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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Supartz injections to bilateral knees. The enrollee has osteoarthritis of bilateral knees. At a follow-up visit, she reported worsening, ongoing pain. The enrollee indicated her knee buckles, she has pain at the posterior aspect of the knee, and she reported throbbing pain with swelling. She reported the last Supartz injections provided relief for over six months. Her physician recommended another round of viscosupplementation injections, because they have helped her in the past. The enrollee indicates her physician wishes to defer knee replacement surgery because of her young age and good health status. She reports the Supartz injections have kept her knees from getting worse and they last much longer than cortisone injections. Prior injections have yielded positive pain relief results; keeping this enrollee active. Literature describes osteoarthritis as a common condition, which results in pain, reduced mobility, and decreased function. Corticosteroids have been a mainstay of osteoarthritis treatment; providing short-term pain improvement. A large number of recent studies have demonstrated hyaluronic acid (Supartz) is a viable treatment option; showing longer-term improvement in both pain and function. Literature indicates a single injection of hyaluronic acid (Supartz) is safe and effective for six months for treatment of knee osteoarthritis.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 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 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 Percocet 10/325 mg. The U.S. Food and Drug Administration (FDA) discussed the nature of generic medications and their regulation. The FDA concluded that generic drugs are 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. 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 provider prescribed Percocet for the patients pain control until she undergoes back surgery. Although the prescription is for Percocet, a generic version of the medication, which is oxycodone-acetaminophen, is on the Health Plans formulary. A review of the patients Controlled Substance Utilization Review and Evaluation System (CURES) report demonstrates that the patient filled prescriptions for oxycodone-acetaminophen in August and September 2019 and there was no report of adverse events in the medical records available for review. Based on the available medical records for review, and the FDAs section on generic medications, the requested brand name Percocet is not indicated. Accordingly, the requested Percocet 10/325 mg 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 reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (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. The patient has shown moderate to severe withdrawal symptoms per CIWA scoring. The patient does not have any reported biomedical conditions, but does have post-traumatic stress disorder (PTSD) and major depressive disorder (MDD). The patient is willing to change, yet he continues to exhibit mood swings and anger, without a high level of accountability. He shows self-sabotaging behaviors, which suggest that he is not yet able for meaningful change. The patients anxiety and mood symptoms have been pervasive in his life and are likely to persist placing him at high risk for relapse with self-medication. His partial compliance with medication will leave his symptoms partially treated, further putting him at risk for relapse. The patients recovery environment is supportive, but he has been unable to cope independently in an environment with minimal support. The patient requires a safe and stable living environment in order to develop his recovery skills, thus qualifying for ASAM Level III treatment, similar to what patient has received at the RTC. Given the severity of the patients illness, the RTC 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS), including 1 unit of CPT code 90867, 34 units of CPT code 90868, and 1 unit of CPT code 90869. Per the American Psychiatric Association (APA) practice guidelines, repetitive transcranial magnetic stimulation (rTMS) is indicated for patients with major depression who have failed at least one antidepressant medication. In addition, TMS is appropriate for patients who have responded to a prior course of TMS. This patient has ongoing major depressive disorder with suicidal ideation as well as a decline in functioning. He is distressed in all spheres and poses a risk of further decompensation without adequate treatment to alleviate his symptoms. He has failed treatment with CBT as well as multiple psychotropic medications trials in the past due to adverse effects as well as poor treatment response. The records document that the patient attained a significant positive response to TMS in the past. Based on the current APA guidelines, this patient meets the criteria for TMS therapy. Accordingly, the requested TMS including 1 unit of CPT code 90867, 34 units of CPT code 90868, and 1 unit of CPT code 90869 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 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 enrollee is requesting authorization and coverage for a power wheelchair (Group 3). The enrollee has spinal paralysis, chronic pain, neuropathy, hypertension, uncontrolled type-2 diabetes, and hyperlipidemia. At an office visit, the enrollee requested an electronic wheelchair for increased mobility. He had right shoulder pain for many months. His provider prescribed an x-ray and a referral to durable medical equipment for the power wheelchair.  The enrollee indicates his ability to use a regular wheelchair is limited. He reports limitations of strength, endurance, range of motion, and coordination. He has pain and muscle spasms in his lower back impair his ability to push himself. This enrollee lives at home with his family, in a wheelchair-accessible home.  He has 24-hour formal and informal care for his needs.  He can independently propel his standard manual wheelchair; however, community access is limited.  A durable medical equipment evaluation noted the enrollee is able to self-propel a manual wheelchair. His upper extremity strength was noted to be 4/5. The records do not support that this enrollee's condition could not be managed with a lesser device, such as a group one power-mobility device or lightweight manual wheelchair.  The necessity for a group three device is not established. Literature indicates individually configured manual wheelchairs improve the ability to self-propel, prolonging mobility and endurance and preventing the development of secondary problems. Literature indicates bimanual, lever-driven propulsion has the potential to exercise healthy movement synergies, which may in turn help drive use-dependent motor recovery. Studies show motorized wheelchairs can have detrimental long-term effects by increasing cardiovascular risk and insulin resistance.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nasal dermal sinus cyst (NDSC) surgery with dilatation maxillary sinus (CPT code 31295) and NDSC surgery with dilatation frontal sinus (CPT code 31296). Based on the available clinical documentation, the request for balloon sinus dilatation is not likely to be more beneficial in managing the patients chronic rhinosinusitis, as compared to other available standard therapies. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) clinical consensus statement on balloon sinus dilatation achieved consensus with the statement that Balloon dilation is not appropriate for patients with sinonasal symptoms and a CT that does not show evidence of sinonasal disease. In this patients case, the sinus CT did not document any evidence of frontal sinus disease, but it did show occlusion of the right-sided ostiomeatal complex by mucosal thickening. Overall, there is a lack of radiographic evidence or correlative symptoms of frontal sinus disease in this patient to justify frontal balloon sinus dilatation. Given these findings, the requested nasal dermal sinus cyst (NDSC) surgery with dilatation maxillary sinus (CPT code 31295) and NDSC surgery with dilatation frontal sinus (CPT code 31296) are not 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 nasal dermal sinus cyst (NDSC) surgery with dilatation maxillary sinus (CPT code 31295) and NDSC surgery with dilatation frontal sinus (CPT code 31296) are 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 requested services are 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 reviewers 1, 2, and 3 are board certified in otolaryngology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Acthar 80 unit/mL gel. Adrenocorticotropic hormone, such as repository corticotropin injection (HP Acthar gel), is currently indicated for the treatment of patients with multiple sclerosis relapses. This patient has profoundly demyelinating multiple sclerosis. Timely and effective resolution of multiple sclerosis relapse is critical to minimizing residual deficits, which can result in neurologic disability. Alternatives to oral and intravenous corticosteroids include HP Acthar gel, plasmapheresis, and intravenous immunoglobulin. Acthar gel is a viable choice for patients who are unable to tolerate traditional therapies. Both methylprednisolone and HP Acthar gel have demonstrated efficacy in reducing short-term disability after exacerbations of multiple sclerosis. The rate of neuropsychiatric side effects observed in Acthar gel patients is low. The data support Acthar gel as a viable alternative for the treatment of acute exacerbations of multiple sclerosis, particularly in patients who have a history of neuropsychiatric disorders. All told, Acthar 80 unit/mL gel 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 Acthar 80 unit/mL gel is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Tramadol for chronic back pain. A magnetic resonance imaging scan showed congenital spinal canal stenosis, with moderate spinal canal stenosis with core deformity, no edema. The enrollee indicates the pain is constant and radiates down her right arm and into her hand.  There is numbness and tingling in her right arm and stiffness in her neck. The enrollee has tried gabapentin but discontinued it because she believed it was causing increased bladder incontinence. She tried duloxetine, which made her stomach burn. The records indicate the enrollees pain medicine specialist prescribed nortriptyline but the enrollee did not want to try it. The enrollee reports multiple medication trials, with very uncomfortable side effects. Her physician indicated the symptoms appeared consistent with cervical radiculitis. The enrollee received a cervical epidural steroid injection. The physician ordered Meloxicam, 7.5mg, once or twice daily as needed and topical lidocaine as needed.  The enrollee indicates she has tried anti-depressants and anti-epileptics. These medications resulted in multiple side effects. She received no benefit from acupuncture. She is requesting authorization of Tramadol for short-term relief of flare-ups. She indicates Relafen and Robaxin are not effective for acute severe back pain. Governmental agency guidelines do not support the chronic use of opiates for non-malignant pain.  Literature indicates though these guidelines have been criticized and misapplied in some cases, the risks of long-term oral opiate use in non-malignant pain are substantial.  The requested medication is not medically reasonable in this case.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology 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 patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) 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. Applying CALOCUS, this patient meets the criteria for IOP services. The patient has been at some risk of harm (score 2) due to substance use and reports of prior self-harm without suicidal ideation. The patient has demonstrated moderate functional impairment (score 3). The records document that she has a difficult relationship with her parents, but has shown recent gains in the IOP setting. Documentation supports significant comorbidities (score 3) due to the presence of psychiatric and substance use concerns. The patients recovery environment is mildly stressful (score 2) due to academic pressures from her parents. Her recovery environment is supportive (score 2), as her parents have participated in the IOP program, but struggle to be emotionally attuned to the patients difficulties. The patient has significantly improved since she started IOP treatment (score 2), given her ability to manage recovery in the context of the IOP. The patients parents have been obstructive to treatment (score 3), as they have been struggling to schedule and participate in family therapy. This gives the patient a composite score of 17, which is consistent with high-intensity community-based services, such as IOP. Given these findings, the IOP 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 65-year-old male who has been diagnosed with osteoarthritis of both knees. The patient received bilateral knee cortisone injections. It was noted that the patient received three weeks of pain relief from prior cortisone injections. The patient reported bilateral knee pain. Physical examination findings revealed restricted and painful range of motion in both knees. Tenderness was noted over the medial and lateral femoral condyles. The patient received bilateral knee Synvisc One injections. The provider recommended follow-up for repeat Synvisc-One injections in six to nine months. Five months later, it was noted that the patient had experienced significant pain relief with the prior Synvisc-One injections. The patient has requested authorization and coverage for a Synvisc-One injection in both knees. The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether a Synvisc-One injection in both knees is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has had pain relief from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments including corticosteroid injections, with the alternative being total knee arthroplasties. Medical evidence supports the requested services in this clinical setting. Therefore, a Synvisc-One injection in both knees is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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.