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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. The procedure is approved by the U.S. Food and Drug Administration. TMS is well tolerated with fewer barriers than electroconvulsive therapy. Further, the American Psychiatric Association (APA) recommends TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. Considering the medical records submitted for review, endorsement from the APA and support in the peer-reviewed literature base, TMS is a safe, appropriate treatment consistent with good medical practice. The therapy would be reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the request for TMS is medically necessary for treatment of 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 16-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that in terms of recovery environment, the records support a score of 3 for environmental stress. He has a moderately stressful environment. He has frequent interpersonal conflicts with his mother. Regarding environmental support, the records support a score of 3.  There is limited support in his environment.  The patients mother will participate in care through phone conversations. It does not appear other family members are involved in the care of the patient.  In terms of resiliency, the patient demonstrated a moderate response to treatment, and the records support a score of 3.  The patient has an inconsistent capacity to deal with life stressors. His recovery has been maintained for only moderate periods of time, but only with strong professional support in structured settings. He has a limited ability to follow through with treatment recommendations. In terms of acceptance and engagement, the records support a score of 2. At the initiation of treatment, the patient was obstructive with treatment. However, around the dates in question, the patient was able to develop positive relationships with his clinicians and care providers.  Thus, the patient has a composite score of 19.  Based on these criteria, the patient could have been discharged to a less restrictive environment into a partial hospitalization program during the dates of service in dispute. All told, residential treatment center services were not and are not medically necessary for the 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 expertise 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: An enrollee has requested authorization and coverage for Korlym 300 mg for treatment of the enrollees Cushings syndrome. Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting.  Cushings syndrome is a collection of signs and symptoms due to prolonged exposure to cortisol. It is associated with poor quality of life, morbidity, and increased mortality.  While optimum treatment typically consists of selective and complete resection of the causative tumor, the development of new drugs offers clinicians several choices to treat patients with residual cortisol excess following the surgery.  The U.S. Food and Drug Administration has approved the antiprogestin Korlym (mifepristone) for control of hyperglycemia secondary to hypercortisolism in adults with endogenous Cushings syndrome, who have type 2 diabetes or who have glucose intolerance and have not responded to or are not candidates for surgery. Multiple case reports and small series have suggested that mifepristone administration leads to clinical improvement (weight loss, decrease in glycemia and blood pressure, improvement in psychiatric symptoms) in the majority of Cushings syndrome patients. Moreover, the literature also suggests that mifepristone does not pose the risk of hepatotoxicity, a rare but potentially serious side effect of ketoconazole. According to the submitted documentation, this patient is a good candidate for therapy with Korlym. Her Cushings syndrome is complicated by severe insulin resistance, which is complicating her diabetic control. All told, Korlym 300 mg is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage to remain in a skilled nursing facility and continue physical therapy for treatment of the enrollee, who has a history of congestive heart failure. Findings:  The physician reviewer found that This patient has a history of dilated cardiomyopathy with an ejection fraction of 20-25% and New York Heart Association (NYHA) class III-IV congestive heart failure.  He has had multiple episodes of volume overload in the last year requiring intensive diuresis.  He was hospitalized with volume overload and pneumonia. He was aggressively treated in the hospital over a week and medically stabilized.  He has been receiving care at the skilled nursing facility, primarily for deconditioning.  He had made very modest functional progress.  He was continuing to require minimum assistance for transfers and very short distance ambulation.  He continued to require minimum to moderate assistance for his basic self-care.  There are no indications in the records that the patient would have been expected to make further significant gains. Overall, his function had plateaued at a level where significant custodial assistance would have been expected for an indefinite period of time.  The patient could have returned to the community with custodial level support for assistance with basic activities of daily living and mobility or have been transitioned to longer term care. He had multiple conditions that were very chronic, but otherwise stable.  There were also stage 1 pressure injuries that were being treated conservatively.  There were, however, no documented medical or nursing issues requiring ongoing inpatient level care.  Although the medical literature generally supports subacute or skilled nursing facility level inpatient rehabilitation in a variety of clinical settings including severe cardiomyopathy, the medical literature does not support the necessity of this intervention indefinitely in the absence of expected clinically significant functional progress. The available records do not demonstrate that he had any skilled therapy, nursing or medical needs requiring ongoing inpatient hospital level care.  All told, it was not and is not medically necessary that this patient remain in a skilled nursing facility and continue physical therapy.  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: An enrollee has requested authorization and coverage for Norco 10-325 mg for treatment of the enrollees chronic lower extremity pain. Findings:  The physician reviewer found that Norco is medically necessary for treatment of the patients medical condition. In this case, the patient has an opioid agreement that is very specific in terms of modifying the treatment plan. The opioid agreement specifies that the treating provider will evaluate how well the opioid medication is working. However, the records submitted for review lack documentation showing pain assessments or assessments of the patients function. A pain assessment should include the current level of pain, the lowest and highest reported levels of pain over the period since the last assessment, the average level of pain, the intensity of pain after taking the opioid medication, how long it takes for pain relief to occur, and how long the pain relief lasts. The treating provider would be expected to measure function using any of the readily available tools for measurement. In terms of the planned weaning, a slow taper is recommended and the longer the patient has taken opioids, the more difficult they are to taper. A suggested taper is 10% every two to four weeks. When tapering, patients should be monitored to ensure that pain and function do not worsen as worsening pain and function would support the medical necessity of ongoing opioid therapy. In this case, the patient has been taking Norco on a long-term basis and is opioid dependent. The result of a repeat urine drug screening was positive for Norco and cannabis. The provider recommended slow weaning planned at 60 tablets with a plan to decrease further to 10 tablets the next month and then discontinue the medication. The quantity prescribed represents a 1/3 decrease which is not appropriate for weaning and a further decrease of more than 80% is planned for the next month. If tapered too quickly, worsening pain and function could occur due to withdrawal and the patient has significant comorbid medical conditions that would place him at risk for an adverse outcome if the withdrawal symptoms were severe. For these reasons, Norco 10-325 mg is medically necessary for the treatment of the patients medical condition at this time.  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 physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine for treatment of the enrollee's pain. Findings: The physician reviewer has found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient is not following the opiate maintenance agreement, and the urine toxicology screens are inconsistent with the prescription.  Therefore, the morphine should not be refilled. Opiate maintenance agreements are an essential part of treatment.  Chou and colleagues documented the dangers of chronic opiate therapy for non-malignant pain and that some of these dangers arise from patients not following the prescription.  The current medical evidence does not support the requested medication in this clinical setting.  All told, morphine is not medically necessary for the 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for back surgery to fuse back bones for treatment of her low back pain. Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  Evidence-based, peer-reviewed literature supports the use of lumbar fusion for patients with degenerative disc disease with radiating pain associated with severe degenerative changes. This patient presents with worsening low back pain radiating into the right lower extremity. Functional difficulty was documented with activities of daily living. The signs/symptoms were consistent with imaging evidence of significant L5-S1 intervertebral collapse with severe foraminal stenosis and significant Modic changes. There were no degenerative or significant findings at any other spinal level. Evidence of a reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. The provider has opined that decompression surgery alone would be inadequate to restore the intervertebral height and stabilize the area. Therefore, the requested back surgery to fuse back bones with a one day length of stay is medically necessary for treatment of 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine and cervical spine for evaluation of her back pain and neck pain.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The only reason to obtain an imaging study is if it will alter the course or type of therapy.  In this patients case, there is no indication of reduced reflexes or current signs of a radiculopathy.  The American College of Radiology (ACR) has attempted to provide evidence-based guidelines which will help to guide choices for diagnostic procedures. In this clinical setting, for the patients neck pain, the ACR has recommended plain x-rays as a first line study, and specifically states that MRI of the cervical spine is generally not appropriate. Were the patient to have specific neurological signs or symptoms, then an MRI may be appropriate. Similarly, the ACR has established appropriateness guidelines for low back pain, and, as with cervical spine pain, MRI is not routinely recommended unless there are additional signs or symptoms.  Additionally, findings on MRI do not necessarily correlate with symptoms.  It is well-known that a patient may have incidental findings on an MRI that are not symptomatic, and, conversely, may have relatively unimpressive findings on MRI but may be experiencing significant symptoms. In this patients case, it is already known that she has degenerative changes.  Without additional clinical findings, it is unlikely that a surgical procedure is appropriate.  In this clinical setting, an intensive conservative approach to her therapy is first warranted.  All told, the requested MRI of the lumbar spine and cervical spine are not medically necessary for the 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has request requested authorization and coverage for left knee injections with Orthovisc for treatment of osteoarthritis on his left knee.  Findings: The physician reviewer found that medical guidelines and literature support repeated cycles of viscosupplementation treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment.  There is no maximum amount of injections established by high quality scientific evidence. In this case, the patient has been diagnosed with left knee osteoarthritis. He has undergone two prior viscosupplementation series, with positive results documented in terms of significant pain reduction and improved function. He is currently reporting progressive worsening of his knee pain and difficulty in gait. He reported that he was unable to take anti-inflammatory medications and did not want to take pain medications. He reported inadequate relief with prior physical therapy. The medical evidence supports the requested services in this clinical setting.  All told, the requested left knee injections with Orthovisc are medically necessary for the 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for physical and occupational therapy for treatment of the enrollee who has a recent history of fractured hip.Findings: The physician reviewer found that there is support in the documentation submitted and in the literature for the requested services. The patient is status post hip fracture as described above. His surgery appears to have been uncomplicated, and he has improved with the treatments provided. However, he has not been progressed to community level mobility and is still unable to perform lower body activities of daily living (ADL) without assistance. He is showing improvement in terms of his ambulation distance and appears capable of further improvement including ambulating on stairs and uneven surfaces. The therapy being requested would reasonably be expected to include a progression to a less restrictive assistive device and use of adaptive equipment for lower body ADLs. There is a reasonable goal of reducing his burden of care enabling him to function independently in the community. For these reasons, the requested physical and occupational therapy are medically necessary for treatment of this 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 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: An enrollee has requested authorization and coverage of Epclusa for 12 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that  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.