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 reimbursement for any or all of the intensive outpatient program (IOP) level of care services provided by Evolve Growth Initiatives. 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 2. The patient had some risk of harm, due to recurrent suicidal ideation and urges to self-harm while enrolled in partial hospitalization program (PHP) and IOP. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to academic difficulties and interpersonal conflicts. 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 3. The patient had a moderately stressful environment due to the parents separation and the patients reports of being triggered by his mothers drinking. With regard to level of support of the recovery environment, the records support a score of 2 due to the parents participation in treatment and in treatment planning. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management due to persistent symptoms despite multiple hospitalizations, two courses of residential treatment, and prior IOP treatment. With regard to treatment acceptance and engagement, the records support a score of 2 due to the patients active participation in treatment. Thus, the patient has a total score of 17. In this case, the recommended level of care is high intensity community-based services. This is consistent with the IOP level of care that the patient received. Therefore, IOP level of care services provided by Evolve Growth Initiatives were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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 Aimovig.Aimovig (erenumab) is a calcitonin gene-related peptide (CGRP) approved for episodic and chronic migraine. CGRP monoclonal antibodies (mAbs) are biologic agents that have demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3 randomized, placebo-controlled trials. Erenumab can be administered every four or 12 weeks by subcutaneous injection and does not require dose titration. Erenumab may achieve rapid treatment effects over days to weeks and is effective in patients who have failed prior preventive treatment, as well as in those on concurrent oral preventive treatments. The lack of need for slow dose escalation, the rapid onset of therapeutic benefits, and the favorable tolerability profiles are advantages of injectable therapies. In 2018, the American Headache Society (AHS) position statement noted that treatment with anti-CGRP mAbs is indicated when all of the following are met: there is a diagnosis of International Classification of Headache Disorders third edition (ICHD-3) migraine with or without aura. Additionally, the patient must demonstrate an inability to tolerate (due to side effects) or inadequate response to a six-week trial of at least two of the following: topiramate, divalproex sodium/valproate sodium (Depakote), beta-blocker (metoprolol, propranolol, timolol, atenolol, nadolol), tricyclic antidepressant (amitriptyline, nortriptyline), and/or serotonin-norepinephrine reuptake inhibitor (venlafaxine, duloxetine). Alternatively, the patient may demonstrate an inability to tolerate or inadequate response to a minimum of two quarterly injection (six months) of onabotulinumtoxinA. In this case, the patient has a history of chronic migraines. However, there is no documentation in the record of failure of other oral preventive medications. The patient does not fit AHS criteria for initiation of CGRP monoclonal antibody therapy. For these reasons, Aimovig is not medically necessary for the treatment of the patients medical condition.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 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 proton beam radiation therapy (CPT codes 77520 x 28, 77522 x 28, 77523 x 28, 77525 x 28, 77014 x 28, 77387 x 28, G6002 x 28, 77427 x 6, 77336 x 6, 77300 x 6, 77301 x 6, 77334 x 6, 77280 x 6, 77290 x 6, 76498 x 1, and 76497 x 1).Currently, there is insufficient clinical data to discern whether treatment with proton beam therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Vapiwala and colleagues performed a multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer. The authors compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found no difference in disease control between the two modalities. A position statement released by The American Society of Radiation Oncology (ASTRO) stated, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity-modulated radiation therapy technique. In conclusion, proton beam radiation therapy (CPT codes 77520 x 28, 77522 x 28, 77523 x 28, 77525 x 28, 77014 x 28, 77387 x 28, G6002 x 28, 77427 x 6, 77336 x 6, 77300 x 6, 77301 x 6, 77334 x 6, 77280 x 6, 77290 x 6, 76498 x 1, and 76497 x 1) is not medically necessary for the treatment of the patients medical condition.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 radiation oncology 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 oxycodone 30 mg, and/or Soma 350 mg. The Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain state that, Nonpharmacologic therapy and nonopioid 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 nonopioid pharmacologic therapy, as appropriate. The CDC noted that patient should continue opioid therapy when there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Federation of State Medical Boards (FSMB) guidelines recommend, 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. Researchers evaluated the risks of combining opioids with muscle relaxers. The authors concluded that, opioid users who concomitantly used skeletal muscle relaxers had a slightly increased risk of opioid overdose hospitalization or emergency department visits compared to those who used opioids alone. In this case, the patient is requesting high dose opioid therapy in conjunction with Soma, which is a muscle relaxer, which is a dangerous drug combination due to elevated risks of respiratory depression and overdose. The CDC guidelines support continuation of chronic opioid therapy for non-cancer pain only if the benefits outweigh the risks and with use of the lowest possible doses to manage chronic pain. In this clinical setting, the risks of continuing opioid therapy and Soma outweigh the benefits of this regimen. The provider recommended a medication regimen including Percocet to manage the patients chronic pain that is consistent with the current guidelines. The provider also included a plan for the patient to taper off other agents which may increase her risk for adverse events. All told, the requested oxycodone 30 mg, and Soma 350 mg are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medications 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 subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 2250 mg. Pittman and colleagues note that almost all patients with systemic sclerosis have gastrointestinal manifestations, including small intestinal bacterial overgrowth (SIBO). Polkowska-Pruszynska and colleagues report that SIBO remains a diagnostic and therapeutic challenge and is a significant clinical problem among patients suffering from systemic sclerosis. According to Gatta and Scarpignato, rifaximin (brand name Xifaxan) treatment is effective and safe for the treatment of SIBO. Barkin and colleagues note that rifaximin is the most commonly prescribed antibiotic regimen for SIBO therapy. The dose and duration of 550 mg three times daily for 14 days is consistent with regimens used in current medical literature. In this case, the patient has a diagnosis of scleroderma with symptoms consistent with SIBO. In this clinical setting, given the risk of and prevalence of SIBO in patients with scleroderma, the requested medication is medically indicated. Therefore, Xifaxan 550 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 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:  An enrollee has requested authorization and coverage for sit to stand frame system.According to Gibbs and colleagues, there is a lack of high-grade evidence to support that use of passive standing devices significantly improve clinically-relevant health or functional outcomes over available standard therapy, such as active exercise using volitionally intact muscles. The effects of the type of passive exercise in a standing frame on bone health, in the setting of paralysis due to spinal cord injury, are unproven. According to Newman and Barker, with respect to pressure injuries/wounds, the standing feature would potentially mitigate risk in some areas, but would also introduce new areas that would be at risk for pressure ulcer development. There is no clinically significant net gain. At this time, there is a lack of high-grade evidence to support that use of this type of device provides clinically significant benefits with respect to other health outcomes in the setting of these types of neurological conditions. While standing frame use may improve tolerance of passive standing, there are no indications that this translates to improvements in functional activities. In the present case, the records do not support that the patient would be expected to become a functional ambulator through use of this device, as there is an absence of sufficient neurological motor strength in the relevant muscle groups. There is a lack of support for the requested equipment in this clinical setting. Therefore, the requested sit to stand frame system (HCPCS E0637) is not medically necessary for the treatment of the patients medical condition. 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium. Findings:  The physician reviewer found that Findings: Three out of three physician reviewers found that the authorization and coverage for computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium is likely to be more beneficial for the enrollee than any available standard therapy.Based on American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, an elevated computerized tomography (CT) calcium score would be considered a risk enhancing factor to determine the need for statin therapy in borderline or intermediate risk patients (5% to 7.5% 10-year cardiovascular disease risk). Based on current AHA/ACC guidelines, computed tomography calcium scanning for further refinement of cardiovascular risk in borderline or intermediate risk patients would be indicated and reasonable. In this case, the patients 10-year cardiovascular risk is 7.2%, indicating the borderline-intermediate risk category. The patient also has the risk enhancing factor of a family history of early cardiovascular disease. Therefore, computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium (CPT - 75571) is likely to be more beneficial for the evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for alprazolam. Based on data from the American Academy of Sleep Medicine (AASM), alprazolam is not recommended as a first-line medication in the treatment of insomnia in patients over 65 years of age (Sateia, et al.; Edinger, et al.). The records provided for review indicate that this patient has been treated with alprazolam for 30 years for a diagnosis of insomnia. This suggests that the patients insomnia has not been appropriately evaluated and treated. In addition, the patients lengthy treatment with alprazolam does not support continued treatment with this medication. There is a lack of documentation that the patient has been thoroughly evaluated by a sleep specialist. Furthermore, this patient is taking other medications that can cause severe side effects when taken with alprazolam. The patients letter and his records support a likely diagnosis of sleep maintenance insomnia. Patients with sleep maintenance insomnia are evaluated and treated for any underlying causes such as sleep apnea, and cognitive behavioral therapy provides an effective long-term treatment. There is a lack of evidence that this patient has been treated with cognitive behavioral therapy. Given these findings, the requested alprazolam 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 with subspecialty certification in sleep 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Cartiva joint arthroplasty, a synthetic cartilage implant, used during surgery. This patient presented to her provider with complaints of ongoing great toe pain. Per the providers notes, imaging revealed narrowing of the dorsal cartilage interval of the first metatarsophalangeal joint with associated osteophytes. The patient also developed secondary hallux valgus interphalangeus with the left big toe impinging on the second toe. The patient underwent placement of the Cartiva implant for treatment of great toe pain. The Cartiva implant utilized in this patients surgery is not supported by adequate data in the peer-reviewed medical literature when compared to cheilectomy or arthrodesis. A prospective randomized multicenter trial reported by Baumhauer and colleagues compared the Cartiva implant to arthrodesis found that the Cartiva implant outcomes were not inferior to arthrodesis. However, the Cartiva interposition hemiarthroplasty implant continues to be evaluated to determine whether the procedure is safe and effective in the long-term as an alternative to cheilectomy and arthrodesis. Therefore, the Cartiva joint arthroplasty, a synthetic cartilage implant, used during surgery was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Findings:  Two of the three physician reviewers found the Cartiva joint arthroplasty, a synthetic cartilage implant, used during surgery was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entyvio. This patient presents with a history of ulcerative colitis. Currently, the provider noted that the patient is experiencing a flare of his condition. The patient has been treated with prednisone. Prior treatment has also included Asacol. The patients provider has recommended treatment with Entyvio. As noted in the medical literature, Entyvio has been demonstrated to be safe and effective for the treatment of patients with ulcerative colitis (Rubin, et al.). In addition, one study found evidence of superior response to Entyvio when compared to tumor necrosis factor agents such as infliximab in patients with ulcerative colitis (Sands, et al.). The American Gastroenterological Association (AGA) guidelines state that, Patients, particularly those with less severe disease, who place higher value on the potential safety of medications, and a lower value on the relative efficacy of medications, may reasonably choose vedolizumab (Sands, et al.). Additional data have reported on the efficacy of Entyvio for the treatment of patients with ulcerative colitis in high-quality studies, including randomized controlled trials (Mosli, et al.; Lin, et al.). Given this support, the requested Entyvio 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 internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.