Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for autologous hematopoietic stem cell transplantation for treatment of the enrollees multiple sclerosis. Findings:  The 3 physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. The medical records provided for review do not indicate that the patient has failed or is otherwise unable to tolerate or take other U.S. Food and Drug Administration (FDA) approved treatments for multiple sclerosis. The records note treatment with Betaseron and Copaxone. However, multiple other therapies are available and FDA approved with demonstrated efficacy and low morbidity for multiple sclerosis. The medical evidence has not demonstrated that the efficacy of autologous hematopoietic stem cell transplantation exceeds other available multiple sclerosis therapies. Thus, the requested autologous hematopoietic stem cell transplantation is not likely to be more effective than other treatment options. Final Result: The 3 reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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

Nature of Statutory Criteria/Case Summary: A 53-year-old female enrollee has requested authorization and coverage for the magnetic esophageal sphincter augmentation (LINX procedure) for treatment of the enrollees gastroesophageal reflux disease (GERD) with severe atypical chest pain. Findings:  The physician reviewer found that appropriate patient selection is crucial before anti-reflux procedures. In prelude to surgical intervention for GERD, Jobe and colleagues noted that it is critical to document the presence of abnormal distal esophageal acid exposure, especially when anti-reflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach. This patient has GERD as based on pH recording that has not benefited to a significant degree from acid suppression treatment. Anti-reflux surgery with LINX is appropriate in the patients case and can be expected to be more beneficial than standard therapy. Final Result: All three reviewers determined that the requested procedure is likely to be more beneficial for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the autonomic nerve system function test for enrollee's suspected diagnosis of postural orthostatic tachycardia syndrome (POTS).  Findings:  Three physician reviewers found there is sufficient medical literature supporting the utility of autonomic nerve system function testing in this clinical setting. Although autonomic testing is not indicated for all patients, it does have select utility in patients suspected to have autonomic deficiencies and no clear cause for these symptoms, such as in this case. The patient had orthostasis and autonomic symptoms without a clear etiology and autonomic reflex testing was performed. In this case, the autonomic testing was able to provide a clear etiology. The diagnosis of POTS is critical to help guide clinical management and limit further testing. For the reasons provided, the autonomic nerve system function testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in neurology 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment for treatment of the enrollees behavioral health conditions.Findings:  The physician reviewer found that in order to objectively determine if the patient meets criteria for length of stay, the Level of Care Utilization System will be utilized. This is an accepted, national standard for determining the appropriate level of care for adults.  In terms of risk of harm, the records support a score of 2. There was no documentation of prior suicide attempts, and the patient did not have any suicidal ideation. With regards to functional status, the records support a score of 3.  The documentation indicated moderate impairment. It appeared that the patients alcohol use was having a significant deterioration in his ability to fulfill his responsibilities. In terms of medical/addictive/psychiatric comorbidity, the records support a score of 3.  The patient has alcohol use disorder and depression. The patients recent substance use has had detrimental effects to the patient. With regards to recovery environment, the records support a score of 3. The patient has a moderately stressful environment.  In terms of level of support, the records support a score of 3. It appears that the patients wife is supportive of the patient, but their relationship has been strained by the patients substance use. With regards to response to treatment and recovery, the records support a score of 3.  The patient had a history of various periods of sobriety in the past. His longest period of sobriety was 16 months. In terms of engagement and recovery status, the records support a score of 3.  The patient had limited engagement and recovery.  The patient participated in treatment but seemed to lack confidence to change despite intentions to do so. Thus, the records support a total score of 20.  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 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 reimbursement for air and associated ground ambulance transportation services provided for treatment of the enrollees medical condition status post-traumatic spinal cord injury. Findings:  The physician reviewer found that the air and associated ground ambulance transportation services provided were medically necessary for treatment of the patients medical condition. There is sufficient support in the peer-reviewed literature to support the services at issue in this clinical setting. Colleagues found an association between time to rehabilitation after a spinal cord injury (SCI) and lower functional level, concluding that Earlier rehabilitation following traumatic SCI may improve patients functional status at discharge. In this case, the patient sustained a cervical spinal cord injury with impairment of function. Timely rehabilitation can minimize health risks and improve functional outcomes. To receive early specialized rehabilitation air and ground ambulance were medically necessary. As such, the request for air and associated ground ambulance transportation services provided were medically necessary for treatment of the patients medical condition. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: A male enrollee has requested authorization and coverage for oxycodone HCL 10 mg tablets, three times per day for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patient is requesting coverage for oxycodone HCL 10 mg tablets, three times per day. The formulary alternatives include oxycodone-acetaminophen tablets, which is the same drug in a different formulation (immediate release). The immediate release tablets can be dosed every four hours to produce the same effect as the extended release. Additionally, there were no urine toxicology results included in the records submitted.  There is a lack of support for the requested medication in this clinical setting.  All told, oxycodone HCL 10 mg tablets, three times per day 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 58-year-old male enrollee has requested authorization and coverage for Optune treatment for treatment of the enrollees glioblastoma multiforme.  Findings:  The physician reviewer found that Central nervous system tumors are classified by the World Health Organization based on their proliferative potential, morphology, and molecular genetics and are conferred grades I-IV. Anaplastic astrocytomas and glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy. Chemotherapy prolongs survival, but the gains are modest. The standard of care is to resect the glioblastoma multiforme maximally followed by treatment with temozolomide. Most glioblastoma multiforme tumors recur, and then the treatment options are limited. This patient has exhausted these options.  Optune treatment was approved by the U.S. Food and Drug Administration (FDA) for the treatment of recurrent glioblastoma multiforme. Recently, the FDA expanded the indication for Optune treatment to include newly diagnosed glioblastoma multiforme when used along with temozolomide and radiation therapy. There is sufficient medical evidence to demonstrate the safety of Optune treatment. Thus, the requested Optune treatment is likely to be superior over other available treatment alternatives.  Final Result: Two of three 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 number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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 reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services provided. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Findiings: The physician reviewer found that based on the Level of Care Utilization System (LOCUS) criteria, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is two (2), a low risk of harm. The patient did not have any suicidal or homicidal ideation. The patient has a functional status score of three (3), moderate impairment. The patients drinking impairs his ability to fulfill his responsibilities and obligations. The patients medical and psychiatric co-morbidity score is three (3), significant co-morbidity. The patients recovery environment score is one (1), low stress environment. The patient lives in an apartment with his spouse. He reports that their relationship is stable and his wife is supportive. The patients level of support score is two (2), supportive environment. The patients wife and friends are supportive of the patient and his desire for sobriety. The patient has a moderate response to treatment and recovery score of three (3). The patient obtained recovery during a structured setting in a RTC for 45 days. He has a history of relapse. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient is motivated for recovery and is compliant with treatment recommendations. Based on these criteria, the patient has a total score of 16, which would meet criteria for treatment in a less restrictive environment such as outpatient treatment. Therefore, the IOP services provided were not and are not medically necessary for treatment of the patients medical condition.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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a two-year-old enrollee has requested reimbursement for the Foundation One gene test for evaluation of the enrollees metastatic chordoma. Findings:  2/3 of the physician reviewers found that the Foundation One genomic testing of this patients recurrent tumor was an appropriate test in this clinical setting, and was more likely to lead to beneficial treatment than any available standard therapy. There is no available standard therapy for recurrent metastatic poorly differentiated chordoma in children. The standard treatment for chordoma is surgery and radiation although there are reports of responses to chemotherapy. This patient was treated with a broad range of standard chemotherapy prior to Foundation One testing. Thus, the Foundation One test was an important first step in finding a biologically plausible agent, and that this testing is consistent with standard practice for a patient in this situation. There is increasing evidence that tumor genome testing frequently yields targetable mutations and that drugs targeting these mutations can result in meaningful clinical responses. In a recent study of children with malignancies, of 91 children with sequenced tumors, genetic mutation findings resulted in a change in therapy in 23 children, and nine of those children had ongoing responses to therapy for 8-16 months. Given this support, the Foundation One gene test performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in pediatrics with sub-specialty certification in pediatric hematology and oncology 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.Physician reviewer number two is board certified in pediatrics with sub-specialty certification in pediatric hematology and oncology 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.Physician reviewer number three is board certified in pediatrics with sub-specialty certification in pediatric hematology and oncology 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 anakinra (Kineret) 100 mg/0.67 mL subcutaneously daily for treatment of the enrollees autoinflammatory syndrome.  Findings:  The physician reviewer found that The request for anakinra (Kineret) 100 mg/0.67 mL subcutaneously daily is medically necessary for treatment of the patients medical condition. A review of the peer-reviewed literature supports the use of Kineret for the treatment of the autoinflammatory condition, Schnitzlers syndrome. Schnitzlers syndrome is a rare and under recognized disorder. The presence of the chronic urticarial lesions and the monoclonal IgM component, which define the syndrome, are virtually constant. Intermittent fever, joint symptoms, and the increase in acute-phase reactants are also very frequent. The clinical course of the disease is usually chronic, with no spontaneous remissions, and treatment is difficult and often ineffective. Recent reports have described a dramatic response of some of these disorders to Kineret. Chronic urticaria, unresponsive to antihistamines is characteristic of Schnitzlers syndrome. Kineret, an IL-1 receptor antagonist has been associated with an excellent outcome. Within 24 hours of commencing Kineret, patients have had almost complete resolution of symptoms, and has since been able to return to work full time. Discontinuation of Kineret for one day, was associated with a rapid disabling return of symptoms in patients. Patients with Schnitzler Syndrome were shown to have a complete response, both symptomatically, and with a reduction in inflammatory markers and white cell count, to anakinra. The reported universal response to Kineret suggests a key role of IL-1 in the pathophysiology. Given the nature of the patients medical condition and lack of symptom improvement with conventional therapy, treatment with Kineret 100 mg/0.67 mL subcutaneously daily has been established as medically necessary for treatment of the 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 allergy and immunology 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.