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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Antabuse (disulfiram) 250 mg. Based on the current practice guidelines from the American Psychiatric Association (APA), Antabuse is a treatment option for patients with alcohol use disorder. The records provided for review support this patient has a long history of alcohol use disorder. The patient remains at high risk for serious medical consequences with alcohol relapse. For this patient, the benefits of ongoing Antabuse treatment outweigh the risks. Moreover, treatment with Antabuse has been better tolerated over naltrexone and has been beneficial in maintaining the patient's substance use recovery. The patient is motivated to maintain sobriety with good social support. The provider has recommended continuation of Antabuse to help facilitate this patients sobriety, as it is consistent with current medical guidelines and recommendations. For these reasons, Antabuse (disulfiram) 250 mg is medically necessary for treatment of this patient.Final Result: The reviewer determined 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 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 Accutane 40 mg. The U.S. Food and Drug Administration (FDA) approves the use of Accutane (generic name isotretinoin) for the treatment of severe acne. A study describes isotretinoin as the most effective treatment for acne. In this case, the patient has a diagnosis of acne vulgaris with scarring, indicating a severe condition. The records documented the patient had been treated with isotretinoin with good response, and the provider has recommended continued therapy. In this clinical setting, the requested medication is medically indicated. Therefore, Accutane 40 mg 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 parent of an enrollee has requested authorization and coverage for Ensure formula.Poor nutrition is common in individuals with cerebral palsy and has a wide-ranging impact on their health and well-being (Rempel, G.). Ruiz Brunner and colleagues conducted a cross-sectional study to describe the nutritional status of children with cerebral palsy (CP) and to analyze their risk of undernutrition based on their Gross Motor Function Classification System (GMFCS) level. They found that there is a high prevalence of undernutrition associated with CP (GMFCS levels IV and V) and that risk of severe undernutrition increases with increased motor compromises. Bell and Samson-Fang note that children with severe cerebral palsy, and particularly those with oropharyngeal dysfunction, are at high risk of poor nutritional status. They note that first-line treatment typically involves oral nutritional support for individuals with cerebral palsy who are safe to consume an oral diet. Enteral tube feeding may need to be considered in individuals with undernutrition where poor weight gain continues despite oral nutritional support, or in those with oropharyngeal dysphagia and an unsafe swallow. Jesus and Stevenson recently emphasized the importance of optimizing nutrition and bone health in children with cerebral palsy, because the consequences of poor growth and malnutrition range from decreased bone density, muscle mass, and quality of life to impacts on intellectual quotient, behavior, attention, social participation, healthcare utilization, and health care costs.In this case, the patient has cerebral palsy, and is unable to chew regular food. Despite being on Megestrol, an appetite stimulant, the patient has documented progressive weight loss, and with a BMI of 16.7, he is underweight. The etiology of the patients weight loss is unclear from the documentation provided. The patient has radiographic evidence of osteopenia and will be at risk of fractures. The medical literature confirms the importance of maintaining good nutritional status for patients with cerebral palsy. Under these circumstances, the requested Ensure formula is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested nutritional product is medically necessary to treat 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 patients parent has requested authorization and coverage for Norditropin Flexpro 15 mg/1.5 mL daily injection. Based on the Centers for Disease Control and Prevention (CDC) standards for this transgender male patient, his height tracked between the ninth and 15th percentiles, which was within normal ranges for males. The patients height was normal at the sixth percentile for transgender males, despite a low growth velocity. The available measurements support that this patient has normal stature for a male transgender. The patient does not meet the current U.S. Food and Drug Administration (FDA) approved indications for growth hormone therapy or the generally accepted diagnostic criteria for growth hormone deficiency given the normal bone age, height, and predicted adult height. The patients recently low growth velocity is likely due to malabsorption from partially uncontrolled Crohns disease, appetite suppression by Adderall XR, and/or puberty suppressed by long-acting gonadotropin releasing hormone (GnRH) agonist. All told, the requested Norditropin Flexpro 15 mg/1.5 mL daily injection 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 pediatrics with subspecialty certification in pediatric endocrinology 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 Gilotrif 40 mg tablet once daily for five months. Gilotrif is U.S. Food and Drug Administration (FDA) approved for the treatment of metastatic epidermal growth factor receptor (EGFR) mutated non-small lung cancer or metastatic squamous cell carcinoma with progression after platinum-based therapy. Phase I and II studies have demonstrated promising activity in human epidermal growth factor receptor 2 (HER2) positive breast cancer. However, a Phase III randomized study of Gilotrif in trastuzumab-resistant metastatic breast cancer was halted early due to unfavorable risk-benefit analysis from the Independent Data Monitoring Committee (IDMC) (Hurvitz, et al.). In this case, the provider reported that the patient is in remission. Based on the current peer-reviewed medical literature, there is a lack of support for use of Gilotrif in this clinical setting as preventative treatment. Therefore, the requested Gilotrif 40 mg tablet once daily for five months 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 internal medicine with subspecialty 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ovarian vein embolization.Findings: Two out of three physician reviewers found that the requested ovarian vein embolization is likely to be more beneficial than any other available standard treatments for the patients medical condition.There is sufficient support for the requested services in this clinical setting. Gonadal vein embolization is an appropriately accepted practice in the medical community. Case reports have shown the benefit of this procedure. These studies are difficult to compare, however, due to a number of factors including different diagnostic criteria and techniques for diagnosis and treatment, as well as a failure to provide standardized evaluation of symptoms before and after treatment. Despite these limitations, the reported technical success rates of ovarian vein embolization range from 89 to 100 percent with clinical success rates of 58 to 100 percent (follow-up period of up to five years). Complication rates of 4 to 8 percent have been reported for ovarian vein embolization. Gonadal vein embolization is safe, well-tolerated, and allows for a minimally invasive approach. In this case, the patient has clinical findings and imaging studies that are suggestive of pelvic congestion syndrome. Based on the currently available data, gonadal vein thrombosis for the treatment of imaging proven pelvic congestion syndrome is a medically appropriate intervention and is considered standard therapy for this condition. Thus, the requested ovarian vein embolization is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 reimbursement for all or any of the residential treatment center (RTC) services provided at Mountain Valley Treatment Center.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 3. The patient had a significant risk of harm, due to a history of suicidal ideation and attempts, and recent deficits in self-care.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment. The patient had not attended school for two years, and displayed extreme social withdrawal, deficits in self-care, and conflicts with parents. With regard to comorbidity, the records support a score of 1. The patient did not have comorbidities. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to conflicts with parents and struggles at school due to past bullying and lack of attendance.With regard to level of support of the recovery environment, the records support a score of 2 due to his parents participation in treatment.  In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, due to lack of improvement in mood and anxiety symptoms, and continued avoidance of school even after hospitalization, short-term residential treatment, and intensive outpatient treatment. With regard to treatment acceptance and engagement, the records support a score of 2. The patient actively participated in residential treatment. Thus, the patient has a total score of 18. The records support a 4 in terms of functional status which, per criteria, requires residence-based services. In this case, the recommended level of care is medically monitored residence-based services. The patient met CALOCUS 5b criteria, with a typical length of stay of up to 60 days. This is consistent with the level of care that the patient received at the RTC for the first 60 days. Therefore, RTC services for 60 days at Mountain Valley Treatment Center were medically necessary for the patient.Final Result: The reviewer determined that the services at issue were partially 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 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: An enrollee has requested authorization and coverage for Norco 10/325 mg 90 tablets (30-day-supply).The 2016 Centers for Disease Control and Prevention guidelines state, Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians 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 nonpharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. The April 2017 Federation of State Medical Boards guidelines recommended, Opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. The American Society of Interventional Pain Physicians guidelines state that prescribing of opioids less than 40 morphine equivalents a day is consider low dose therapy. In this case, the patient has chronic low back and neck pain due to moderate to severe canal stenosis of the cervical and lumbar spine. She underwent laminectomy surgery with no improvement in her symptoms. Notes indicate that the patient has been actively involved in physical therapy. She has also tried epidural steroid injections, with limited duration of benefit. She is currently requesting continuation of chronic opioid therapy with Norco. Based on the records, the patient has not shown any aberrant or drug seeking behavior. There is no documentation of inconsistent urine drug screens. The medication is managing the patients pain and allowing for the performance of activities of daily living. The current medical evidence supports the requested medication quantity of 90 tablets per 30 days in this setting. Therefore, Norco 10/325 mg 90 tablets (30-day-supply) are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of this patient. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty 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: The patient has requested authorization and coverage for (1) diclofenac epolamine 1.3% pain patches and (2) transforaminal epidural injection with imaging guidance (fluoroscopy or computed tomography), lumbar or sacral single level (CPT 64483).Findings:  The physician reviewer found that diclofenac epolamine topical patches may be effective for the treatment of acute soft tissue injuries, such as lumbar strains, sprains, and contusions, there is a lack of current medical literature to support their use for chronic low back pain and lumbar radiculopathy. In a systemic review and meta-analysis, Lee and colleagues concluded that lumbar epidural steroid injections were more effective than injections without steroids for improved pain relief and function. Manchikanti and colleagues reported that there is evidence supporting transforaminal epidural injections for the treatment of herniation or radiculitis. In this case, the patient has chronic low back pain with a history of L5-S1 fusion and presents with lumbar radiculopathy. She has tried and failed conservative care, including physical therapy. Given that the current medical literature does not support the use of diclofenac patches in this clinical setting, the requested medication is not medically indicated. As the patients provider has recommended epidural steroid injections to treat her left lumbar radiculopathy symptoms, the requested service is medically indicated. Therefore, (1) diclofenac epolamine 1.3% pain patches are not medically necessary for the treatment of this patient, while (2) a transforaminal epidural injection with imaging guidance (fluoroscopy or computed tomography), lumbar or sacral single level (CPT 64483) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service and medication are partially 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for additional physical therapy (2 times per week for 3 months). While direction and oversight of a postoperative program by a trained physical therapist is clinically appropriate and necessary in the early stages following total joint arthroplasty, current medical literature does not demonstrate a significant benefit of intensive or prolonged standard formal therapy program following total knee arthroplasty. In a systemic review and meta-analysis, researchers report that short-term improvements in physical function and knee range of motion do not clearly differ between outpatient physiotherapy and home-based exercise regimes in patients after primary total knee arthroplasty. Researchers likewise found in a trial of 334 participants that outpatient therapist led rehabilitation was not superior to a single physiotherapist review and home exercise based regimen in patients at risk of poor outcomes after total knee arthroplasty. Researchers observed that the burden of comorbidities appeared to better predict outcomes regardless of rehabilitation approach. In this case, there is no expected marginal benefit with respect to clinical course or outcomes from continued formal physical therapy over a conservative management program of exercise and modalities that can be performed at home. Given that the patient has maximized the expected benefit from supervised formal outpatient therapy, the requested services are not medically indicated. Therefore, additional physical therapy (2 times per week for 3 months) 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 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.