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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for behavioral health psychological testing. The American Psychiatric Association (APA) recommends that psychological testing be used in conjunction with other sources of clinical information, including a clinical interview, interviews with collateral sources, self-reported objective measures, observation of the patient, and review of past records, to create a diagnostic formulation and treatment plan. Psychological and neuropsychological testing may be used to narrow the differential diagnosis when there is lack of diagnostic clarity or lack of progression according to the treatment plan due to possible functional and cognitive limitations, which are not elucidated in the course of a clinical interview and treatment. In this case, the submitted clinical interview, past records, and observation of the patient do not establish a lack of diagnostic clarity or inability to create treatment recommendations. While the patient would benefit from a thorough psychiatric evaluation, including collateral information and objective measures to help direct treatment modality and establish diagnosis, in this clinical setting, the submitted documentation does not establish the lack of clarity in diagnoses necessitating psychological testing. Therefore, behavioral health psychological testing is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lorazepam 1 mg, 90 tablets every 30 days. Findings:  The physician reviewer found that he records provided for review document that this patient has been treated with a high dose of benzodiazepine for anxiety for many years. The providers documented that the patient has not been amenable to guidance on tapering his lorazepam dose or augmentation strategies, which have been attempted over the last year. The patients current treatment plan should include weaning the dose of the lorazepam to the lowest tolerated, individual psychotherapy, and alternative psychopharmacologic options. There is a lack of evidence that the patient has undergone treatment with cognitive behavioral therapy, which has been demonstrated to be effective for patients with anxiety disorder. For these reasons, the requested lorazepam 1 mg, 90 tablets every 30 days is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orencia ClickJect 125 mg subcutaneous weekly. The records provided for review document that this patient has a history of rheumatoid arthritis and protein S deficiency. The provider charted that prior treatment with Enbrel was ineffective and not well tolerated. The provider noted that additional anti-TNF agents are not recommended in this clinical setting. The provider has recommended treatment with Orencia. According to the American College of Rheumatology guidelines, it is recommended for patients to switch drug classes rather than use another form of anti-TNF therapy. The patients protein S deficiency increases her risk for thrombosis, and she is on chronic anticoagulation therapy. Rinvoq and Xeljanz are contraindicated for this patient since these agents have been associated with an increased risk of thrombosis development. Given these findings, the requested Orencia ClickJect 125 mg subcutaneous weekly is medically necessary for 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 rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for one hour a week of the Schroth method of therapy. Findings:  The physician reviewer found that Kalichman and colleagues state that bracing has been found to be the most effective conservative treatment for adolescent idiopathic scoliosis (AIS). However, there is limited evidence that specific physical exercise is also an effective intervention for AIS. Additionally, well-designed and good quality studies are required to assess the effectiveness of different conservative methods in treating AIS. Further, a review by Romano and colleagues found that the effectiveness of manual therapy for the treatment of idiopathic scoliosis remains unclear. In a review of the medical literature, Lotan and Kalichman could not come to a clear conclusion about the effectiveness of manual therapy in the treatment of AIS. Ng and colleagues state that the difference among the many physiotherapeutic scoliosis-specific exercises (PSSEs) and braces has not been studied. As such, no specific PSSE can be recommended. Thus, one hour a week of the Schroth method of therapy is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings: Two out of three physician reviewers found that one hour a week of the Schroth method of therapy was not likely to be more beneficial for you than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in orthopedic surgery and is 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:  An enrollee has requested authorization and coverage for acupuncture services, three times per month.Acupuncture applied to tender points appears to have beneficial effects on neck and shoulder pain and stiffness. Moreover, Vickers and colleagues concluded that acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. In this case, the patient has chronic neck pain with a history of anxiety and depression. The patient has received acupuncture in the past, with positive improvement. The provider reported that acupuncture has been the only treatment that helps the patient. Therefore, acupuncture services three times per month are medically necessary for the 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 oriental 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 patients parent has requested authorization and coverage for one hour of speech therapy weekly for six months. Smith and colleagues note, Language disorder is a cardinal challenge for children with Down syndrome. Eggers and Van Eerdenbrugh report, Speech and language development in individuals with Down syndrome is often delayed and/or disordered and speech dysfluencies appear to be more common. Lieu and colleagues note that hearing loss in children includes worse outcomes in speech, language, education, social functioning, cognitive abilities, and quality of life. Thus, speech therapy would be an important intervention in the development of effective communication for a child with hearing loss. Segura-Pujol and Briones-Rojas report that there are few articles published investigating treatment intensity in children with developmental language disorder. Byers and colleagues note that children with mild or mild-moderate speech sound disorders may benefit more from a shorter, frequent, individual service delivery model over twice weekly, 30-minute group sessions. In this case, the patient has a diagnosis of Down syndrome and bilateral hearing impairment. The records note that he has not done well with remote, Zoom therapies during the pandemic due to impaired hearing and a short attention span. Given that current medical literature supports the use of speech therapy in this clinical setting, the requested services are medically indicated. Therefore, one hour of speech therapy weekly for six months is 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 neurology with special qualification in child 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: The patient has requested authorization and coverage for Phenergan with codeine. Findings: In this case, the patient reports a lingering cough following a COVID-19 infection. The records noted multiple, frequent requests for Phenergan with codeine, a combination medication with an opioid and histamine H1 antagonist that carries the risk of opioid addiction, abuse, and misuse, and noted that the patient refused alternative medications. Given that the submitted records did not indicate symptoms of sufficient severity to support the use of a medication with the risk of a high abuse potential, and the documented frequency of the patients refill requests, the requested medication is not medically indicated. Therefore, Phenergan with codeine is not medically necessary for the 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 internal 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 Synvisc injections in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments, including corticosteroid injections, with the alternative being bilateral total knee arthroplasties in the presence of moderate osteoarthritis at a relatively young age. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc 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: The patient has requested authorization and coverage for a dosage escalation for Inflectra 10 mg/kg to every four weeks. Findings:  The physician reviewer found that Gibson and colleagues note that as the half-life of infliximab (brand name Inflectra) is shorter in patients with acute severe ulcerative colitis than in patients with non-severe ulcerative colitis, more frequent dosing might be required to produce a therapeutic effect. Dumitrescu and colleagues also note that in a study of 157 patients, the strategy of infliximab dose doubling led to short- and long-term event-free survival in patients with ulcerative colitis, who had a loss of response to infliximab, in greater than 50% of the cases. The American College of Gastroenterology (ACG) guidelines for the management of ulcerative colitis support an increase in infliximab dosage in patients with uncontrolled disease and with low infliximab level if anti-infliximab antibodies are absent or at a low level. The American Gastroenterological Association guidelines for therapeutic drug monitoring recommend an infliximab level of 5 ug/mL and note that a level over 10 ug/mL is highly likely to be effective. In this case, the patients infliximab levels are significantly lower and anti-infliximab antibodies are at a low level. While the patient does not have uncontrolled clinical disease, he has a history of inflammation on colonoscopy a year after starting the current dose, placing him at risk for colorectal cancer and severe disease flare. In this clinical setting, the requested medication regimen is medically indicated to reduce the risk for a disease flare requiring hospitalization or surgery, uncontrolled disease, or uncontrolled disease manifesting as dysplasia and leading to colon cancer. Therefore, a dosage escalation for Inflectra 10 mg/kg to every four weeks is 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 internal medicine with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly intravenous infusions of vitamin C. Findings:  The physician reviewer found that (FDA) notes that ascorbic acid, vitamin C, injections may be indicated for the treatment of scurvy and is not indicated for treatment of vitamin C deficiency that is not associated with the signs and symptoms of scurvy. Nauman and colleagues report that while vitamin C has promising results as a potential treatment for cancer as an independent agent and in combination with standard chemotherapies, further randomized placebo-controlled trials such as the ongoing placebo-controlled trials of vitamin C and chemotherapy in prostate cancer are needed. In this clinical setting, given that current medical literature does not support the use vitamin C in the treatment of prostate cancer outside of a clinical trial, the requested service is not medically indicated. Therefore, weekly intravenous infusions of vitamin C are 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 internal medicine with sub-specialty certifications in medical oncology and in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a gastroenterologist consult. Camilleri notes that while traditionally the diagnosis of irritable bowel syndrome (IBS) has been based on the positive identification of symptoms that correlate with several different syndromes associated with disorders such as IBS diarrhea, IBS constipation, functional diarrhea, functional constipation, chronic functional abdominal pain, or bloating, several peripheral and central mechanisms initiate gastrointestinal motor and sensory dysfunctions that may lead to IBS symptoms. The authors further note that such dysfunctions may require evaluation in patients whose symptoms do not respond to first-line treatments. Lacy and colleagues report that IBS diagnosis may involve diagnostic testing. In this case, the patient has chronic gastrointestinal symptoms consistent with IBS, and has ongoing symptoms despite attempting recommended medical therapies for the treatment of IBS. Given that this patient has not responded to first-line treatments for IBS and as alternative possible diagnoses must be considered, the requested service is medically indicated. Therefore, a gastroenterologist consult is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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:  An enrollee has requested authorization and coverage for a Synvisc One injection to the left knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, including corticosteroid injections, with the alternative being a total knee arthroplasty. Therefore, Synvisc One injection to the left knee is medically necessary for the treatment of the patients medical condition. 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.