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

The patient has requested authorization and coverage for Spinraza. The records provided for review document that this patients diagnosis is a severe phenotype of spinal muscular atrophy (SMA) that has substantially deteriorated his ability to function. The documentation reports that the patient has trace arm movement and he is no longer able to maneuver his wheelchair. The patients provider recommended treatment with Spinraza, which is a U.S. Food and Drug Administration (FDA) approved medication for the treatment of patients with SMA. Recent studies have demonstrated that Spinraza is safe and effective for use in this patient population. Researchers found that Spinraza addresses the insufficient level of SMN proteins in this patient population by promoting increased production of full-length SMN proteins. Given the support in the medical literature, the requested Spinraza 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 with expertise in neurodegenerative disorders 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 authorization and coverage for computer-assisted navigation (CPT 20985) for the approved right total knee replacement procedure. Computer-assisted navigation techniques are classified as either open or closed systems. Computer mapping is created with pre-operative imaging via computed tomography (CT) or magnetic resonance imaging (MRI), intraoperative imaging with modified fluoroscopy, or an image-free technique using a surface probe. Clinical practice guidelines do not recommend computer-assisted navigation, since short- and long-term follow-up data have shown no differences in multiple outcome measures. Computer-assisted navigation is not recommended for routine knee arthroplasty and is reserved for patients with significant femoral bony deformity, where conventional intramedullary alignment lacks accuracy. There is insufficient evidence to support computer-assisted navigation for orthopedic surgery in lieu of conventional methods. In this case, the patient is presents with end-stage right knee osteoarthritis and substantial symptoms. However, the submitted medical records do not document the presence of significant bony deformity or other exceptional factors, which would justify computer-assisted navigation. Therefore, the requested computer-assisted navigation (CPT 20985) for the approved right total knee replacement procedure is 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 requested computer-assisted navigation (CPT 20985) for the approved right total knee replacement procedure is 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 requested services are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for binocular vision evaluation and vision therapy services. In-office vision therapy for the treatment of this patients diagnoses of exotropia, tracking difficulties, and suppression of binocular vision are not within the current standard of care. In-office vision therapy may be helpful for some patients with convergence insufficiency, but studies have not shown demonstrated that in-office vision therapy is superior to in-home treatment modalities. In-home vision therapies and observation for convergence insufficiency is the prevailing treatment due to the lack of evidence for and standardization of office-based treatments. This patient has a history of right eye monocular exotropia, tracking difficulties, and suppression of binocular vision. Given the lack of support, the binocular vision evaluation and vision therapy services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for lumbar home traction device. The current data from peer-reviewed, published studies do not support mechanical lumbar traction as clinically effective in the management of chronic low back pain. While data suggest some short-term pain and functional benefits, the data in favor of these findings have also cautioned that these improvements are temporary. Researchers found that compared to no traction or sham treatment, lumbar traction exhibited significantly more pain reduction and functional improvement in the short-term, but not in the long-term. This patient presents with left hip and buttock pain that has been resistant to medications and physical therapy. However, there is a lack of medical literature demonstrating that lumbar traction is appropriate for treatment of this patients symptoms. All told, the requested lumbar home traction device is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential 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. Given these findings, the 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. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in addiction 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 enrollee is requesting authorization and coverage for for the medication, Belbuca 150 mcg (60 buccal films/30 day supply). The enrollee has chronic wrist pain. Electromyography resulted in a diagnosis of carpal tunnel syndrome. The enrollee was evaluated by an orthopedic physician. Records show the enrollee complains of constant bilateral wrist pain. The pain is described as burning, sharp, and shooting. The provider ordered Belbuca, every twelve hours, and hydrocodone-acetaminophen, 10mg/325mg as needed. Records show the enrollee also takes ibuprofen and meloxicam once a day. In this case, the question of whether this should be used for non-cancer modality seems reasonable. There is clear mention of the risks and benefits in the provider notes, and it appears that this is intended to be a short term trial. Therefore, it is reasonable to approve a one-month trial of this treatment.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for a Synvisc-One injection for the right knee. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of pain relief from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One injection for the right knee is medically necessary for treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: At issue was whether the anesthesia service provided was medically necessary to treat the patients medical condition. This is a patient that was seen by an in-plan gastroenterologist and was recommended to undergo a screening colonoscopy with monitored anesthesia care (MAC). When the colonoscopy was performed, the anesthesia provider used MAC with Propofol for sedation during the procedure. The patient received MAC and the medication, Propofol, for sedation during the colonoscopy. The American Society for Gastrointestinal Endoscopy (ASGE) clinical practice guidelines estimate that over half of colonoscopies are currently performed with MAC. Alternate, safe forms of sedation for a colonoscopy are available (such as a combination of an opioid and a benzodiazepine) that do not require constant monitoring with another provider such as an anesthesiologist. However, the increasing standard of care for a routine colonoscopy is MAC as the potential advantages may include individual satisfaction, decreased distractions for the scopist, and shorter sedation and recovery times.  Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) level of care services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying the LOCUS guidelines, this patient met the criteria for RTC level of care services. The patient was at some risk of harm (score 2) given her recent passive suicidal ideation without intent or conscious plan. The patient demonstrated serious functional impairment (score 4) due to her inability to perform ADLs. The patient has no major medical problems (score 1). However, she has OCD, which has manifested in compulsive habits and checking behaviors that have impaired her ability to function. The patients recovery environment was moderately stressful (score 3) considering her marital strife and issues with her spouses alcohol dependence. The patients recovery environment was supportive (score 2) as she lives with her husband and dog. Despite marital strife, the patients husband demonstrated support for the patient. The patient has exhibited poor response to prior treatment (score 4) as the records document failure of IOP as well as a PHP levels of care prior to RTC admission. The patient was positively engaged in treatment (score 2) as her providers described her as adherent with treatment although struggles with the exposure hierarchy. This gives the patient a composite score of 18, which is consistent with high intensity community based services. However, based on her score of 4 for functional status, and 4 for prior to response to treatment, the patient met the requirements for medically monitored residential services, such as RTC. Accordingly, the RTC level of care services were medically necessary for 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 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 authorization and coverage for interlaminar stabilization procedure utilizing the Coflex device (CPT 22867). Based on the records provided for review, this patient meets the criteria for surgical intervention. The records document that she has medically refractory low back pain and lumbar radiculopathy. Imaging has revealed an etiology for her symptoms in the form of a degenerative spondylolisthesis at L4-5 with moderate to severe lumbar stenosis. The patients provider has recommended a posterior decompression surgery with adjunctive placement of the Coflex interlaminar device. However, the documentation does not include standing and lumbar flexion/extension x-rays. If the patients grade 1 spondylolisthesis is not stable, then she is not a candidate for the requested procedure. Moreover, the records do not demonstrate that the patient has been evaluated for osteoporosis, which is a contraindication for use of the Coflex device. The two primary surgical interventions available to this patient include lumbar decompression alone and lumbar decompression with instrumented fusion. Limited data are available comparing lumbar decompression alone with decompression plus the Coflex device. Studies found similar outcomes, without substantial data to support improved outcomes with use of the Coflex device. All told, the requested interlaminar stabilization procedure utilizing the Coflex device (CPT 22867) is 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 requested interlaminar stabilization procedure utilizing the Coflex device (CPT 22867) is 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 requested services are 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 neurological 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

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential 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. Given the findings, the RTC level of care 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. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in addiction 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: This is a patient with idiopathic short stature (ISS). The patient underwent a growth hormone stimulation test with L-dopa and Inderal that peaked at 17 and 5.5. At issue is whether the Humatrope for ISS is medically necessary to treat the patients medical condition. Growth hormone in the treatment of ISS is supported by randomized controlled trials and consensus guidelines. Federal Drug Administration approval for this indication is for non-growth hormone-deficient short stature, defined by height standard deviation less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. This patient has a pretreatment height less than or equal to -2.25 standard deviations. The patients height velocity is not adequate to allow a height in the normal range. Other causes of short stature have been ruled out. The patient meets nationally accepted criteria for the use of growth hormone for ISS.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the Acthar Gel 80 Units daily for 5 days every month. The enrollee has was multiple sclerosis. He was seen by his neurologist and reported spasms of his right foot. Physical examination showed right arm weakness with no fine motor movements in the right hand, decreased range of motion in the right shoulder, and wrist drop after minimal exertion. The patent has right foot drop, right leg weakness, and uses a cane to walk. The patients neurologist reports his multiple sclerosis is progressive, he has debilitating exacerbations, and he has failed treatment with steroids, amantadine, and gabapentin. The neurologist prescribed Acthar Gel 80 units daily for 5 days per month and reports the patient needs this medication to speed the resolution of acute worsening exacerbations of multiple sclerosis. In the absence of relapses, Acthar Gel is not indicated. The patient has never been treated with any disease modifying agents. A letter of medical necessity describes the scientific rationale for Acthar Gel and mentions some negative effects the patient experienced in response to solumedrol, but does not address the use of Acthar Gel in the absence of multiple sclerosis exacerbations, or why the patient has not tried any disease modifying agents. Therefore, the medication Acthar Gel 80 units daily for 5 days per month is not medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician 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 similar medical condition.