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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vyzulta eye drops for treatment of the enrollees open angle glaucoma.  Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested medication. Vyzulta (latanoprostene) is a new medication that combines latanoprost with nitric oxide. This medication has been shown to lower intraocular pressure better than latanoprost. In this patients case, given that the pressure in the right eye has not been adequately controlled, Vyzulta is medically appropriate. There is sufficient support for the requested medication in this clinical setting. Therefore, Vyzulta eye drops are 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 ophthalmology 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 fentanyl patch at 150 micrograms or 125 micrograms. The submitted documentation fails to demonstrate the medical necessity of the requested medication dosages. This patient is on high-dose fentanyl and Ambien. This drug combination carries significant risk. Additionally, clinical practice guidelines advise against maintaining patients on greater than 50 mg of morphine equivalent per day. Researchers studied the long-term use of opiates in polyneuropathy and found little benefit and major adverse outcomes. A slow taper as suggested by her provider is medically reasonable and necessary. Therefore, fentanyl patch at 150 micrograms or 125 micrograms is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that requested medication dosages 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 anesthesiology with sub-specialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for artificial disc replacement. In the medical literature, researchers reported on artificial disc placement in the cervical spine and found the device maintained physiological segmental motion at 24 months after implantation and was associated with improved neurological success, improved clinical outcomes, and a reduced rate of secondary surgeries compared with ACDF. This patient requires a decompression at the level of adjacent degeneration at C4-5 following ACDF. Moreover, there is adequate data that total disc replacement is superior to ACDF in this clinical setting. Accordingly, the requested artificial disc replacement is medically necessary for treatment of this patients intractable neck and right upper extremity pain. 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 neurological 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 prospective authorization and coverage for acupuncture services. The peer-reviewed medical literature supports a series of six sessions of acupuncture as medically necessary in this clinical setting. Studies reported that at six month follow-up after treatment, the acupuncture group showed a significantly greater improvement in pain intensity compared with the control group. Also, the acupuncture group had consistently better results in range of motion, functional ability, quality of life, and NSAIDs intake than the control group. Acupuncture resulted in effective long-term treatment for patients with shoulder pain. This patient underwent treatment with physical therapy, and oral medication, but continued to be significantly symptomatic. Consequently, an acupuncture trial of six sessions for shoulder pain and functional improvement is supported as medically necessary. Thus, six sessions of acupuncture are supported as medically necessary for treatment of this patients shoulder pain.  Final Result: The reviewer determined that a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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 authorization and coverage for enrollee admittance into a neuropsychiatric inpatient facility for observation and treatment. The submitted documentation supports the medical necessity of the requested services. The patient requires an evaluation done in a safe and controlled environment, by providers who are competent to assess the complications and risk of co-morbidities of autistic spectrum disorder. Moreover, the patient is at imminent risk of harm to himself or others. Non-epileptic seizure disorder is not a benign condition and requires expert evaluation and intervention in a controlled environment. Therefore, the requested admittance into a neuropsychiatric inpatient facility for observation and treatment is medically necessary for treatment of the patients medical condition.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A consumer has requested authorization and coverage for Synvisc One hyaluronic acid injection to the left knee. Findings:  The physician reviewer found that 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. Viscosupplementation has a good safety profile, and its use should be considered in some patients with knee osteoarthritis. All told, the Synvisc One hyaluronic acid injection to the left knee is medically necessary for treatment of this patients knee 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for insulin pump. Findings:  Three physician reviewers found that a continuous glucose monitoring system records blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed. This device can help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia. It can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, and evaluate how diet and exercise affect blood sugars. Studies have shown that use of a continuous glucose monitoring system can help optimize glycemic control and can lead to even greater improvement when used in conjunction with insulin pump therapy. The U.S. Food and Drug Administration recently approved the closed-loop insulin delivery system for use in patients with type 1 diabetes who are at least 14 years of age. The system uses an algorithm to automatically adjust basal insulin doses based on readings from a continuous glucose monitor. The medical evidence supports the requested device in this setting. Therefore, the requested insulin pump is likely to be superior over other treatment options. Final Result: The reviewers determined that the requested device 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services including the surgery and inpatient services. This patient presented with an emergent medical condition due to spinal cord compression. The spinal cord compression needed to be resolved as soon as possible. As noted in the medical literature, a patient is more likely to recover function when spinal decompression is performed in a timely manner. The patient was treated appropriately by emergent surgery to relieve the site of spinal cord compression. Since he was still severely affected post-operatively, it was appropriate to perform the MRI scan at that time. All told, the surgery and inpatient services provided were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the services at issue were necessary for treatment of the emergency medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurological 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for GammaCore Vagus Nerve Stimulator. Findings:  Three physician reviewers found that there is sufficient support for the requested device in this clinical setting. This patient has been diagnosed with chronic migraine. GammaCore Vagus Nerve Stimulator has provided relief. This device is appropriate for the acute treatment of migraine and episodic cluster, and the data shows good efficacy and good tolerability. The advantages include lack of drug interactions or medication side effects. Alternatives include triptan medications, nonsteroidal anti-inflammatory drugs and opiates. These alternatives have medication related issues, including side effects, drug interactions, and potential for medication overuse headache. Therefore, the requested GammaCore Vagus Nerve Stimulator is likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested device 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 parent of an enrollee has requested reimbursement for the Wilderness Program services. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth. The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services. Based on this patients clinical history and documentation, at the time of admission to the program, the patient met CASII criteria for outpatient services. The integrative psychiatric notes reported that the patient was sleeping well, had good appetite, and had no suicidal or homicidal ideation. He was cooperative and friendly with a euthymic mood. There was no documentation of the patient endorsing severe depressive or anxiety symptoms, suicidal ideation or self-injurious behavior. There was no documentation of aggressive behavior towards others, impulsivity, or poor functioning while in the program. For these reasons, Wilderness Program services were not medically necessary for treatment of this patients behavioral health issues.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 with sub-specialty 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 stem cell therapy. Cerebral palsy is a condition that results in motor disability. It can be caused by perinatal hypoxic insults, genetic conditions and trauma. Stem cells are undifferentiated cells that are speculated to have regenerative abilities. Stem cells have been shown in vitro to have the capacity to induce angiogenesis and differentiate into different types of cells, including cells of the nervous system. While theoretically stems cells may contribute to improvement in a patients neurological status, there is a paucity of quality data to support this treatment modality as effective in this patients case. The current medical evidence does not support the requested services in this clinical setting. Therefore, the requested stem cell therapy is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Promacta 25 mg. Promacta for ITP is U.S. Food and Drug Administration (FDA) approved for the treatment of thrombocytopenia in patients with chronic ITP who have had insufficient response to corticosteroids, immunoglobulins, or splenectomy. The goal of ITP treatment is to provide a safe platelet count in order to prevent clinically significant bleeding. This patient may have secondary ITP, for which treatment of the underlying cause with rituximab or another agent may be indicated. All told, the records do not support the medical necessity of the requested Promacta 25 mg for treatment of this patients ITP. 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 internal medicine with sub-specialty certifications in medical oncology and hematology 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: A 41-year-old female enrollee has requested authorization and coverage for belt lipectomy (CPT 15834). Based on the medical records provided for review, there is insufficient documentation to define a functional deficit related to the patients mild soft tissue excess of the lower back following weight loss. The patient states that she has some functional compromise associated with the lower back excess, but this is not supported by review of the photographs that show a relatively mild condition. The degree of excess skin viewed on the photographs is mild and not the likely source of the patients back pain. Work-up for other causes of the patients pain has not been documented. To satisfy medical necessity, there should be documentation of chronic rashes unresponsive to typical dermatologic treatment or other functional issues unresponsive to conservative management. This is not present in the medical records provided for review. For these reasons, the requested belt lipectomy is not medically necessary for treatment of this patients medical condition. Moreover, there is inadequate evidence of an abnormal structure of the body. The patient has some mild soft tissue excess of the lower back, which does not support the presence of an abnormal structure of the body. The American Society of Plastic Surgeons (ASPS) noted that there can be situations when skin redundancy can cause a functional deficit, such as a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms. However, this patient does not have any documented functional impairment related to the lower back soft tissue excess. Moreover, the requested procedure is not likely to create a more than minimal improvement in the patients appearance based on the photographs. Thus, the requested belt lipectomy is not reconstructive in nature for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Percocet. The Centers for Disease Control and Prevention (CDC) cautions that opiates are not to be used as first-line therapy in chronic pain. The records document that this patient has significant chronic low back pain. The symptoms and MRI evidence indicates an axial pain component as well as neuropathic pain. The patients providers have engaged in a comprehensive pain management program that includes physical therapy, psychology, and interventional procedures. Additionally, the providers have used medical therapy utilizing various classes of medications. However, there are standard available therapies that have not been exhausted to support long-term opioid treatment. Moreover, there is a lack of data supporting the safety and effectiveness of opiates with cannabis. All told, the requested Percocet is not supported as medically necessary for treatment of this patients chronic pain. 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 expertise 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.