients type 1 diabetes.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 sub-specialty certification in endocrinology, diabetes and metabolism 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 Euflexxa injections. Findings:  Two of the three physician reviewers found that there is sufficient support for the requested services in this clinical setting. Hyaluronic acid injections in the knee are recommended as a possible option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months. The current medical evidence supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. There is no maximum amount of injections established by high-quality scientific evidence. This patient presented with progressive worsening of bilateral knee pain. The patient has failed to adequately improve with recent conservative treatment, including a home exercise program. The patient has previously undergone three series of Euflexxa injections, with excellent pain relief and functional improvement. The medical evidence supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the requested Euflexxa injections are likely to be more efficacious than other treatment options.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 orthopedic 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

An enrollee has requested authorization and coverage for Synvisc injections. The submitted documentation supports that the requested services are medically necessary. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. There is sufficient support for the requested services in this clinical setting. Therefore, the requested Synvisc injections are medically necessary to treat the patients medical condition at this time.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 parent of an enrollee has requested authorization and coverage for Evekeo tablets. Findings:  The physician reviewer found that the submitted documentation supports that the requested medication is medically necessary. The literature on stimulant medications in children indicates that appetite suppression can be a symptom that requires discontinuation of the medication. The literature indicates that trials of stimulant medications of different classes or different preparation such as long-acting or immediate release may impact side effects. A trial of different medications with different chemical compositions or delivery mechanisms can be effective for treatment of attention deficit hyperactivity disorder symptoms while reducing intolerable side effects. In this case, the patient has had trials of other medications that have caused significant side effects and warranted discontinuation of the medication trials. The medical providers decision to try different medications in hopes of reducing appetite suppression and other adverse effects of prior medication trials was prudent and supported by the literature. The requested medication, Evekeo, is U.S. Food and Drug Administration (FDA) approved for the patients condition and has shown to be successful for the patient with few side effects. Under these circumstances, Evekeo is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the 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 child and adolescent 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: An enrollee has requested authorization and coverage for a full in-laboratory sleep study. Findings:  The physician reviewer found that the submitted documentation does not support that the requested service is medically necessary. The American Academy of Sleep Medicine (AASM) has stated that in adult patients for whom there is a concern for obstructive sleep apnea (OSA), a comprehensive sleep evaluation polysomnography is the standard diagnostic test for the diagnosis of OSA. The AASM also states that a home sleep apnea test is an alternative to polysomnography to diagnose OSA in uncomplicated adults who present with signs and symptoms that indicate an increased risk of moderate to severe OSA. In this case, the patient has witnessed apnea and an Epworth scale of 4. The records do not identify that the patient has any complications or risks that would justify the need for an in-laboratory sleep study. The treating physician has not documented any extenuating circumstances that support deviating from the AASM guidelines that indicate that a home sleep apnea test is an alternative to a full in-lab sleep study to diagnose OSA in uncomplicated adults. Therefore, the requested in-laboratory sleep study is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 otolaryngology 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.