Persius/hicric huggingface dataset:
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 residential treatment center (RTC) level of care. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient has a serious risk of harm, due to a history of prior suicide attempt, reported thoughts of suicide and self-harm, and poor insight and judgment. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to inability to fulfill responsibilities for her age level. The patient has been failing her classes, becoming increasingly socially isolative, and reported poor sleep, low energy, and poor appetite.With regard to comorbidity, the records support a score of 4. The patient has major comorbidity, due to the presence of depression, as evidenced by difficulty sleeping, poor appetite, and low energy. In terms of level of stress of the recovery environment, the records support a score of 4. The patient has a moderately stressful environment due to recent conflict with her parents regarding her lack of motivation and personal hygiene.With regard to level of support of the recovery environment, the records support a score of 3 due to the parents efforts to arrange counseling for the patient. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor resiliency and/or response to treatment, as previous outpatient treatment did not ameliorate depressive symptoms or suicidal ideation. With regard to treatment acceptance and engagement, the records support a score of 2. The patient is able to engage in treatment. Thus, the patient has a total score of 25. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the RTC level of care. Therefore, RTC level of care is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent 300mg/mL pre-filled syringe. The U.S. Food and Drug Administration approves the use of Dupixent for the treatment of atopic dermatitis. In a systematic review of systemic immunomodulatory treatments for patients with atopic dermatitis, the review concluded that dupilumab and cyclosporine may be more effective for up to 16 weeks of treatment than methotrexate and azathioprine. In this case, the documentation reflects that the patients condition has been present for several years and has been treated with topical steroids. Given current medical literature, and the patients persistent symptoms, the requested medication is medically indicated. Therefore, Dupixent 300mg/mL pre-filled 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 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 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 authorization and coverage for a highchair/activity chair. Findings: In this case, given that a DME evaluation has recommended a commode chair and a collapsible adaptive tilt-in-space wheelchair that could serve the functions of an activity chair, the requested equipment would be duplicative. Therefore, a highchair/activity chair is not medically necessary to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested equipment 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Dupixent.Findings: Dupixent is an interleukin-4 receptor alpha antagonist that is FDA approved for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. There are very few treatments approved for this condition, and this medication has quickly become a standard, preferred therapeutic option by dermatologists in the community. The medication was approved in 2017, and therefore has not yet made it into Guidelines (these were last updated in 2014). The data supporting its use in moderate-to-severe atopic dermatitis is substantial and it has a very favorable side effect profile in comparison to other systemic agents. In this case, the patient has a history of severe eczema that has not been adequately controlled by treatment with topical steroids, tacrolimus ointment, phototherapy, and courses of prednisone. Dupixent is indicated for the treatment of eczema under these circumstances and has a favorable side effect profile. Accordingly, the requested medication, Dupixent, is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology, with subspecialty certification in dermatopathology, 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 parent of an enrollee has requested authorization and coverage for a 30 day supply of Zoloft.The medical literature does not support that the brand name medication Zoloft has superior efficacy over the generic medication sertraline for the treatment of obsessive compulsive disorder (OCD). Researchers conducted a comparative study of the effectiveness of generic versus brand medications. After analyzing data from more than 3.5 million patients, the authors observed that use of generics provided comparable clinical outcomes to those of the brand-name products for chronic conditions including depression and anxiety. American Academy of Child and Adolescent Psychiatry (AACAP) guidelines indicate that selective serotonin reuptake inhibitors (SSRIs) are the initial medication of choice for pediatric OCD due to their efficacy and generally well tolerated side effect profile. SSRIs shown to be effective and safe in this population include fluoxetine, fluvoxamine, and sertraline. If a patient has not demonstrated a response to generic sertraline 250 mg every day, the likelihood is low that brand name Zoloft would result in a superior response, as the generic medication has the same active content as the brand name medication. In this case, there is no clear clinical documentation of the patients ongoing symptoms, no clear history of treatment except for a list of the patients past medication trials, and no clear description of the patients response to previous treatments. There is no indication that the patient was treated with any other medication for treatment of symptoms related to OCD such as another SSRI such as fluvoxamine or fluoxetine. Under these circumstances, the requested 30 day supply of Zoloft is not medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patient's 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 patient has requested authorization and coverage for Otezla. The records provided for review document that this patient has experienced symptoms consistent with psoriasis for about nine years. In 2016, he reportedly had psoriasis with involvement of about 5% of his BSA. By July 2020, the patient had greater than 70% of his BSA covered with psoriasis. According to the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) joint guidelines, psoriasis is categorized as mild, moderate, and severe. Per these guidelines, severe psoriasis is characterized by involvement of more than 10% of a patients BSA. Based on this patients physical examination, this patient has evidence of severe disease. Researchers noted that although mild psoriasis is generally treated with topical therapies, severe disease supports treatment with biologic agents. This patients provider has recommended treatment with Otezla. However, the records do not document any contraindications to standard of care biologic agents. Given the AAD and NPF guideline recommendations, this patient is a candidate for treatment with an injectable biologic prior to treatment with Otezla. Biologics have been shown to be effective in treating psoriasis with reasonable safety profiles. Otezla does not fall into the biologic category. For these reasons, the requested Otezla 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 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 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 endoscopically assisted surgical expansion (EASE). The records provided for review document that this patient has mild obstructive sleep apnea (OSA). As noted in the peer-reviewed medical literature, non-surgical therapy is considered the first-line approach for patients with mild OSA. Treatment options include oral appliance therapy and continuous positive airway pressure (CPAP). For patients who cannot tolerate or fail to improve with the first-line modalities, surgery is an option. A variety of staged protocols have been developed. However, there is a lack of evidence establishing which surgical procedure is the most effective. The soft palpate can be addressed by uvulopalatopharyngoplasty (UPPP), while the retrolingual, oropharyngeal, and hypopharyngeal areas can be improved with procedures such as genioplasty and hyoid suspension. Maxillo-mandibular advancement has also been shown to improve posterior airway space. There is a lack of data to support an indication for the EASE procedure for the treatment of this patients mild OSA. All told, the requested EASE procedure is not medically necessary for 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 licensed D.D.S., board certified in orofacial and maxillary 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 Evrysdi. The U.S. Food and Drug Administration (FDA) approved Evrysdi in August 2020 for the treatment of SMA in patients two months of age and older. Evrysdi is designed to treat SMA caused by mutations in chromosome 5q leading to survivor motor neuron (SMN) protein deficiency. Evrysdi boosts the ability of an alternative gene SMN2 to produce full-length and functional SMN protein. The in vitro and in vivo preclinical data strongly suggest that functional SMN protein increases, seen in patients blood following Evrysdi treatment, should reflect similar increases in functional SMN protein in the central nervous system, muscle, and other peripheral tissues. This patient presents with type 2 SMA. The records document that he is not eligible for Spinraza due to poor spinal access as he is status post placement of a Herrington rod for scoliosis. Given the current support in the medical literature, the requested Evrysdi 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 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 requested authorization and coverage for Euflexxa injection series 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 ibuprofen and tramadol, and is unable to take NSAIDs. Given the patients limited options, with the alternative being bilateral total knee arthroplasties, and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injection series 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Linzess and (2) surgery to treat irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that The U.S. Food and Drug Administration (FDA) approves the use of Linzess for the treatment of irritable bowel syndrome with constipation, and chronic idiopathic constipation. The American Gastroenterological Association guidelines for the treatment of constipation recommend the use of osmotic and stimulant laxatives prior to advanced agents such as Linzess, stating, A newer agent should be considered when symptoms do not respond to laxatives. In this case, the records noted that the patient reported diarrhea. As Linzess would make diarrheal symptoms worse, it is not medically indicated. Regarding the treatment of GERD, Moore and colleagues note that first line treatments for GERD involve mainly lifestyle and non-surgical therapies. In this case, the documentation does not reflect that the patient has tried and failed medical therapy or has complications due to GERD. The documents do not show a preoperative workup and an endoscopy has not established a diagnosis of GERD. Surgical intervention is also not recommended for the treatment of IBS. Given current medical literature, the requested medication and service are not medically indicated in this clinical setting. Therefore, (1) Linzess and (2) surgery to treat IBS and GERD are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication and service 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 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 patient has requested authorization and coverage for Taltz. Findings:  The physician reviewer found that U.S. Food and Drug Administration (FDA) approves the use of Taltz (ixekizumab), a humanized interleukin-17A antagonist, for the treatment of adults with moderate to severe plaque psoriasis. In a comparison of ixekizumab with etanercept or placebo in the treatment of moderate to severe psoriasis, Griffiths and colleagues noted that in two studies, ixekizumab dose regimens had greater efficacy than placebo and etanercept over 12 weeks. Menter and colleagues noted that the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) guidelines on the management and treatment of psoriasis with biologics recommend ixekizumab as a monotherapy treatment option in adult patients with erythrodermic psoriasis. In this case, the patient has erythrodermic psoriasis and has tried and failed other medications. The documentation reflects that the patient reported significant improvement of his symptoms with Taltz. Given the current medical literature and the providers recommendation that this patient continue treatment with Taltz, the requested medication is medically indicated. Therefore, Taltz 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential facility center (RTC) services. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient was noted to have withdrawal symptoms of vomiting, diaphoresis, and tremors. He declined withdrawal medications. The patients withdrawal needs were safely managed in level 3.1 setting. For dimension 2, the patient does not have active medical problems. His biomedical problems were stable and do not require medical or nurse monitoring.For dimension 3, the patient was diagnosed with depression and PTSD from employment as a paramedic and firefighter. He used alcohol to cope with emotional pain. The patients mental status was stable enough to permit participation, and was assessed as not posing a risk of harm to self or others.For dimension 4, the patient voluntarily admitted himself to RTC treatment after recognizing his inability to stop drinking on his own. The patient recognized specific negative consequences of his alcohol use. He was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.For dimension 5, the patient reported drinking to the point of blackout at least five to seven days per week. He attempted participation in Alcoholics Anonymous (AA) but found the format unhelpful. He was unable to cope with his PTSD symptoms without the use of alcohol. The patient demonstrated limited coping skills to address relapse triggers and urges. He was in imminent danger of relapse with dangerous consequences and needed 24-hour structure to assist in applying recovery and coping skills.For dimension 6, the patient had unstable housing due to going through a divorce, staying in his car in order to drink, and staying with his sister. While he is able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program, continued exposure to the his living environment makes recovery unlikely, and the patient has insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment.Given these findings, the patient met the six ASAM criteria for RTC services. Accordingly, RTC services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.