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

A patient has requested authorization and coverage for Amitiza. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients irritable bowel syndrome with constipation. The submitted documentation supports the medical necessity of the requested medication. The use of an osmotic laxative (Miralax) has not been successful for this patient. The American Gastroenterological Association states that the first line of therapy should be an osmotic agent, and then another type of laxative, such as a stimulant laxative, should be tried before a newer agent such as Linzess or Amitiza is considered, as the newer agents have more adverse effects. In this case, a stimulant laxative (senna) was not effective, and an osmotic laxative (Miralax) was not effective. The records indicated that Amitiza has been effective for this patient. There is sufficient support for the requested medication in this clinical setting. For these reasons, Amitiza 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous positive airway pressure (CPAP) machine. Treatment with a CPAP is considered appropriate when an AHI greater than or equal to 15 is determined by a home or laboratory based sleep study and when the patient has either had an APAP (automatic positive airway pressure) titration trial or a split-night sleep study to determine the appropriate settings of the CPAP.  Ongoing use of a CPAP device is indicated for patients who demonstrate compliance with therapy.  In a 90-day period, the patient should use the CPAP device for greater than or equal to four hours per night on 70% of nights. Type 4 devices have highly variable diagnostic performance and most do not include a conventional measure of sleep. This can result in limited information.  An adequate device is one that, at minimum, measures nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry. Alternatively, devices that use peripheral arterial tonometry (PAT) with oximetry and actigraphy are appropriate. In this patients case, the home sleep study performed incorporated the use of pulse oximetry, actigraphy, monitoring for snoring, and airflow.  It is considered a type 4 sleep study.  The diagnosis of obstructive sleep apnea has been based on a type 4 sleep study that is considered limited by design.  The results noted that there was insufficient non-supine study time to assess the severity of non-positional obstructive sleep apnea.  The recommended treatment was either a CPAP machine or a mandibular advancement splint.  It appears that at some point the patient used a CPAP machine without appropriate adherence.  There is no documentation to support that a CPAP machine has been helpful to alleviate her symptoms. Therefore, the requested CPAP machine 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 internal 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX procedure. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings: The documentation provided does not support the superior efficacy of the requested procedure in this clinical setting. The patient has GERD as based on pH recording. However, the patient reports benefit to a significant degree from acid suppression treatment with Aciphex, and as such cannot be considered medically refractory to acid blocker drugs. In addition, implantation of LINX in this clinical setting must be approached with caution given the patients reported dysphagia, as well as Barretts esophagus. Given these two latter concerns, LINX is not likely to be more beneficial for treatment of her GERD than the available standard therapy. Final Result: All three reviewers have determined that the requested procedure is 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg BID. The Health Plan has denied this request indicating that the medication is not medically necessary for treatment of the enrollees plaque psoriasis. The submitted documentation supports the medical necessity of the requested medication. The enrollee is requesting coverage for Otezla for treatment of chronic plaque psoriasis. He has tried and failed therapy with topical steroids and methotrexate. The enrollee has a documented needle phobia. The enrollee has tried and failed a systemic agent. It is unreasonable to require the enrollee to undergo cognitive behavioral therapy or anti-anxiety medications to address the needle phobia prior to approving the current effective therapy, which is U.S. Food and Drug Administration approved for this enrollees condition. The medical evidence supports the requested medication in this clinical setting. Therefore, Otezla 30 mg BID is medically necessary for the treatment of this enrollee.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be upheld. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A minor represented has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. Findings:  The physician reviewer found that the progress notes do not reflect severe regular emotional outbursts or other issues that would warrant IOP level of care treatment. The progress notes indicate the patient was uncooperative in treatment. Admission records suggest the treatment goals are related to improvement of social relationships skills, reduction of anxiety, and improvement of family relationships. The patient reportedly shaved off parts of her hair, but the documentation does not indicate any other issues with aggression or behavior outbursts. The progress notes do not indicate that the patient was demonstrating any serious mood symptoms or psychosis. The progress notes do not reflect active suicidal ideation on the part of the patient. The progress notes indicate the patient has a history of self-harm behaviors. She was not experiencing self-harm during the IOP according to the progress notes. For these reasons, the IOP services provided were not and are not medically necessary for treatment of this 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 with sub-specialty 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 parent of an enrollee has requested authorization and coverage for treatment once per week with a psychiatrist or psychologist who specializes in selective mutism. As noted by researchers, selective mutism has been defined as an anxiety disorder in the diagnostic and statistical manual of mental disorders (DSM-5). Cognitive behavioral therapy (CBT) is the recommended approach for children with selective mutism, which is offered by trained mental health providers such as psychiatrists or therapists trained in this technique. Follow-up studies at one and five years demonstrated significant improvement in patients with selective mutism, with 70% of children in complete remission at the five-year mark. The use of CBT by a psychiatrist or therapist in selective mutism is considered the standard of care. Accordingly, the requested treatment once per week with a psychiatrist or psychologist who specializes in selective mutism is 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 pediatrics with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Canadian crutches for treatment of the enrollee, who has a history of ankle pain. Findings:  The physician reviewer found that submitted documentation fails to demonstrate the medical necessity of the requested equipment. The records document chronic ankle and foot pain. The physical examination was unremarkable, and the patient reported that he had an x-ray which was negative for a fracture. There is no documentation of a more recent injury or abnormal x-ray or laboratory studies.  Chronic foot and ankle pain can be a common problem among adults. Often, the cause can be suggested by the location of pain and physical findings on examination.  In this case, there is no documentation to suggest the etiology of the pain.  It is possible it is arthritic, inflammatory or a tendinopathy. The treatment of tendinopathies of the ankle varies depending on the location of injury. Common treatment includes analgesics, rest and an arch support or heel wedge or custom foot orthosis. The Canadian crutch is a combination of an underarm crutch and an elbow crutch. In this case, there is no documentation to support that the patient has been treated with conservative care and requires crutches to support non-weight bearing status. Therefore, the requested Canadian crutches are 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for cervical epidural steroid injection (CESI). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees chronic neck pain.Overall, there is good evidence for the effectiveness of cervical interlaminar epidural injections in managing cervical disc herniation and fair evidence in managing central spinal stenosis and post surgery syndrome. The operative report pertains to the interlaminar epidural injections. These injections are noted to be safe and effective. Two injections have been given to this patient with good long term results with the first injection given, and reports of one week relief with the second injection. Based on the review of the literature, the injections are safe and effective. The patient reports severe pain and is in need of pain relief in a rapid, safe, and effective manner. As such, the documentation provided supports the medical necessity of the requested CESI for the management and 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 orthopedic surgery. 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 Afrezza insulin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees diabetes, type I.There is support in the medical literature for the requested medication in this clinical setting. Afrezza is an inhaled insulin with ultra rapid pharmacokinetic-pahrmacodynamic (PK-PD) properties that enable improved postprandial glycemic control in adults with type 1 or type 2 diabetes. This inhaled insulin has a PK/PD profile with a rapid onset of action and a short duration of action that differentiates it from subcutaneous administered rapid acting insulin analogs and earlier inhaled insulins (Heinemann and Parkin). Afrezza is not intended as a substitute for traditional basal therapy with injectable long-acting insulin, but may be used to provide prandial insulin coverage. It must be used in combination with long acting insulin in patients with type 1 diabetes. Afrezza is more quickly absorbed than subcutaneous insulin therapies and has a shorter duration of action. It appears to be noninferior compared with subcutaneous insulin regimens, and is associated with less hypoglycemia. Thus, it may serve as an alternative insulin agent in patients reluctant to administer multiple subcutaneous injections of insulin daily or in patients who experience late postprandial hypoglycemia with subcutaneous insulin. The patient indicates a risk for nocturnal hypoglycemia, which is probably the result of late postprandial hypoglycemia. The risk of late postprandial hypoglycemia can be minimized with Afrezza. This type of insulin might help the patient address hyperglycemia without delayed hypoglycemic response. From the submitted record, the patient has risk of hypoglycemia with the current subcutaneous insulin regimen. Based on the documentation provided, Afrezza has been demonstrated as medically necessary for the management and treatment of this patients diabetes.  Final Result: The reviewer determined that 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret 100-40 mg. The Health Plan has denied this request indicating that the medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 2b. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 2 patients should be treated with Mavyret. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg is medically necessary for 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: Upheld Decision of Health Plan

A patient has requested authorization and coverage for Praluent pen 75 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients hyperlipidemia. The submitted documentation does not support the medical necessity of the requested medication. The records indicate that this patient has hyperlipidemia with prior tolerance to both atorvastatin and ezetimibe with good results. Praluent is a proprotein convertase subtilisin/kexin type 9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein cholesterol. The documentation provided does not sufficiently support that either of these categories are present or that the patient cannot tolerate atorvastatin and ezetimibe to treat the patients hyperlipidemia. Therefore, the requested Praluent pen 75 mg 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 in internal medicine with sub-specialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

ature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an ultralight wheelchair for treatment of the enrollee, who has a history of spastic diplegic cerebral palsy. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment. This patients mobility and subsequently his ability to actively participate in home, school, and community activities are significantly impacted by his medical condition. He uses several pieces of adaptive equipment, but is unable to participate fully due to fatigue and muscle weakness. Per the records, he requires appropriate adaptive equipment to allow for maximum participation in home, school, and community activities. The requested ultralight wheelchair will provide this patient with independence and allow him to participate in activities and optimize his functional potential. Thus, the requested ultralight wheelchair is medically necessary for the 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 pediatrics 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.