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

The enrollee is requesting reimbursement for behavioral health residential treatment center level of care. The enrollee has a medical history of depression, anxiety, and unspecified personality disorder and entered residential treatment. The reason for admission included treatment resistance, as evidenced by a failure of efforts to provide treatment on an outpatient basis in the past; with and without medication. The enrollee had passive death wishes without suicide plan or intent, but only when his pain was very severe. The enrollee indicates he had been suffering from depression for many months. Neither his subjective well-being nor his level of functioning was improving. He was concerned he would continue to need frequent psychotherapy indefinitely to avoid getting worse. At the residential treatment center, he felt confident about improving sufficiently to return to a life path that includes his most important personal and vocational goals. The enrollee has received regular outpatient psychological and psychiatric treatment without success. His therapist recommended residential psychological treatment because he believed outpatient treatment was not leading to improvement in the enrollees condition. The medical literature indicates the psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the enrollees safety, but also to promote improvement in the enrollees condition. The determination of an appropriate setting for treatment should also include consideration of the enrollees ability to adequately care for himself, provide reliable feedback to the psychiatrist and cooperate with treatment of major depressive disorder. Randomized controlled trials have shown that residential care may provide an efficacious short-term alternative to inpatient care for voluntary enrollees with urgent behavioral health conditions. The provider noted the enrollee had an emotional disconnect, mood was depressed and affect restricted. Although the enrollee had significant deterioration in function, which had been unresponsive to an appropriate course of treatment at a less intensive level of care, the records failed to support the enrollee could not have been treated at a lower level of care. There is insufficient evidence in the record the enrollee was a threat to himself or others. Medical evidence does not support the services at issue in this clinical setting. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for surgical insertion of interspinous process spacer. At this time, there is a lack of high quality evidence to support the use of interspinous spacer devices in lieu of laminectomy, which remains the gold standard for lumbar spinal stenosis. The 2011 clinical guidelines from the North American Spine Society (NASS) suggest that there is insufficient evidence to make a recommendation for or against the placement of an interspinous process spacing device in patients with lumbar spinal stenosis. In this case, the patient presents with lumbar stenosis and neurogenic claudication. The guidelines support laminectomy in this clinical setting. Based on the current medical literature, the requested surgical insertion of interspinous process spacer is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested surgical insertion of interspinous process spacer is not likely to be more beneficial for treatment of the patients 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

The enrollee is requesting reimbursement for intensive outpatient program (IOP) level of care. The enrollee entered an intensive outpatient program after one month in an inpatient program. She has diagnoses of post-traumatic stress disorder (PTSD) and depression and was on a medication regimen. At the time of admission to the IOP, she was not suicidal, but reported an involuntary psychiatric commitment in the past due to the possibility of her being a danger to herself or others. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The recommended level of care is level II, low intensity community based services. Medical evidence does not support the IOP level of care during this time period.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for three Supartz injections in the left knee (Codes 20610 and J7321). The patient has tried and failed other conservative treatments with the alternative being surgery, which may not be effective. The patients chronic left knee pain due to chondromalacia of patella involving the medial face is Grade 3. This is associated with relatively severe symptoms, including pain, catching, locking, and difficulty with weight bearing. The patient has been treated with non-steroidal anti-inflammatory drugs (NSAIDs), opioids, physical therapy, and corticosteroid injection without significant relief. Given these findings, the requested three Supartz injections in the left knee (Codes 20610 and J7321) are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for Acthar Gel 80units/ml 2x (5ml) vials every 35 days.Highly purified (H.P.) Acthar has a corticotropin effect, and with that, the same potential side effect profile as steroids with respect to osteoporosis, glaucoma, cataracts, weight gain, increased blood pressure and glucose intolerance. The literature indicates that H.P. Acthar is still in clinical trials. At the present time, there are no good, randomized, double blinded, placebo-controlled studies in support of H.P. Acthar for rheumatoid polymyositis or other forms of myositis, but rather small reports. H.P. Acthar is still being studied in clinical investigations as well as for other indications such as rheumatoid arthritis and sarcoidosis. In this case, while the submitted documentation indicates that the patient has a history of non-response to steroids or steroid intolerance, the patients records do not make clear that the patient actually received full dose methotrexate up to 25 mg weekly for at least 12 weeks. Additionally, there does not appear to have been a trial with Imuran, Cellcept, tacrolimus, Cytoxan or other disease-modifying antirheumatic drugs (DMARDs), which may be more helpful, long term, than Acthar gel. Under these circumstances, Acthar Gel 80 units/ml x2 (5ml) vials every 35 days is not medically necessary to treat 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 internal medicine, with subspecialty 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
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. For dimension 1, the records document that the patient has experienced alcohol induced seizures and daily blackouts, which place the patient at risk for withdrawal. The patient meets dimension 2, due to his history of alcohol poisoning and fractures from falls while intoxicated. For dimension 3, the patient has post-traumatic stress disorder (PTSD) with anxiety, depression, and irritability. The patient meets dimension 4, as he is generally motivated but unready to dig deeper and obtain insight. The patient does not have the recovery skills necessary to maintain sobriety. For dimension 5, the provider noted that the patient remains at high risk of relapse due to his poor insight into the disease of addiction and no coping skills to address his anxiety other than substance use. The patient also meets dimension 6, as the providers noted that the patient requires more of the structure and support provided at the RTC level of care. In the community, the patient has poor support and strained relationships with family. The patient requires a safe and stable living environment in order to develop his recovery skills. Based on the documentation reviewed, the patient qualifies for ASAM Level III treatment, which is similar to the services provided at the current RTC. Given the severity of the patients illness, the RTC services provided 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for clonazepam 1 mg and the tapering off Norco. The U.S. Food and Drug Administration (FDA) has approved clonazepam for short-term relief of anxiety symptoms and for treatment of epileptic seizures. The FDA has not approved clonazepam or benzodiazepines for the treatment of CIDP, Guillain-Barre syndrome, or chronic pain. The 2016 Centers for Disease Control and Prevention (CDC) guidelines state that providers should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. In this case, the patient was on a combination of clonazepam and Norco for the treatment of CIDP, Guillain-Barre syndrome, and chronic pain. She had multiple inconsistent urine drug screens with the presence of THC and oxycodone. She received her last 30-day supply of Norco before she was discontinued from chronic opioid therapy. The combination of benzodiazepines and opioids present well-known risks to the patient. The patient was given a 30-day supply of opioids. It is unlikely that she will encounter any significant withdrawal symptoms, as it has been weeks since her last opioid dose. Based on the medical records, clonazepam 1 mg and the tapering off of Norco 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

An enrollee has requested authorization and coverage for Euflexxa injections for the right knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, there is documented evidence of good lasting benefit from prior injections. The patient has tried other conservative treatments, but Euflexxa has helped her the most. Under these circumstances, Euflexxa injections for the right knee are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for endoscopic foraminal decompression of spinal cord at left L4-5. Researchers concluded that endoscopic foraminotomies allow for effective foraminal decompression, though clinical studies are necessary to further evaluate complications and efficacy. In this patients case, there is evidence of spinal instability at L4-5 as well as presence of a synovial cyst, which is another sign of spinal instability. Given the presence of spinal instability, further decompression would likely exacerbate the patients lumbar radiculopathy. The efficacy of endoscopic foraminotomy in addressing the patients spinal instability is not supported in the medical literature. All told, the requested endoscopic foraminal decompression of spinal cord at left L4-5 is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurological 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

The patient has requested authorization and coverage for right coronary artery and left circumflex artery intracoronary stents with coronary angioplasty and a possible transcatheter MitraClip procedure. The patient has significant left ventricle dysfunction secondary to ischemic cardiomyopathy, but with viable myocardium noted on magnetic resonance imaging (MRI) study. He also has significant mitral insufficiency contributing to his severe dyspnea. Initially, he was considered for coronary artery bypass graft (CABG) and possible mitral valve repair, but a re-evaluation determined him to be at increased risk for open surgical procedure. He has two-vessel coronary disease without left anterior descending (LAD) coronary artery stenosis, making percutaneous coronary intervention of similar effectiveness to CABG and less invasive in this higher risk patient. Since he also has mitral insufficiency that may be contributing to his symptoms, combining this procedure with a percutaneous mitral clip placement may prevent the need for high-risk open surgery in this patient. Based on his higher surgical risk, non-LAD CAD, and mitral valve disease, these percutaneous procedures provide the lowest risk and least invasive ways of treating his cardiac conditions. Given this support, the requested right coronary artery and left circumflex artery intracoronary stents with coronary angioplasty and a possible transcatheter MitraClip procedure is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology 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 reimbursement for gene panel testing (CPT: 81200, 81209, 81223, 81242, 81251, 81252, 81255, 81260, 81290, 81330, 81404 x 3). This patients wife is known to be a carrier for NPHS2-related nephrotic syndrome, a serious condition that is inherited in an autosomal recessive manner. NPHS2-related nephrotic syndrome is a steroid-resistant nephrotic syndrome characterized by infantile or childhood onset of nephrotic syndrome. The condition is progressive resulting in end-stage renal failure. Since this is a recessive condition, the patient may be a carrier without showing any signs of the disorder. Should the patient also be a carrier, any child born to the couple would have a 25% chance of having the condition. Identification of the couples reproductive risks would allow for informed decision making in their family planning. All told, the gene panel testing (CPT: 81200, 81209, 81223, 81242, 81251, 81252, 81255, 81260, 81290, 81330, 81404 x 3) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in genetics 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 compounded liquid formulation of Remeron (mirtazapine) 15 mg/15 mL to facilitate a 5% monthly taper down dosage. This patient has a history of depression, which is being treated with Remeron. Due to side effects including sleep disturbance and weight gain, the patient has attempted to discontinue the medication. Wilson and Lader noted that there is a general consensus as to tapering the drug slowly over a period of weeks or months in order to reduce incidence and severity of antidepressant discontinuation syndrome. The lowest dose of mirtazapine tablets is not low enough to facilitate a 5% per month reduction off the patients initial 30 mg dose. Rapid dissolve tabs are not easily breakable and are more difficult to split than regular tablets. In order for this patient to taper off Remeron, the requested compounded liquid formulation will allow for a 5% monthly taper down dosage until the medication is discontinued. All told, the requested compounded liquid formulation of Remeron (mirtazapine) 15 mg/15 mL to facilitate a 5% monthly taper down dosage 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 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