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

The patient has requested authorization and coverage for Euflexxa injections in both knees. The patient has been diagnosed with bilateral knee osteoarthritis. 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. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of lasting benefit from prior viscosupplementation injections. Furthermore, the patients options are limited. Corticosteroid injections only provided temporary benefit. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections in both knees are medically necessary for the 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: An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient has met Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. For dimension 1, the patient had post-acute withdrawal as evidenced by elevated Clinical Opiate Withdrawal Scale (COWS) scores as high as 17. The patients intense cravings to use placed him at high risk of relapse. For dimension 2, biomedical conditions and complications, the patients continued substance use disorder constituted a grave danger to his health, as he is at high risk of relapse, overdose, and death from overdose. For dimension 3, emotional, behavioral, or cognitive conditions and complications, the patient's mental status is sufficient to permit participation, as he understands his medication regimen but often is inconsistent with taking it properly. For dimension 4, readiness to change, the patient has nearly non-existent insight into his illness and his judgment is poor. For dimension 5, relapse, continued use, or continued problem potential, the patient has been unable to control his substance use disorder outside of a 24 hour structured environment where 24 hour resources and support are available. For dimension 6, recovery environment, records indicate that the patients recovery environment is absent outside of the residential treatment center and consists of drug users and dealers. The submitted documentation thereby reflects that the patient requires a safe and stable living environment in order to develop his recovery skills, thus qualifying for ASAM Level 3.5 treatment at least, which is similar to what the patient has received at the facility. Therefore, the requested residential treatment center services were, and are, medically necessary for treatment of the patients condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary for treatment of the patients 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 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. Based on CALOCUS criteria, this patient does not meet the criteria for RTC level of care. The patient has been at low risk of harm (score 1) as evidenced by notes reporting progress in skills and no reports of self-harm or suicidal ideation. The patient has demonstrated mild functional impairment (score 2) as she has caught up in school and although she still reports some bouts of anxiety and worry, these symptoms have been manageable. The patient has significant comorbidities (score 3) considering her history of generalized anxiety disorder and depression as well as substance abuse. However, the patient demonstrated positive skills development in a contained treatment environment. The patients recovery environment has been moderately stressful (score 3) since the patient has been able to navigate the RTC environment in a positive manner, but continued to have significant anxiety requiring support. The patients recovery environment has been supportive (score 2) as the notes indicate the patients family has made efforts to support the patient, although the mother-child relationship is noted to be strained and difficult. The patient has shown significant resiliency to treatment (score 2) with lack of improvement in lower levels of care. The patient has exhibited the improved ability to manage stressors as evidenced by the ability to maintain gains despite the stress of a conflict with a peer. The patient has been constructive in treatment (score 2) as the patient has been an active participant in the RTC milieu. This gives the patient a composite score of 15, which is consistent with low intensity community based services. Given these 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 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 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 the medication, Otezla tablets. The enrollee has plaque psoriasis. A progress note reports the enrollee has symptoms of redness, itching and pain, and that she had been using calcipotrine cream, 0.05 percent, as needed. The progress note documented psoriasis to the enrollees back and knees. At a follow-up, the physician prescribed Enstilar for the enrollee. A subsequent note reports the enrollee described her symptoms as worsening and that she had not seen any improvement from the Enstilar. The enrollee reported wanting to start biologics or Otezla. The physician noted the enrollee would require laboratory testing prior to starting Cosentyx. The physician provided the enrollee with an Otezla starter pack. In order to be approved for Otezla, the enrollee must try, fail, have a contraindication to, documented adverse effect to or provide any clinical reason why the preferred available standard of care medications, such as methotrexate, psoralen and ultraviolet A, ultraviolet B, cyclosporine, or acitretin, cannot be used. The enrollee does not have contraindications that are sufficient to avoid preferred therapies.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 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: An enrollee has requested reimbursement for inpatient hospitalization services.The submitted documentation supports that the services at issue were medically necessary. The patient sustained a fall with a head injury, and in the days following his injury the patient continued to have episodes of recurrent syncope, which can be suggestive of subdural hematoma. The patient's symptoms may have been secondary to urinary obstruction and gastroenteritis. Additionally, since the patient had sustained a scalp laceration, there was a high likelihood that he could develop a subdural hemorrhage, based upon his age group and nature of injury. The patient was also noted to be febrile. Under these circumstances, inpatient observation was medically indicated. Accordingly, inpatient hospitalization services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 been diagnosed with cervical strain/sprain and C6-7 degenerative disc disease.  The provider noted the patient was involved in an accident in which the patient was rear-ended while riding his motorcycle. He sustained multiple injuries for which he was hospitalized and underwent treatment for a distal fibular fracture. The provider noted an x-ray of the cervical spine revealed mild C6-7 degenerative disc disease with facet arthropathy. Physical examination findings included pain with extension and flexion of the spine. The patient has requested authorization and coverage for an MRI without contrast of the cervical spine (CPT 72141). The Health Plan denied the request and reported the requested service is not medically necessary for the evaluation of this patient. At issue in this case is whether an MRI without contrast of the cervical spine (CPT 72141) is medically necessary for the evaluation of the patients medical condition. The American College of Radiology noted, MRI is the gold standard for imaging diagnosis of traumatic soft-tissue injuries of the neck. In the setting of persistent neck pain after cervical trauma, MRI may be useful for identifying ligament sprains, muscle strains, disc herniation, and bone bruising, which are the most likely causes of persistent pain. In this case, the patient was involved in a motor vehicle accident with a loss of consciousness. The patients continuing neck pain for two years warrants additional evaluation with imaging studies to plan appropriate treatment, which can only be done if the pain source is accurately identified. The medical evidence supports the requested service in this clinical setting. Therefore, an MRI without contrast of the cervical spine (CPT 72141) 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) of heart without contrast (CPT 75571). This patient reports chest pain and shortness of breath, but few risk factors for cardiovascular disease. She has a family history of cardiovascular disease in her father, but the records do not state that his condition was premature or early onset. For this patient, coronary CT calcium scanning for evaluation of chest pain or shortness of breath is not consistent with the guideline recommendations. Coronary CT scanning can evaluate patients with borderline cardiovascular risk when considering pharmacologic therapy with statin. This patients records do not include a lipid profile for review. She has not been risk stratified and there is no current plan for consideration of statin therapy. Therefore, the requested CT of heart without contrast (CPT 75571) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested CT of heart without contrast (CPT 75571) is 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 requested services 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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 authorization and coverage for cyanoacrylate adhesive treatments (CPT 36482). The treatment recurrent symptomatic disease requires documentation of clinical symptoms, duration of reflux, and diameter of veins to be treated. This patient presents with persistent venous insufficiency and asymptomatic varicose veins of the right lower extremity. Treatment has included compression stockings and ablation therapy. Accepted therapies in this clinical setting include endovenous radiofrequency or laser ablation, foam ablation, surgical extirpation, or cyanoacrylate injection. All are approved therapies with similar closure and complication rates. Based on current data, the use of cyanoacrylate adhesive is safe and effective, and may be used without tumescent anesthesia and medical compression stockings. Given this support, the requested cyanoacrylate adhesive treatments (CPT 36482) 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 surgery with subspecialty certification in vascular 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sclerotherapy (CPT 36471). According to the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) have developed clinical practice guidelines the records provided for review do not support an indication for left SSV treatment. There is a lack of documentation of the location of the symptomatic residual varicosity in the thigh. The patient underwent GSV and SSV radiofrequency ablation and foam sclerotherapy in January 2020. There is no documentation in the medical records of functionally limiting symptoms or ulceration in the distal left lower extremity in the distribution of the distal SSV. Further, the patients symptoms may still improve following the recent procedures. All told, the requested sclerotherapy (CPT 36471) is 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 requested sclerotherapy (CPT 36471) is 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 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 reviewers 1, 2, and 3 are board certified in surgery with subspecialty certification in 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 hereditary angioedema with positive laboratory tests. The patient was provided with a sample of Firazyr for any future angioedema attacks. The patient reported shortness of breath and chest tightness. The patients C4 complement and C1 inhibitor quantitative levels were noted to be low. The patient has been treated with prednisone, Symbicort, and albuterol, without improvement. The patient has requested authorization and coverage for Firazyr (icatibant 30 mg/ 3 mL syringe). The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Firazyr (icatibant 30 mg/ 3 mL syringe) is medically necessary for the treatment of this patient. Tourangeau and colleagues reported, C1 inhibitor (C1INH) has recently been approved in the United States for the treatment of acute attacks in hereditary angioedema (HAE) patients. The literature suggests that treatment with C1INH is most effective when administered early in an attack. Home infusion of C1INH allows for the earliest possible intervention since patients can initiate therapy at the first sign of symptoms. The authors also noted, Icatibant, a bradykinin B2 receptor antagonist administered by subcutaneous injection, was approved for treatment of acute attacks in Europe in 2008 and in the United States in 2011. Longhurst and colleagues reported, Experience shows that access to self or assisted infusion with C1INH reduces severity and duration of attacks, improves HAE-related quality of life, reduces time off work, education or domestic duties, is safe, and is very popular with participants. The medical evidence supports the requested medication in this clinical setting. Therefore, Firazyr (icatibant 30 mg/ 3 mL syringe) is 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 internal medicine and allergy and immunology 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 been diagnosed with atherosclerotic heart disease of native coronary artery without angina. The patient was noted to be taking Zetia 10 mg and simvastatin 10 mg. The provider noted the patients low-density lipoprotein (LDL) level increased to 110 mg/dl while taking Zetia. The patient reported intermittent pain with exertion. His diagnoses included hypertension and hyperlipidemia. The patients low-density lipoprotein (LDL) cholesterol level was 174 mg/dl. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted the patient had tried and failed Zetia, simvastatin, and atorvastatin. The documentation noted that simvastatin caused leg pain. The patient also been treated with stent procedures. The patient has requested authorization and coverage for Repatha Pushtronex injection 420 mg/3.5 ml once a month. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Repatha Pushtronex injection 420 mg/3.5 ml once a month is medically necessary for the treatment of the patients medical condition. Sabatine and colleagues reported, Evolocumab, a monoclonal antibody that inhibits proprotein convertase subtilisinkexin type 9 (PCSK9), significantly reduced LDL cholesterol levels in short-term studies. Navarese and colleagues reported, In conclusion, treatment with PCSK9 antibodies produces profound reductions in LDL cholesterol and lipoprotein (a), with an apparently similar level of safety and an important preliminary signal of survival benefit compared with no anti-PCSK9 treatment. Thus, PCSK9 monoclonal antibody therapy seems to be a safe and effective strategy for patients with dyslipidemia. In this case, there is documentation that the patients LDL was elevated at 110 mg/dl while taking Zetia. There is also documentation of the patients intolerance to at least two statin medications, including atorvastatin and simvastatin. In addition, the patients simvastatin dose was 10 mg per day, which shows intolerance to low intensity statin treatment. The medical evidence supports the requested medication in this clinical setting. Therefore, Repatha Pushtronex injection 420 mg/3.5 ml once a month is 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 internal medicine with sub-specialty in cardiovascular disease 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.