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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Belbuca (buprenorphine HCl buccal film 150 mcg). The records document that this patient has tried and failed several other pain medications multiple other long-acting pain medications including Fentanyl patch, Tramadol ER and Nucynta ER. His provider has requested to switch the opioid tolerant enrollee from Oxycodone to Belbuca in order to provide continuous pain relief with the additional benefit of abuse deterrent properties of the medication. According to the U.S. Department of Health and Human Services, patients who need treatment for pain but not for addiction should be treated within the context of a medical or surgical setting. They should not be transferred to an opioid maintenance treatment program simply because they have become physically dependent on prescribed opioids in the course of medical treatment. This patients provider reports that the treatment goal is to treat the patients pain in a more effective manner with a more favorable risk-to-benefit ratio. The U.S. Food and Drug Administration (FDA) approved indication for Belbuca is for the management of pain severe enough to require daily continuous long-term opioid treatment and for which alternative treatment options are inadequate. The providers notes state that the purpose of prescribing Belbuca is to allow for the safer weaning of oxycodone for post-operative pain control while still affording the patient continuous management of his pain. Furthermore, by using Belbuca, the provider is significantly lowering the patients daily morphine equivalents of 112 morphine milligram equivalents. Based on all information available for review and the current available guidelines, the requested Belbuca (buprenorphine HCl buccal film 150 mcg) to treat the patients chronic pain is medically necessary.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 anesthesiology with subspecialty certification in pain management 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 patient has requested reimbursement and prospective authorization and coverage for proton beam radiation therapy (including CPT codes 77014, 77263, 77336, 77427, 77470, 77523, and G6002). In this this clinical setting, there is medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for this patients orbital tumor. The patient requires a high radiation dose to the orbit of at least 60 Gy, which is above the tolerance of the nearby optic structures. The proton plan is able to effectively spare the orbit, optic nerve, and optic chiasm compared to what a standard photon plan would achieve. Furthermore, this technique may allow for preservation of the eye so that the patient will not require orbital exenteration. Based on these reasons, the proton beam radiation therapy (including CPT codes 77014, 77263, 77336, 77427, 77470, 77523, and G6002) was and is likely to be more beneficial for treatment of the patients medical condition than standard therapy.Final Result: Two of the three reviewers determined that the services at issue were and 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:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology and is actively practicing.  All three 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: The patient has requested authorization and coverage for Vascepa. Based on the records provided for review, the patient presents with hypertriglyceridemia that does not exceed 500 mg/dL and is not associated with any documented coronary disease or pancreatitis. The records suggest that treatment of this patients hypertriglyceridemia is being considered to help reduce his overall cardiovascular risk. However, randomized trials have not directly compared most agents for the reduction of cardiovascular risk in patients with hypertriglyceridemia. Although statin therapy is generally less effective in reducing triglyceride levels compared to other therapies, the proven efficacy of statins to reduce cardiovascular risk supports their utility when cardiovascular risk reduction is the primary goal of treatment. Moreover, there is a lack of data demonstrating that targeting treatment to lower triglyceride levels reduces overall cardiovascular risk in patients with significantly elevated LDL cholesterol. This patients records document only one statin trial and no other attempts at statin therapy. Since the patients hypertriglyceridemia is not severe as defined by over 500 mg/dL, and there is no documented treatment failure or intolerance to other statin medications, Vascepa is not supported as 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 internal medicine with subspecialty certification in cardiovascular 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for gene test (CPT 81256) for elevated ferritin levels. Findings:  The physician reviewer found that the health plan has denied this test as experimental/investigational. A review of the records indicates the patient was diagnosed with elevated ferritin levels in her blood.  She underwent genetic testing to screen for hemochromatosis, which is a genetic iron disorder that causes excess iron in the body.  According to current peer-reviewed medical literature, identifying hereditary hemochromatosis (HH) is important because treatment is highly effective and safe and can prevent virtually all of the disease complications if instituted at an early stage of the disease.  HH may be suspected in individuals with unexplained fatigue, symptoms of iron overload in specific organs, unexplained liver function test abnormalities, high ferritin, or high transferrin saturation.  HFE mutation testing is appropriate in most individuals with documented iron overload as a means of determining the genetic contribution.  Patients with abnormal iron studies should be evaluated as patients with hemochromatosis, even in the absence of symptoms. Medical records explain and support that his patient has elevated ferritin, pre-diabetes, and mildly abnormal liver function tests (LFTs), and that is the reason the genetic test was obtained.  Current understanding of hemochromatosis incorporates the fact that some 30% of patients with familial occurrence of iron overload never develop symptoms of the disease. Guidelines recommend screening for hemochromatosis in patients with abnormal iron studies, liver disease or end organ damage, and this patient had these factors.  . Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical  condition. Therefore, the health plans denial is overturned. Credentials/Qualifications: Three reviewers are board certified in Hematology and Oncology and are actively practicing.  All three 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transoral incisionless fundoplication (TIF). The efficacy of TIF has been studied in randomized controlled trials. However, the conclusions are inconsistent. In addition, the American College of Gastroenterology guidelines for treatment of gastroesophageal reflux disease (GERD) report that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy. In 2013, the Society of American Gastrointestinal and Endoscopic Surgeons reported that numerous published series have reported significant adverse events and that there is a lack of sham-controlled trials comparing TIF with anti-reflux surgery. Furthermore, there is a lack of data supporting the long-term safety and efficacy of endoscopic procedures for GERD in patients with complicated GERD, which is defined to include patients with Barretts esophagus. This patient is noted to have Barretts esophagus, which has not been shown to benefit with the TIF procedure over standard therapies. All told, the requested TIF procedure utilizing the EsophyX device (CPT code 43210) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested TIF procedure utilizing the EsophyX device (CPT code 43210) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. For these reasons, the Health Plans denial should be upheld. Final Result: The reviewers determined that the requested TIF procedure utilizing the EsophyX device (CPT code 43210) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in gastroenterology 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 authorization and coverage for a power wheelchair with seat elevator and power standing feature. In the peer-reviewed medical literature, colleagues noted that power wheelchairs can have a positive impact on user well-being, self-esteem, pain, activity and participation. The records provided for review document that the patient has undergone a wheelchair evaluation by a rehabilitation medicine specialist. That provider has determined that a power wheelchair with seat elevator and standing feature is medically necessary. The patients current power wheelchair is seven years old and the patient has demonstrated his ability to use the wheelchair safely in this historical period. The patient underwent a face-to-face wheelchair evaluation. The providers assessment of the patients condition is congenital quadriplegia, right swan neck deformities, contractures of the right elbow, wrists, and knee, hearing impairment, and chronic low back, hips, knee pain. He indicates that he has arthritis in his hips and transfers hurt his hips especially to the stander. The stander is reported as difficult to access and he indicates that a standing wheelchair (sit-stand electric feature) would help eliminate this. He also reports that the patients pain is improved with standing, which is worse when sitting all day. At the end of the evaluation, he states that his new power chair should also have a retractable joystick on the left, head rest adjustable and removable for access, trunk supports, abductor pad, anterior tilt to help with transfers, elevating leg rests for pressure relief and positioning of joints and back, solid back, elevating seating seat for ADL independence. The providers evaluation and findings are consistent with the recommendations in the current medical literature. All told, the requested power wheelchair with seat elevator and power standing feature is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation.Findings:  Two of the three physician reviewers found that the submitted records fail to demonstrate the superior efficacy of the services at issue. The therapy for overactive bladder includes behavior modification, pelvic floor therapy, anticholinergics, antimuscarinics/beta blockers, biofeedback, percutaneous tibial nerve stimulation, Botox and sacral modulators. In this patients case, the records noted that the medications Detrol and Myrbetriq were tried. The records did not document that the patient failed a trial of Vesicare. The medical evidence has not established an additional benefit of percutaneous tibial nerve stimulation over Vesicare. Percutaneous tibial nerve stimulation is likely to have the same efficacy as Vesicare over the short-term. Therefore, percutaneous tibial nerve stimulation was not and is not likely to be more effective than other treatment options.Final Result: The reviewers determined that the services at issue were not and 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 reviewers 1, 2 and 3 are board certified in urology 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Accent 1000 with Unity Language loaded, CPT code E2510, with accessories: 84 location key guard, Xtreme case, and strap handle. Findings:  The physician reviewer found that there has been increasing research demonstrating positive patient outcomes with the use of augmentative and alternative communication (AAC) devices by young patients with autism. In addition, recent data demonstrates emerging support for the effectiveness of aided AAC interventions in teaching children with autism. An AAC encompasses various modalities that can replace or augment a patients speech and other existing communication skills. Autistic patients are most likely to benefit, especially those who fail to develop sufficient speech skills for daily functional communication. This patient population is at particular risk of developing problem behaviors, limited academic learning, and poor social networks. This patient was not able to communicate his daily needs with the picture exchange communication system. However, he has demonstrated his ability to communicate his daily needs with the Accent 1000 device. Given the patients success with use of the Accent 1000, and lack of response to other options, the Accent 1000 with Unity Language loaded, CPT code E2510, with accessories: 84 location key guard, Xtreme case, and strap handle, is medically necessary for this patient.Final Result: The reviewer determined that the requested equipment 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 pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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 enrollee has requested coverage for Humira. A review of the records indicates this patient was diagnosed with psoriasis.  She was previously treated with methotrexate and fluocinonide. However, she felt poorly with the methotrexate because she was experiencing flu like symptoms and abdominal pain.  She also reported the topical medications were not helping.  The records detailed that 8% of the patients body surface area was affected by her diagnosis, and the recommendation was made for laboratory studies and initiation of Humira medication. According to the medical literature, Humira is appropriate for a patient to utilize when they have been diagnosed with plaque psoriasis, and there is evidence of a body surface area that has been affected of at least 3% to 10%.  Within the documentation, it was noted that 8% of the patients body surface area was affected with psoriasis.  The documentation also detailed that she had a medication trial and failure of methotrexate, as well as topical medications.  Humira is approved by the FDA for treatment of adult patients with moderate to severe chronic plaques psoriasis who are candidates for systemic therapy or phototherapy. Treatment success rates with Humira were positive in studies.  Given the above, the utilization of Humira to treat the patient's plaque psoriasis is consistent with current standards of care.  Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The parent of an enrollee has requested coverage for inpatient psychiatric treatment services. The health plan has denied this request as not medically necessary. The records indicate the enrollee with a history of anorexia nervosa, anxiety disorder, and depressive disorder was admitted for inpatient psychiatric treatment for treatment of eating disorder symptoms. She had acute food and fluid refusal, was over exercising, had reports of passing out, having blackouts, having compromised vitals, and requiring nasogastric tube placement for feeding in the past.  She had behavioral dysregulation, elopement attempts, was agitated and inconsolable. She had suicidal ideation and did not want to live with depressive and anxiety symptoms.  She had diagnoses of anorexia nervosa, generalized anxiety disorder, and depressive disorder.  She had past hospitalizations and had past partial hospital program, residential, and outpatient treatment.  She took Duloxetine and Zyprexa, and had taken Abilify, Celexa, and Ativan.  She was discharged and the plan was to transfer her to residential treatment and keep her in the hospital until the transfer. According to the medical literature, patients with serious medical consequences due to eating disorder symptoms, severe weight loss or poor nutritional status are candidates for inpatient treatment.  A review of the medical records documents a patient with a severe and acute eating disorder with significantly abnormal vital signs requiring medical interventions due to the life threatening nature of her behaviors related to her eating disorder. In this case, this patient had reports of acute food refusal and had past complete starvation to the point of passing out, having blackouts and requiring nasogastric tube placement for feeding.  She had other behavioral and mood symptoms before and during her hospital stay.  She needed to remain in this 24 hour setting as she could not safely be treated outside of this setting. Final Result: The reviewer determined that the requested service is medically necessary for thetreatment of the enrollees medical condition. Therefore, the health plans denial should beoverturned. Credentials/Qualifications: The physician reviewer is board certified in Psychiatry and 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 similar medical condition.