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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Opana. Medical guidelines state that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. In addition, there is no mention that behavior therapy has been completed despite much research to support its use . Moreover, not all non-opioid medications classes have been optimized or tried. Thus, the Opana provided on 5/25/18 was not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the medication at issue was 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for osteopathic manipulation services. A study of the immediate effects of osteopathic treatment compared with therapeutic exercise showed that both interventions were associated with immediately improved range of motion (ROM) and pain after treatment. The American Osteopathic Association guidelines for osteopathic manipulative treatment do not show high quality supporting manipulation over other care techniques for chronic low back pain. Overall, there is a lack of evidence to support that long-term osteopathic manipulation is more beneficial for chronic neck and low back pain than any standard therapy. Thus, the osteopathic manipulation services provided were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the osteopathic manipulation services provided were not and are 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 osteopathic manipulation services provided were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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: A enrollee has requested authorization and coverage for Jublia solution. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of Jublia solution. The records do not demonstrate the patient has failed treatment with oral terbinafine. The patient reports a history of prior treatment with Harvoni for hepatitis C.  The medical records provided do not document that the patient continues to have active hepatitis C virus. As Harvoni treatment is highly effective in the treatment of hepatitis C virus, the patient may no longer have active disease. In the absence of documentation demonstrating active hepatitis C virus or other contraindication to the use of terbinafine, the medical necessity of Jublia solution has not been established. 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 sub-specialty certification 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: A enrollee has requested reimbursement for intensive outpatient program services received. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The Health Plan noted that the patient had improved with treatment and was not in a state of distress. However, it is important to conceptualize IOP placement as a programmatic episode of care, as opposed to daily units of service. Further, studies suggest improved functionality and decreased mortality associated with individuals who complete intensive outpatient programming. In this case, the patients positive presentation on was the result of the treatment course as a whole including its targeted end date. Despite anxiety and a positive tetrahydrocannabinol drug screen, both of which were suggestive of the need for on-going treatment, the patient was consolidating the treatment experience and solidifying aftercare plans, which were particularly imperative as the patient had a long history of poor self-esteem, rejection sensitivity and need for validation. At the time, this summation of care and preparation for discharge was both important and appropriate clinical activity for an IOP program. This clinical setting was safe and consistent with good medical practice in the United States, while the services were reasonably expected to facilitate a smooth transition to the outpatient setting. Further, the duration of services were aligned with community practice standards. As such, intensive outpatient program services received was 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 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 Xeljanz 5 mg tablet. Review of the submitted evidence demonstrates that the requested Xeljanz 5 mg tablet is medically necessary for treatment of the patients medical condition. In this case, the patient has seronegative rheumatoid arthritis, Sjogren's syndrome and a positive ANA. The submitted documentation demonstrates the patient has failed methotrexate and hydroxychloroquine. Further, there is evidence the patient has previously done well with Xeljanz with no evidence of synovitis. Given the patients history of positive ANA, a tumor necrosis factor inhibitor (TNFi) such as Enbrel or Humira would not be recommended. Therefore, the requested Xeljanz 5 mg tablet is medically necessary.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 rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for substance abuse detoxification and residential treatment center services received. Findings:  The physician reviewer found that at the time of admission to detoxification and then residential level of care, the patients vital signs were stable and the patients scores were in the mild range. The patient was not receiving medications to manage withdrawal symptoms. The patient in this case had no documentation of active withdrawal symptoms, unstable vital signs, ongoing need for medical monitoring, suicidal or homicidal ideation, aggression, self-injurious behavior, non-response or adverse response to medications, difficulty with attending to activities of daily living, dangerous or non-supportive recovery environment, or repeated failure of treatment at lower level of care such as intensive outpatient programs or partial hospital programs which would support treatment at the detoxification and/or residential level of care.  Research has shown that intensive outpatient programs for alcohol and drug use disorders can be as effective as inpatient treatment for most individuals seeking care. Based on the clinical documentation provided and current medical literature, the patient's admission to detoxification and residential level of care was not medically necessary. 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 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: A enrollee has requested reimbursement for all or any of the residential treatment center services provided. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the services at issue. The patient presented to the intensive outpatient program (IOP) with a history of substance use, which was mainly alcohol. The records noted that during treatment, the patient was cooperative, calm, and insightful into the patients psychological needs. The progress notes did not indicate that the patient had psychosis, paranoia or mania symptoms. The records did not indicate other severe psychiatric symptoms that would require intensive psychiatric care. The patient did not have self-harm behaviors and was medically stable. The medical record did not indicate the presence of any withdrawal symptoms. With regards to acute intoxication and/or withdrawal potential, the patient had a risk rating score of zero due to lack of withdrawal. In terms of biomedical condition and complications, the patient has a risk rating score of 0-1 due to no active serious medical problems. With regards to emotional/behavioral or cognitive conditions and complications, the patient has a risk rating score of 0-1 indicating some mild issues that were noted to be under good control with medications. In terms of readiness to change, the patient has a risk rating of 2 due to low motivation to change with some interest in continued treatment. With regards to relapse, continued use, or continued problem potential, the patient has a risk rating of 2 due to minimal sobriety. With regards to recovery/living environment, the patient has a risk rating of 1-2 due to no mentioned sober living environment. Overall, the patients presentation suggests risk-rating scores that range from 0 to 2. This overall risk rating is consistent with intensive outpatient services. In summary, all or any of the residential treatment center services provided 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 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: A patient has requested authorization and coverage for Lyrica. The Health Plan has denied this request on the basis that the requested medication is not medically necessary for treatment of the enrollee's foot pain. Review of the submitted documentation supports the medical necessity of Lyrica in this clinical setting. The patient presents with traumatic neuropathy with motor involvement. The submitted records reveal the patient has EMG-confirmed peroneal neuropathy (sensorimotor). He has a history of treatment with gabapentin. Gabapentin is contraindicated in this patient as it caused mental confusion, which is a known side effect of the drug. As such, gabapentin is not appropriate for this patient due to well recognized neurologic side effects. Lyrica has been approved by the U.S. Food and Drug Administration for treatment of neuropathic pain. As such, the requested medication is medically reasonable and necessary for treatment of this patients medical condition.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 pain medicine and 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Entyvio infusion treatment (300 mg for a total of six visits given over 27 weeks) at a hospital based center. The hospital-associated infusion setting is not supported for medical reasons based on the provided documentation, except on 7/13/18. The medical documentation does not reflect that the patient has experienced a severe or life-threatening reaction with previous infusions of Entyvio (which she is stabilized on), or that she has a medical condition which renders her unstable, exceptionally complex, or otherwise unsafe for or unable to have Entyvio infusion at home or at an outpatient infusion facility.  Outpatient or home infusion of biologic medications such as Entyvio has been shown in medical literature to be safe and effective with appropriately-trained monitoring staff, and studies have shown high patient satisfaction with home infusion and outpatient infusion facilities.  However, an exception is warranted for the infusion date of 7/13/18, as the patient will not have the ability to make alternative arrangements, and a delay in Entyvio infusion can result in a loss of remission. For these reasons, Entyvio infusion treatment (300 mg for a total of six visits given over 27 weeks) at a hospital based center on 7/13/18 is medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the requested services is 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 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 intravenous immunoglobulin (IVIG) (HCPCS - J1569 Gammagard). In the peer-reviewed medical literature, researchers reported that systematic review of available trial and case report data did not reflect clinical significant benefit from use of IVIG with treatment of adult related multiple sclerosis. Cross and Naismith similarly reported that IVIG had not shown significant benefit in a majority of patients treated both acutely and chronically with IVIG for multiple sclerosis in adults. The medical records indicate that this patient is an older adult with multiple sclerosis. IVIG has not demonstrated significant short- or long-term benefit for treatment of adult related multiple sclerosis. The records do not reflect any mitigating circumstances such as signs of immune related encephalitis. Thus, the requested IVIG (HCPCS - J1569 Gammagard) is not medically necessary for the patient based on the medical records provided for review. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly individual psychotherapy services. Current mental health practice is focused on aggressive treatment of anxiety and depression in the acute phase of illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Thus, it is not uncommon for weekly sessions to be clinically appropriate. In this patients case, the most recent summary of care letter was authored nearly three months ago. Thus, the current status and clinical needs of the patient are unknown at this time. Further, the absence of a comprehensive psychiatric or psychological evaluation including developmental history, medical history, substance use history, treatment history including medication trials, prior treatment settings and previous evidence-based therapeutic intervention(s), and critical longitudinal documentation such as progress notes, barriers to progress, multidisciplinary contributions, physical examination and quantifiable objectives to achieve patient-centered goals makes it impossible to determine if weekly treatment is having positive effect in bolstering autonomy and resiliency while mobilizing the patient towards remission.  However, the abrupt change to monthly sessions after six years of treatment was impractical particularly since the primary care physician reported Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scores in March 2018 that were consistent with a moderate to severe illness burden. Considering the apparent chronicity of the mental illness, weekly therapy session for four weeks, followed by one therapy session every two weeks for a period of six months was and is medically necessary.  Final Result: The reviewer determined that a portion of the services at issue was and is 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 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 panniculectomy. In this patients case, the records document a moderately overlapping symptomatic lower abdominal pannus. She is documented to have functional impairment with chronic rashes as well as periodic open sores.  She has attempted conservative management with typical topical dermatologic treatment, including powder. In this clinical setting, a panniculectomy would likely significantly improve her functional impairment and is medically necessary. Additionally, the patients condition constitutes an abnormal structure of the body. She has direct evidence of active rashes around the umbilicus that are noted to be chronic. The treatment of her obesity has led to an excess skin overlap around the umbilicus. Obesity is considered a disease. The requested surgery is planned to improve her function as the result of pain and chronic rashes/open sores. Per the records, the requested panniculectomy is likely to create a normal appearance to the extent possible and would provide more than a minimal improvement in the appearance of the patient. Thus, the requested panniculectomy is reconstructive in nature. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic 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.