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

Nature of Statutory Criteria/Case Summary: 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 does not meet Level 3 criteria for RTC services. Applying the ASAM framework, this patient is being treated for opioid withdrawal with buprenorphine. The records documented elevated Clinical Opiate Withdrawal Scale (COWS) scores consistent with moderate withdrawal. The patient reported some difficulty coping with withdrawal discomfort. The patient has no reported comorbidities. The patient endorsed depression and auditory hallucinations. His psychiatric symptoms have not distracted from his recovery efforts. He has been able to participate in group therapy sessions. The provider noted that the patient has difficulty controlling his impulses. The patient willingly entered treatment as a voluntary participant. Due to the chronicity and severity of his substance use, he appears to have limited insight into how his substance usage has affected his ability to cope and function. The patient is currently on buprenorphine 24 mg and he continues to have cravings to use. He relapsed immediately after a prior RTC admission of 30 days. The patient lives with his parents who are both in recovery. His girlfriend does not use substances. Based on these findings, the patient does not meet the criteria for dimensions 2 or 6. Therefore, the RTC level of care services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with subspecialty certification 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture services. There are adequate data in the peer-reviewed medical literature to support a role for acupuncture treatment in the management of patients with chronic back pain. Researchers concluded that when compared to no treatment, acupuncture achieved better outcomes in terms of pain relief, disability recovery and better quality of life, but these effects were not observed when compared to sham acupuncture. Indications for care discontinuation include resolution, intolerance, lack of measurable improvements or non-compliance including non-compliance with aerobic and strengthening exercises. After an acupuncture trial is completed, additional acupuncture treatments are recommended based on progressively greater, incremental objective gains. Based on the available documentation, this patient presents with chronic back pain. He reports that his back pain improved with acupuncture services. However, the records do not report any measurable, progressive, significant, objective functional improvement obtained with previous acupuncture to support additional acupuncture. Therefore, the requested acupuncture services are 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 a licensed acupuncturist, board certified in oriental medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Emgality. According to the American Headache Society (AHS), there are four injectable preventive therapies available for the treatment of migraine including Botox and three monoclonal antibody (mAb) targeting calcitonin gene-related peptide (CGRP) agents, such as Emgality, or targeting the CGRP receptor. Emgality is U.S. Food and Drug Administration (FDA) approved for episodic and chronic migraine. Emgality 120 mg is for monthly use following an initial loading dose of 240 mg. In this case, the patient has a history of chronic migraines that have not adequately responded to oral preventative medications. The use of Botox has been effective in reducing the number of headache days though her headaches have recently become more severe. The addition of Emgality has further diminished the severity and number of headache days. Per the AHS statement, it is appropriate for this patient to be treated with an anti-CGRP mAb she has chronic migraine refractory to standard preventatives. As noted in the AHS statement, after three months of treatment with an anti-CGRP mAb, a patient should continue treatment if there is a reduction in mean monthly headache days of 50% relative to pretreatment baseline and other documented benefits. Per the AHS consensus statement, anti-CGRP mAbs (such as Emgality) lack hepatic metabolism and renal clearance and therefore avoid interactions with concomitant drugs. Anti-CGRP mAbs may be added to or used in conjunction with other oral or injectable preventive treatments for migraine. In the study by Robbins, patients managed with a combination of Botox and a CGRP inhibitor (such as Emgality) improved clinically 40 to 80% over baseline, and no interactions or problems were observed with the combination of medications. Per the medical evidence, combination therapy with Emgality and Botox can be safe and effective. In this case, the patient experienced a documented reduction of migraines from 45 of 90 days to 13 of 90 days, with improved severity, and less need for rescue medication. All told, the requested Emgality 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 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 patients parent has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework, this patient met the criteria for RTC services already provided, but she does not meet the requirements for readmission to RTC level of care. This gives the patient a composite score which is consistent with medically monitored community-based services. According to CALOCUS, due to the patients scores on functional impairment and environmental stressors, the patient met the criteria for Level 5 medically monitored residence-based services. In addition, due to disrupted interpersonal interactions and the patients history of self-harm, impulsivity, and limited response to prior intensive treatment, she qualified for Level 5B intermediate stay medically monitored residence-based services. Per CALOCUS, typical length of stay at this level of care is up to 60 days, which support the RTC services provided. Therefore, the RTC 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 with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an enrollee has requested authorization and coverage for three-to-five 20-minute speech therapy sessions per week. Researchers state that childhood apraxia of speech (CAS) affects a child's ability to produce sounds and syllables precisely and consistently, and to produce words and sentences with accuracy and correct speech rhythm. They state that it is a rare condition, affecting only 0.1% of the general population. A deficit in motor programming or planning is thought to underlie the condition. The American Speech-Language-Hearing Associations clinical topic on childhood apraxia of speech states that a high treatment dosage for CAS is consistent with principles of motor learning. The clinical topic states that for younger children, the frequency and length of sessions may need to be adjusted (e.g., shorter, more frequent sessions are often recommended). In this case, the patient has severe childhood apraxia of speech, resulting in severe expressive language delay. This discrepancy is likely to lead to frustration and impair the patients social interaction with adults and her peers. Under these circumstances, intensive speech therapy is necessary and appropriate as well as consistent with American Speech-Language-Hearing Association guidance. Accordingly, four 20-minute speech therapy sessions per week are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are partially medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for voice and communication therapy services. The World Professional Association for Transgender Health (WPATH), a worldwide authority on transgender health issues, has stated that treatments that may be medically necessary treatments for gender dysphoria include voice therapy and/or surgery (WPATH Position Statement on Medical Necessity, 2016). The WPATH has also stated that voice and communication therapy may help to alleviate gender dysphoria and be a positive and motivating step towards achieving ones goals for gender role expression (WPATH Standards of Care, 2012). In this case, the patient has a diagnosis of gender dysphoria and seeks the assistance of a qualified voice and communications therapist in order to establish greater congruence with her gender identity. Authoritative guidelines from the WPATH support that voice and communication therapy may help to alleviate gender dysphoria. Under these circumstances, the requested voice and communication therapy services are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested 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 criteria for RTC services. Applying the ASAM framework, this patient has demonstrated significant protracted withdrawal symptoms and her treating providers have been trying to mitigate this with Sublocade, intensive psychosocial treatment and programming in a 24-hour monitored setting. The patient relapsed despite treatment with a Sublocade injection after she prematurely left the treatment facility. The patient has a diagnosis of type 1 diabetes mellitus with a history of ketoacidosis. Thus, continued substance use poses a significant risk to the patients health. The patients blood sugar levels were poorly controlled on admission. However, these appeared to stabilize as treatment progressed through close monitoring of her diet and frequent redirection. She also has extreme cravings for sugar due to withdrawal. The patients mental status is sufficient to permit participation. Her inability to control her impulsive behaviors has demonstrated that she has been unable to control her substance use without 24-hour support and redirection. The patient has significant impulse control problems and cognitive distortions due to her PTSD and lengthy history of substance use. She isolates and withdraws socially and has poor decision-making skills. These factors require a structured program offering a 24-hour milieu. The patient continues to have cravings and other psychiatric symptoms, which predispose her to self-medicate. She is at serious risk of relapse given her homeless state, her impulsivity and the COVID-19 restrictions. The patients recovery environment is too chaotic to support her recovery goals. She has been aggressive toward her family in the past. Due to relapse, she was removed from her sober living facility and she cannot return to her family home until she has been sober for one year. Given these findings, the subacute RTC level of care 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 subspecialty certification 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for continued skilled nursing facility (SNF) services. Pelvic fractures, including pubic ramus fractures, are associated with significant complications . Management is generally non-operative, with pain control and ambulation as tolerated. The records provided for review demonstrate that this patient sustained an inferior pubic ramus fracture that was managed non-operatively with weight bearing allowed as tolerated. Treatment in the SNF has included physical therapy. However, the records document that she has plateaued at ambulating with contact guard assistance. There is no report of ongoing progress with self-care. Based on the current medical literature, the patient can continue her rehabilitation in the community. Although she has multiple chronic medical conditions, the patient does not require nursing or medical treatment in an inpatient setting. Therefore, continued SNF services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework, this patient meets the criteria for IOP services. The patient has been at significant risk of harm (score 3) due to an overdose and serious self-harm. The patient has demonstrated moderate functional impairment (score 3) considering his conflicted relationship with his parents and sobriety achieved in the past few months in the context of the IOP. The patient has significant comorbidities (score 3) given his diagnosis of Tourettes disorder and recent substance abuse that has been arrested due to use of a highly structured setting. The patients recovery environment is mildly stressful (score 2) with disruptions related to the current shelter-in-place order, conflict with his parents, and discomfort caused by parental expectations. The patients recovery environment is supportive (score 2) due to his parents active participation in therapy and treatment planning. The patient has exhibited limited response to treatment (score 3) due to inconsistent capacity to deal with stressors and maintain normal development, and difficulty following treatment recommendations. The patient has been incompletely engaged in treatment (score 3) with a lack of investment in therapy sessions. This gives the patient a composite score of 19, which is consistent with high intensity community based services, such as IOP. Per CALOCUS, minimal oversight should be required for this level of service and reviews should not be required more often than every two weeks for persons with acute conditions and every two months for those with more slowly evolving conditions. Given the patients recent serious self-harm and depressed mood, he qualifies for up to two months of continued IOP treatment from 4/9/20 forward. All told, the IOP 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 subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: 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. The patient continues to show evidence of protracted withdrawal symptoms as evidenced by agitation, anxiety, sweating, tactile disturbances, and tremors. He is working with his providers on medical and psychosocial strategies to mitigate these symptoms. The patient has a history of intravenous drug use, which places him at heightened risk of contracting blood borne diseases. He is also at risk of contracting COVID-19 as he is homeless and given his known impulsive nature and history of overdose. The patient has sufficient mental status to permit participation. He is highly impulsive and his self-gratification and poor judgment make it difficult for him to control his substance use without 24-hour support. His functional deficits, such as planning to cut his wrists with a razor, and subsequent staff intervention further highlight his need for an RTC level of treatment. The patients perspectives impair his ability to make decisions regarding his care. His judgment has been impaired by his need for immediate gratification and inability to control his substance use outside of a structured setting. The patient continues to have protracted withdrawal symptoms that have required medication-assisted treatment and intensive psychosocial interventions. He has expressed that he would be unable to return to his home environment, where he has become aggressive, due to family stressors. The provider reported that the patient was found to have diverted medications and other paraphernalia while in the program and he continues to require intensive support and redirection. The patients recovery environment is too chaotic to support his goals of sobriety. He acknowledged that he is unable to return home and maintain sobriety. 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 subspecialty certification 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.