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

The patient has requested authorization and coverage for a computed tomography (CT) scan of the brain. This patient complains of headaches that have persisted for a number of days. She complains of fever, chills, headache, nasal congestion, and cough. The patient reports that her cough is producing green sputum. The patients neurological examination has been unremarkable. The records provided for review do not suggest that the patients complaint of headaches is due to a central nervous system process. The patients history and findings are suggestive of an upper respiratory infection. The CT brain imaging is not likely to provide any insight with relation to occipital neuralgia. All told, the requested CT scan of the brain is not medically necessary for evaluation of 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 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

Nature of Statutory Criteria/ Case Summary: At issue is whether the medication, Belsomra 20 mg tablets, #60 tablets per 30 days is medically necessary to treat the patients medical condition. This is a patient with chronic insomnia and sleep apnea that started a trial of the medication, Belsomra in 7/15. Regular use of Belsomra 40 mg at bedtime was documented from 7/16 through 1/20. Follow-ups with the provider show trials of Ambien, Lunesta, Rozerem and Sonata with the loss of insomnia benefit with time. The patient was intolerant of trazodone, Remeron, Elavil, Prozac, Paxil and Zoloft. The patients insomnia severity index was 25.5 (severe) and the fatigue severity scale was 53 (severe) in 2016. The insomnia severity index was 16-20 (moderate) and fatigue severity scale 31 (moderate) in 1/20. Few medications treat only chronic insomnia. Medications such as antidepressants (such as Prozac or Zoloft), anti-anxiety medication (such as temazepam) or antipsychotics (such as clozapine or Haldol), are given for their side effects to induce sleep, for insomnia. Belsomra was one of the first medications specifically for the treatment of chronic insomnia. The American Association of Sleep Medicine (AASM) practice guideline lists Belsomra as the first choice of medication for chronic insomnia treatment. Management of sleep apnea and insomnia can be challenging. In this case, the balance that satisfies the patients insomnia symptoms and at the same time affords the patient to be compliant with CPAP, appears to be met. Review of literature demonstrated that 40 mg is a dose that is given in many studies. Side effects increased to 30% with the 40 mg dosage but Hong et al found no adverse effect on sleep apnea with a dose of 40 mg.  In this case, the patient has done well on a 40 mg dose for many years. Reducing the dose of Belsomra may be a long-term goal that is best left to the discretion of the treating provider.   Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in sleep 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Alphagan P eye drops. The authors concluded that there was no statistically significant difference in the intraocular pressure (IOP)-lowering efficacy of the medications evaluated. This patient has been treated with timolol, with increased IOP levels, for her diagnosis of primary open angle glaucoma. Treatment with Alphagan P resulted in improved IOP levels. However, there is a lack of data demonstrating that higher concentrations of brimonidine would not be as effective and might cause side effects not observed with Alphagan P. The records provided for review do not demonstrate that the patient has failed treatment with the Health Plans formulary alternatives, which include a generic formulation of brimonidine. Thus, the requested Alphagan P eye drops are not medically necessary for treatment of this patient. 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 ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with insomnia. The patient reported multiple issues, including insomnia. The provider discussed sleep hygiene with the patient and increased the dose of trazodone to 200 mg. The patient has requested authorization and coverage for a weighted blanket. The Health Plan denied the request and reported the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a weighted blanket is medically necessary for the treatment of the patients medical condition. Schutte-Rodin and colleagues reported, Psychological and behavioral interventions are effective and recommended in the treatment of chronic primary and comorbid (secondary) insomnia. The authors also noted, Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies when possible. In this case, the patients insomnia may be complicated by other underlying problems. Weighted blankets are not considered the standard of treatment in sleep practices or guidelines for insomnia treatment. The medical evidence does not support the requested equipment in this clinical setting. Therefore, a weighted blanket is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 sleep 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 patients parent has requested reimbursement for inpatient mental health 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. Applying the CALOCUS guideline to this patients presentation, the patient did not meet the criteria for inpatient mental health services. The patient was at significant risk of harm (score 3) due to suicidal ideation and excessive use of alcohol and other drugs resulting in potentially harmful behaviors. The patient demonstrated moderate functional impairment (score 3) given the conflict with her family, deterioration in school performance, and her inability to engage in activities of daily living. The patient has significant co-morbidities (score 3) with a history of depression and substance use disorder. The patients recovery environment was moderately stressful (score 3) considering her recent loss of a close friend, academic difficulties, and exposure to substance abuse via peers. The patients recovery environment was supportive (score 2) as her parents were noted to be actively participate in her treatment. The patient did not have any substantial prior experience with treatment (score 1) per the records provided for review. The patient was non-collaborative (score 4) in treatment, due to her actively hostile relationship with providers and her refusal to participate in treatment or take medications. This gives the patient a composite score of 19, which is consistent with high intensity community based services. This level of care includes an intensive outpatient program (IOP) that allows the patient to live at home while still receiving multiple hours of treatment per week, usually including individual, group, and family therapy. Given these findings, the inpatient mental health services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 authorization and coverage for magnetic resonance imaging (MRI) of the left shoulder. This patient presents with complaints of left shoulder pain with paresthesias in her hands. Prior imaging of the left shoulder revealed calcific deposits in the rotator cuff. Although calcific tendinitis is a common shoulder disorder, it requires differentiation from dystrophic calcification in a chronic rotator cuff tear. These two conditions should be differentiated by obtaining an MRI scan of the shoulder as the pathogenesis and treatment for these two conditions is different. Although routine conventional x-rays demonstrated calcific deposits, an MRI scan is appropriate to evaluate any coexisting pathology. Therefore, the requested MRI of the left shoulder is medically necessary for evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has been diagnosed with psoriasis. The patient reported having psoriasis on his trunk for several months. Physical examination findings included psoriasis located on the right upper abdomen and upper back. The provider noted that the patient has been treated with Cosentyx, and this resulted in an 8% reduction in symptoms. Per the submitted documentation, the patient has tried and failed treatment with calcipotriene, clobetasol, oral prednisone, and Stelara injections. The patient has requested authorization and coverage for Cosentyx. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Cosentyx is medically necessary for the treatment of the patients medical condition. This patient has requested coverage for Cosentyx (secukinumab). Researchers reported, Secukinumab is U.S. Food and Drug Administration (FDA) approved for the treatment of adult plaque psoriasis. The authors also noted, Secukinumab is recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis. Studies reported, The importance of IL-17A in psoriasis pathogenesis has been validated by the clinical efficacy of secukinumab in pivotal 52-week phase III trials; secukinumab was shown to be superior to placebo and to etanercept in achieving a strong and sustained response with a favorable safety profile. In this case, the patient has tried and failed treatment with calcipotriene, clobetasol, oral prednisone, and Stelara injections. The provider also noted the patient has been treated with Cosentyx, and this resulted in an 8% reduction in symptoms. The medical evidence supports the requested medication in this clinical setting. Therefore, Cosentyx 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 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

The patient has requested authorization and coverage for cervical magnetic resonance imaging (MRI) without contrast and lumbar MRI without contrast. The American College of Radiology (ACR) guideline states that MRI is appropriate for patients with new or increasing cervical radiculopathy and for patients with chronic neck pain when radiographs show degenerative changes, and particularly after failure of conservative management. Lumbar spine MRI is helpful when a patient has completed a minimum of six weeks of conservative treatment and has failed to show substantial improvement on clinical reevaluation. This patient presents with a history of progressive chronic neck and back pain. The patient reports severe neck and back pain, which has worsened and is limiting ability to function. Clinical examination revealed diminished upper and lower extremity reflexes, hand weakness, and positive straight leg raise with radiculopathy. The most recent MRI studies were reported a few years ago with prior surgical consultations. He has failed recent conservative treatment including medications and daily home exercise, as well as physical therapy, chiropractic care, and acupuncture. Given the significant change in the patients signs and symptoms, as well as functional limitations and reflex changes, the requested cervical MRI without contrast and lumbar MRI without contrast are medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

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. 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. This gives the patient a composite score which meets the criteria for medically monitored community based services, as well as high intensity community based services, such as IOP. Given this support, 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

The enrollee is requesting authorization and coverage for Acthar Gel. The enrollee has a diagnosis of membranous glomerulonephritis. An assessment note reports the enrollees disease process is associated with a rising creatinine, and that the enrollees prognosis at the current time would appear to be poor even with immunosuppressive therapy. The provider ordered Acthar gel for the enrollee. The providers appeal letter noted tacrolimus, cyclosporine, rituximab and mycophenolate would all have adverse effects on the enrollee. A review of the literature shows Acthar gel is an approved medication for the treatment of proteinuria associated with nephrotic syndrome, and is considered a viable treatment option for this enrollee whose renal condition has worsened on a standard treatment regimen. Considering that this enrollee has tried and failed on immunosuppressant mediations, Acthar Gel is considered medically necessary to treat this enrollees refractory nephrotic syndrome.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in nephrology 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 Entyvio 300 mg every 4 weeks. The patient has been diagnosed with ulcerative colitis. Medical literature states that in a prospective study of patients with Crohns disease or ulcerative colitis receiving induction therapy with vedolizumab, low trough levels of vedolizumab at week six are associated with need for additional doses (given at week 10 and then every four weeks). All patients receiving these additional doses achieved a clinical response four weeks later. In this case, the patient has tried and failed treatment with mesalamine, Uceris, prednisone, Humira, and infliximab. The patient was noted to experience breakthrough symptoms at three to four weeks after his Entyvio infusion. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, Entyvio 300 mg every 4 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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: Overturned Decision of Health Plan

The patient has requested reimbursement for residential treatment center (RTC) and reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential services, and Level 2.5 partial hospitalization 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 patients anxiety and depression continue to be problematic, but are appropriate for the PHP setting. PHP services are comprised on 20 or more hours per week and is a step-down from the 24-hour care that is provided with Level 3.5 RTC services. Given these findings, the RTC level of care services, and PHP level of care services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.