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 meets Level 3.5 criteria for clinically managed high-intensity residential services. This patient was still experiencing protracted withdrawal symptoms in the most recent records. The patient has reported hearing voices, anxiety, and agitation. The provider noted that the patients withdrawal symptoms have included paroxysmal sweating with visible moisture on his face, agitation, bone and joint aches, and palpable tremor. The patient has a diagnosis of uncontrolled diabetes mellitus with severe, potentially life threatening blood sugars. The ASAM confirms that diabetes is more difficult to manage in persons with substance use disorders. He is also hepatitis C and elevated liver enzymes. The patients overall mental status is sufficient to permit participation in this RTC. He is oriented to person, and place, but at times not the situation due to his persecutory beliefs and auditory hallucinations. The patient has been unable to control his substance use without 24-hour support. The patients perspectives impair his ability to make care decisions. Prior treatment with multiple RTC admissions and detoxification services resulted in relapse shortly after discharge. The patient remains at high risk for overdose or self-harm due to his severe addiction and comorbid impulsivity, psychosis, and persecutory beliefs. He has poor insight and judgment, which he has demonstrated by falling asleep while driving. He requires 24-hour support to work through his need for immediate gratification, impulsivity and self-sabotaging behaviors. He struggles with frequent nightmares and terrifying hallucinations that further perpetuate his suicidal risk. The patient continues to experience cravings and he is at imminent danger of relapse if not in a 24-hour treatment setting. The patients recovery environment is too chaotic to support his treatment goals and he is unsure where he will live after discharge. Given these 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 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Actemra 162 mg / 0.9 ml syringe. Tocilizumab (Actemra) is noted to be useful in treatment of those patients with active rheumatoid arthritis who have not responded adequately to tumor necrosis factor (TNF) inhibitors. Tocilizumab is a non-TNF biologic. The 2015 American College of Rheumatology (ACR) Guideline for the Treatment of Rheumatoid Arthritis indicates that if immunoglobulin (Ig) disease activity remains moderate or high despite diseasemodifying antirheumatic drug (DMARD) monotherapy, then the use of combination traditional DMARDs, the addition of a tumor necrosis factor inhibitor (TNFi), or the use of a non-TNF biologic or tofacitinib are recommended (all choices with or without methotrexate, in no particular order of preference), rather than continuation with DMARD monotherapy alone. In this case, the patient has active, moderate to severe rheumatoid arthritis. She has failed two different TNFi, methotrexate, Plaquenil and Orencia. Although the patient has not failed two preferred TNFi, the ACR guidelines do not recommend the trial of a third TNFi. The patient has also responded well to Actemra in the past. Under these circumstances, the requested medication Actemra 162 mg / 0.9 ml syringe is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in 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: 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 3.5 criteria for clinically managed high-intensity residential services. This patient underwent detoxification from heroin and alcohol with suboxone and Librium taper. He completed his Librium taper and was on suboxone 12 mg twice daily. He was no longer complaining of symptoms or signs of withdrawal. The patient does not have any documented biomedical conditions. He is noted to have comorbid anxiety, but following evaluation, he was not diagnosed with a psychiatric disorder. The patient has demonstrated limited readiness to change. The patient endorsed that his motivation for attending treatment was due to legal issues. He was able to articulate the negative consequences of his drug use, but he has shown little understanding on the affects substance abuse has on his ability to cope and function. Due to the intensity and chronicity of his usage, he appears to have little insight or awareness about the importance of ongoing care. The patient reported that he has used drugs for many years and he did not exhibit understanding of any triggers for his usage. He was treated with suboxone to help with cravings. The patient lives at home with his mother, who is supportive. There are no logistical impediments to preclude his participation in therapies. Applying the ASAM framework, the patient does not meet the criteria for dimensions 1, 2, 3, and 6. Given these findings, 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for weekly talk therapy sessions, either in-person or telehealth. This patient has been diagnosed with major depressive disorder and he has a significant history of alcohol and cannabis use. However, he has been in remission from these substances for at least four months. The American Psychiatric Association (APA) supports depression-focused psychotherapy as an initial treatment choice for patients with mild-to-moderate depressive disorder. The APA noted that there are adequate data to recommend the use of cognitive behavioral therapy (CBT), interpersonal psychotherapy, psychodynamic therapy, and problem-solving therapy in individual and group formats in this clinical setting. The frequency of psychotherapy sessions depends on the severity of symptoms, co-occurring disorders, cooperation with treatment, and the patients availability of social supports. The frequency of visits should enable creation and maintenance of a therapeutic relationship, ensure treatment adherence, and address the patients depressive symptoms and suicide risk. Simon and colleagues reported that psychotherapy is efficacious for the initial treatment of unipolar major depression based upon numerous randomized trials. This patient has been sober for a few months and is continuing to report depressive symptoms of a moderate severity. The prior substance abuse diagnosis that is now in remission should not detract from the importance of treating his depression diagnosis. All told, the requested weekly talk therapy sessions, either in-person or telehealth, are 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 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

The patient has requested authorization and coverage for Acute rehabilitation services including speech therapy and occupational therapy through telehealth conferencing, four hours per day, five days per week. In the present case, the patient has sustained embolic strokes. Functional impairments due to acquired brain insults such as stroke can range from mild to profound. While natural recovery evolves with time, many impairments are addressable by compensatory measures and directed rehabilitation efforts. The standard of care for this patients condition includes rehabilitation services, first in the inpatient setting, followed by rehabilitation in the community setting, based on impairments and the potential for achieving functional goals. Most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke and gains are slower in the subsequent stages. For this patient, further rehabilitation services can be provided on an intermittent basis in the community. There is a paucity of published data establishing the clinical effectiveness of the proposed telerehabilitation services for this patients condition. Moreover, the records do not support that the patient requires rehabilitation services for four hours per day, and there is no expectation that this volume of therapy would provide a marginal benefit for the patient over standard rehabilitative care. All told, the requested acute rehabilitation services including speech therapy and occupational therapy through telehealth conferencing, four hours per day, five days per week 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for laparoscopic radiofrequency ablation of fibroids. This patient has heavy bleeding, pelvic pain, and bulk symptoms. Ultrasound demonstrated that the patients fibroids are intramural and less than 6 cm. Standard options for treatment include hysterectomy, myomectomy, and uterine artery embolization. Radiofrequency ablation procedure is a less invasive alternative treatment for myomas of appropriate size and location. Researchers found that radiofrequency ablation of uterine fibroids reduces fibroid volume, provides significant durable improvements in fibroid-related quality of life, and is associated with favorable reintervention rates. Based on the peer-reviewed medical literature, the requested laparoscopic radiofrequency ablation of fibroids is 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 likely to be more beneficial for treatment 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 obstetrics and gynecology 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 for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met 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 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 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

An enrollee has requested authorization and coverage for the Gardasil 9 vaccine series. Updated recommendations of the CDC Advisory Committee on Immunization Practices (ACIP) for vaccination against human papillomavirus (HPV) note that the public health benefit of HPV vaccination in all adults greater than 26 years of age is minimal, but that shared clinical decision-making regarding HPV vaccination is recommended for some adults aged 27 to 45 years, because some persons who are not adequately vaccinated might benefit. In this case, the patient is within the 27 through 45 years age range identified by the ACIP. Furthermore, the updated recommendations of the ACIP state that shared decision-making regarding HPV vaccination is recommended for this population. The patients treating provider recommended the Gardasil 9 vaccine series considering the patients history of multiple homosexual sex partners, and one PAP smear which demonstrated low-grade squamous intraepithelial lesion (LGSIL) although biopsy was negative and subsequent PAP smears have been negative. This represents shared decision-making. Therefore, the patient meets the ACIP criteria regarding shared decision-making and regarding the recommended age range. Accordingly, the requested Gardasil 9 vaccine series is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in infectious disease, 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 magnetic resonance imaging (MRI) of the right knee. She presents with complaints of persistent right knee pain and swelling with startup pain and stiffness. Clinical examination findings revealed mild loss of range of motion, trace effusion, patellofemoral crepitus, and negative ligament and meniscal signs. The patient was treated with activity modification, non-steroidal anti-inflammatory drugs (NSAIDs), and a home exercise program. X-rays demonstrated mild degenerative joint disease and no fracture. The providers impression included a probable bone bruise. Current evidence-based medical guidelines and peer-reviewed literature do not support MRI in this clinical setting. The American College of Radiology (ACR) recommends MRI for adults with a history of fall when x-rays do not reveal evidence of fracture and there is clinical suspicion of internal derangement. MRI is considered the optimal imaging modality for identifying meniscal, ligament, chondral, and non-displaced bone injuries about the knee. In the medical literature, Parent and colleagues recommended evaluating knee pain in older patients with a comprehensive medical questionnaire, thorough physical examination, and radiographs. Conservative non-pharmacologic and pharmacologic therapies should be attempted and allowed sufficient time to take effect before considering further evaluation with MRI. All told, the requested MRI of the right knee is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: The patient has been diagnosed with relapsing-remitting multiple sclerosis. The records noted that recent magnetic resonance imaging (MRI) demonstrated multiple subcortical and periventricular white matter lesions and a single tiny enhancing lesion in the right cerebellar white matter, radiologically suspicious for multiple sclerosis. The MRI was initially done because of symptoms of hearing loss and intermittent tinnitus. The provider noted that a lumbar puncture confirmed findings consistent with multiple sclerosis with 12 oligoclonal bands in the cerebrospinal fluid. The patient reported right hand/forearm numbness and tingling that began two to three years prior. The provider noted that the patient was John Cunningham (JC) virus antibody negative. During that visit, the provider and patient discussed the diagnosis of multiple sclerosis and the need for medication. The documentation noted concerns regarding side effects. The patient reported a history of multiple side effects to medications in general, including anaphylaxis. She reported that she desired to avoid injectable medications. The patient has requested authorization and coverage for Tecfidera (dimethyl fumarate), 120 mg daily for two weeks and 240 mg daily thereafter. The Health Plan has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The Health Plan noted that the formulary alternatives include Extavia, glatiramer and Gilenya. This denial is the subject of this appeal and determination. At issue is whether Tecfidera (dimethyl fumarate), 120 mg daily for two weeks and 240 mg daily thereafter is medically necessary for the treatment of this patient. Dimethyl fumarate had a lower annualized relapse rate versus the interferons, glatiramer and teriflunomide populations and similar to fingolimod populations. Thomas and colleagues reviewed the safety of the three oral agents approved by the U.S. Food and Drug Administration for the treatment of relapsing-remitting multiple sclerosis, fingolimod, teriflunomide and dimethyl fumarate. Finally, the safety profile of Tecfidera is potentially less harmful than Gilenya, the other oral alternative. Therefore, Tecfidera (dimethyl fumarate), 120 mg daily for two weeks and 240 mg daily thereafter is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Inspire Upper Airway Stimulation system. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) considers upper airway stimulation via the hypoglossal nerve to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea (OSA) in patients who are intolerant or unable to achieve benefit with positive pressure therapy. A meta-analysis by Gillespie and colleagues has demonstrated clinically significant decreases in observed mean AHI scores and improvements in quality-of-life scales. The stimulation treatment for apnea reduction (STAR) trial showed upper airway stimulation provides significant improvement in sleep-related quality of life outcome measures with effects maintained across a five-year follow-up. This patient has failed multiple management modalities including continuous positive airway pressure (CPAP) with different masks and dental appliances with continued OSA symptoms. Therefore, the requested Inspire Upper Airway Stimulation system is 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in otolaryngology with subspecialty certification in sleep medicine and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in otolaryngology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.