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

The patient has requested authorization and coverage for Epidural steroid injections. Epidural steroid injections have a clinically established role in the short-term management of low back pain when a patients pain is associated with symptoms of nerve root irritation and/or low back pain due to disc extrusions and/or contained herniations, and the pain is unresponsive to conservative treatment, including but not limited to pharmacotherapy, exercise or physical therapy. A systematic review by researchers found that lumbar epidural steroid injections were more effective for improved pain relief and function than injections without steroids. The American Society of Interventional Pain Physicians (ASIPP) concluded that for lumbar disc herniation with radiculitis, there is adequate evidence demonstrating short-term and long-term relief with local anesthetics with steroids. In a follow up statement, ASIPP reiterated that, the evidence is good for caudal epidural, interlaminar epidural, and transforaminal epidural injections with or without steroids in managing disc herniation or radiculitis. In this case, the patient presents with chronic back pain with radiation into the lower extremities that has persisted despite prior lumbar spine surgery. The patients physical examination is notable for positive straight leg test. The patient underwent a previous epidural steroid injection, with reported alleviation of pain and improvement in performing ADLs. Given these findings, the requested epidural steroid injections 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for intravenous (IV) lidocaine. Researchers found that IV lidocaine is effective and reasonably safe for the patients with proper monitoring and precautions, and the central anti-nociceptive and anti-hyperalgesic effects may allow for a wean from offending overused medications. In this case, the patient has debilitating chronic intractable migraines and chronic daily headaches refractory to multiple abortive and preventive medications and interventions. In retrospective studies, IV lidocaine can result in improvement of chronic daily headaches and withdrawal of analgesic medication. Given this support, the requested IV lidocaine infusions are 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 requested IV lidocaine infusions are 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

An enrollee has requested authorization and coverage for a Flexitouch pneumatic compression device and half leg garment. The submitted documentation does not support that the requested pneumatic compression device and associated half leg garment are medically necessary at this time. Intermittent pneumatic compression using a pump with leg garment can be a useful complement for maintenance edema management, with the foundation of care being compression wraps/garments. Intermittent pneumatic compression, however, is not a substitute or alternative for appropriate conservative care, particularly given that intermittent pneumatic compression may cause complications and it may not be well tolerated. In this case, there is insufficient documentation that the patient has undergone formal complete manual lymphatic drainage therapy demonstrating significant edema reducibility in the affected lower limb. A rigorous trial of compression wraps/garments after successful complete manual lymphatic drainage would be appropriate conservative care in this patient's setting. While the submitted records reflect that the patient has undergone lymphedema therapy, there is no clear evidence of significant volumetric reduction (i.e., with measurements). Moreover, there was evidence of noncompliance with compression garment use at home. Under these circumstances, a Flexitouch pneumatic compression device and a half leg garment are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested devices 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for hydrocodone (Norco). The Centers for Disease Control and Prevention (CDC) guidelines state that, non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Providers should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. In this case, the patient has physical examination findings suggestive of low back and knee pain. Treatment has included nortriptyline, acetaminophen and Flexeril. The provider referred the patient to physical therapy for non-opioid based treatment as well as participation in a chronic pain clinic, which are consistent with the standard of care. The patient has been intermittently treated with Norco due to multiple emergency department visits. However, she has not fully exhausted non-opioid therapy, including participation in physical therapy, chronic pain clinic, and a weight loss program. Based on the medical records available for review and the current guidelines, the requested hydrocodone (Norco) 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: Upheld Decision of Health Plan

An enrollee has requested reimbursement and authorization and coverage for custodial care services at a skilled nursing facility. The submitted documentation does not support that the services at issue and requested services were, or are, medically necessary. The patient is presumed to have sustained some type of spinal cord injury or injuries years ago. More recently, however, the patient had mostly normal strength in all 4 limbs. There were no bowel or bladder issues, and imaging review noted no residual pathology in the spinal cord or other neurological structures. The patient has had problems with his right leg which appear to be primarily orthopedic in nature. Notably, the patient fractured his right leg in the remote past and developed a chronically short right leg. While he has been unable to functionally and safely ambulate, he has been able to use a wheelchair for independent mobility. Based upon the submitted documentation, the patient has had no medical, nursing, or rehabilitation issues that have required care or ongoing care in a skilled nursing facility. The patient has chronic functional impairments without indication of a prospect for functional improvement. He is otherwise independent at a wheelchair level, possibly requiring minimal levels of custodial level assistance as needed for toileting. This level of assistance can be provided by a nonprofessional caregiver, and the patients use of a wheelchair for mobility does not require skilled nursing facility level care. Based on the submitted documentation, the patients care could be safely provided in a lower level of care than at the skilled nursing level. Therefore, reimbursement and authorization and coverage for custodial care services at a skilled nursing facility were not, and are not, medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Orthovisc injections, three doses in the left 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 options are limited to a total knee arthroplasty. The patient has tried and failed other conservative treatments, including failed arthroscopic debridement, analgesics, NSAIDs, intra-articular corticosteroids, and physical therapy without significant benefit. Imaging studies show articular cartilage wear. The provider is requesting viscosupplementation with Orthovisc injections. Therefore, Orthovisc injections, three doses in the left knee, are medically necessary 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

The patients parent has requested authorization and coverage for 40 hours per week of 1:1 applied behavioral analysis (ABA) services, eight hours per week of supervision, 0.5 hours per week of parent training, and two total hours for reassessment. The National Autism Center has identified ABA as the most evidence-based treatment for children and adults on the autism spectrum. The Behavior Analyst Certification Board (BACB) has developed guidelines for providers to identify essential components of ABA and clarify authorization requests. Regarding comprehensive treatment, the guidelines state that comprehensive ABA refers to treatment of the multiple affected developmental domains, such as cognitive, communicative, social, emotional, and adaptive functioning. Maladaptive behaviors, such as noncompliance, tantrums, and stereotypy are also typically the focus of treatment. Although there are different types of comprehensive treatment, one example is early intensive behavioral intervention where the overarching goal is to close the gap between the clients level of functioning and that of typically developing peers. These programs tend to range from 30-40 hours of treatment per week. This patients treatment plan included 19 goals, two parent goals, and four problem behaviors that occur at a rate of 33 to 53 times per hour. In addition, the patients scores of the VB-MAPP assessment were low, displaying 12 of a possible 170 points. Furthermore, the patients score on the barriers assessment was below average, indicating the patient displays significant barriers that need to be addressed. ABA can help the patient become more independent and acquire receptive and expressive communication, as well as social, motor, and adaptive skills. The patient meets the criteria for ABA, as the services requested are the most evidence-based treatment for autism, the patient has a diagnosis of autism, and the treatment request falls within the guidelines set by the BACB. All told, the requested 40 hours per week of 1:1 ABA services, eight hours per week of supervision, 0.5 hours per week of parent training, and 2 total hours for reassessment 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 a licensed B.C.B.A, board certified in psychology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for the Re-Walk Personal 6.0 System (wearable robotic exoskeleton) for paraplegia. The physical therapy assessment indicates the enrollee has a T4 complete spinal cord injury (SCI). She has achieved a level of modified independence with all of her daily activities from a wheelchair level. The enrollee completed a trial in the clinic with the ReWalk System. She met all the basic criteria for home use, was fitted for the system, and has demonstrated independence in the basic functions of the ReWalk System. With the ReWalk, the enrollee has demonstrated the ability to perform functional skills that include sit to stand, stand to sit and ambulating with Lofstrand crutches up to 400 feet with minimal to moderate assistance on indoor surfaces. According to the medical literature, robotic exoskeletons have emerged as a rehabilitation tool that may ameliorate several existing health-related consequences after spinal cord injury. However, evidence to support its clinical application is still lacking.  Clinical trials are currently underway to address some limitations and maximize benefits in rehabilitation settings.  Considering the limited data and/or small sample size of current published studies, it is still premature to make solid recommendations about clinical use of exoskeletons after SCI. The literature indicates rehabilitation practitioners should proceed with caution regarding the clinical application of robotic exoskeletons. Future high-quality studies are warranted to investigate the effects of robot-assisted training on functional and cardiopulmonary recovery of patient with SCI. In summary, the efficacy of the Re-Walk System needs to be demonstrated in a larger study. Final Result: The reviewer determined that the requested services were 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: Overturned Decision of Health Plan

An enrollee has requested reimbursement for the 10 prenatal genetic tests  Foresight Carrier Screen. The American College of Medical Genetics and Genomics (ACMGG) recommends offering carrier screening for cystic fibrosis to all female patients using a 23-mutation panel. The American College of Obstetricians and Gynecologists (ACOG) also recommends carrier screening for cystic fibrosis and spinal muscular atrophy to all patients of childbearing age. The expanded carrier screening is efficient, as it includes carrier screening for cystic fibrosis, and spinal muscular atrophy. Given this patients age and family history, the 10 prenatal genetic tests  Foresight Carrier Screen were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the 10 prenatal genetic tests  Foresight Carrier Screen.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation 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 genetics 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

The patient has requested authorization and coverage for Mavyret 100-40 mg three tablets daily for eight weeks. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated regardless of fibrosis stage. The guidelines recommend three Mavyret tablets daily for eight weeks for non-cirrhotic treatment-naive genotype 1a patients. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis. For these reasons, Mavyret 100-40 mg three tablets daily for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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 certification in gastroenterology 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 is requesting authorization and coverage for the medication, Simponi 100 mg every 14 days. The enrollee has a history of ulcerative colitis pancolitis. The injectable medication Simponi, 100mg every 14 days has been prescribed.  The record indicates the enrollees condition is difficult to control.  He has been receiving Simponi every four weeks, but it was only effective for two weeks.  He would have two solid bowel movements daily for the first two weeks. By weeks three and four he had up to three to four bowel movements daily, with blood.  The enrollee has long-standing ulcerative colitis with active disease, despite treatment with four different biologic agents and with intolerance to immunosuppressive drugs, except for prednisone.  A progress note indicates a colonoscopy showed active pancolitis with rectal sparing.  The provider recommended the patient continue Simponi and escalate the dose to every two weeks. The record indicates overall improvement with Simponi, but the patient was concerned because he had experienced increased symptoms prior to the next injection.This enrollees symptoms are poorly controlled with the current dosage regimen of every four weeks.  CellCept was stopped due to elevated liver function tests (LFTs). The failure of alternative treatments warrants off-label dosing under the care and guidance of his provider. The Simponi prescribing information notes the indications for use include achieving and sustaining clinical remission and that it has demonstrated efficacy in refractory ulcerative colitis in phase 2/3 studies. A study indicates treatment with subcutaneous golimumab induces clinical response, remission, and mucosal healing.  It results in an increased quality of life in larger percentages than placebo. In a follow-up study, golimumab maintained a clinical response through week 54 in patients with moderate-to-severe active ulcerative colitis who responded to induction therapy. Patients who received 100 mg golimumab had clinical remission and mucosal healing at weeks 30 and 54.                                                          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 gastroenterology 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.