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

The enrollee is requesting authorization and coverage surgically assisted rapid palatal expansion with LE FORT 1-2 piece w/o graft. The enrollee has a history of underdevelopment of the bones of the upper jaw, obstructive sleep apnea, and an unusually large tongue. A progress note reported prior treatment had provided minimal improvement in his sleep quality. The enrollee reports his upper palate is too small and his enlarged tongue cannot be positioned properly in his mouth, which affects his breathing, eating, and speech, and causes drooling and destruction of his teeth. Studies report surgically assisted rapid palatal expansion allows for stable skeletal expansion of the upper jaw, with minimal risk of long-term relapse. Transverse deficiency correction through surgically assisted rapid palatal expansion will directly improve airway space, chewing, and speech. In addition, the health of the oral cavity is improved to avoid further injury.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in oral and maxillofacial 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for individual psychotherapy services. The enrollee is requesting coverage for continued sessions with her current psychologist. The enrollees psychologist believes the enrollee should continue with her current therapist so as not to disrupt continuity of care. All individuals with alcohol use disorder should be encouraged to participate in some type of psychosocial treatment; commonly, some form of alcohol counseling and participation in a mutual help group.  Counseling in many substance use disorder treatment programs is based on the principles of 12-step programs, such as Alcoholics Anonymous. The sessions also focus on helping people avoid situations in which they are likely to encounter alcohol or drugs or triggers for their use, to plan safe social activities, and to continue attendance at mutual help groups between counseling sessions.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested reimbursement for skilled nursing facility (SNF) services. The records provided for review do not support that this patient required treatment at the SNF level of care. The patient did not require skilled nursing services with the specialized skill, knowledge, and judgment of a skilled professional nurse. The patient did not have a tracheostomy tube, enteral feedings, complex wound care, or other SNF level of care nursing need. This patients functional level and weight bearing limitations did not require ongoing SNF level skilled therapy services. The patient did not require these skilled nursing or skilled therapy services on a daily basis. Although the patient might have benefited from physical and occupational therapies, these services were not required on a daily basis in the SNF setting. All told, the SNF services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty 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

The enrollee is requesting reimbursement for inpatient hospital level of care. The enrollee had a total thyroidectomy for thyroid cancer. She had metastases to her lymph nodes and was admitted to out-of-the-country hospital for surgery. During the procedure, a vocal cord polyp was removed and a drain was placed. The drain was removed on the fourth day and the enrollee was discharged. The enrollee reports thyroid cancer removal requires full anesthesia and therefore requires pre-surgical testing and full hospitalization. The enrollees physician reports the decision to fully admit the enrollee to the hospital was to further monitor her pain following surgery. The literature shows this enrollees procedure had can be done in a short hospital stay. The services provided on the first day of stay were not medically necessary on an inpatient basis, as routine pre-operative evaluations, including a cardiology consultation and anesthesia consultation, could have been done as an outpatient. As for the last day of stay, the surgery was performed the day before. There are no medical records provided beyond a post-hoc letter indicating the need for pain control on the last day.  Thus, there is no support for inpatient status on the last day.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in general 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollees parent is requesting authorization and coverage for residential treatment center (RTC) services. The enrollee has major depressive disorder and anxiety. She entered the residential treatment center level of care. The goals of the program are to provide treatment for presenting issues, to provide clinical assessment, and to assist the family in creating an aftercare plan to support long-term change. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. The enrollee is at a low risk of harm and has a support system in place. The enrollee is able to develop a trusting, positive relationship care providers. The enrollees composite LOCUS score correlates with Level II; however, due to a score on Dimension V, the recommended level of care is Level III, high intensity, community-based care.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The enrollee requested reimbursement for CustomNext-Cancer 81-gene testing panel. The genetic counselor ordered a genetic testing sample. Literature shows this panel includes 81 hereditary cancer predisposition genes associated with many different types of cancer; including breast, ovarian, prostate, pancreatic, colon, and gastric. Due to her mother's history, she meets criteria for testing of various genes related to the susceptibility to pancreatic cancer. These genes would be reasonable for testing; however, others on the panel would not support a result of improvement in health outcome. The 81-gene comprehensive panel includes genes unrelated to the hereditary predisposition to cancers that have been present in her family.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in clinical genetics 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

The enrollee is requesting authorization and coverage for the medication Cimzia. The enrollee has a history of type 2 diabetes mellitus and necrobiosis lipoidica diabeticorum. She has been experiencing exacerbations of necrobiosis lipoidica diabeticorum, with red nodules, itching, and pain. She has tried multiple medications, and none of these have relieved her symptoms. A case study demonstrated successful treatment of necrobiosis lipoidica with adalimumab, an anti-tumor necrosis factor medication. However, researchers report a larger sample size is needed, and the response to the medication in both diabetic and non-diabetic individuals requires further study. Literature shows necrobiosis lipoidica is a difficult disease to manage, despite a large number of treatment options. Randomized control trials are lacking to evaluate the many treatment methods and establish a standard plan of care. This enrollee tried and failed multiple medications; including three anti-tumor necrosis factor medications. The records do not provide sufficient information as to why an additional anti-tumor necrosis factor medication would be beneficial.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. 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 patient has requested authorization and coverage for computed tomography (CT) scan of the chest. Given this patients history of chronic symptoms, smoking, and occupational inhalational exposure, the American College of Radiology (ACR) supports a CT of the chest without contrast with high-resolution imaging. The bilateral upper lobe ground glass opacities on recent imaging are interstitial lung changes. A repeat CT would be helpful to evaluate resolution, progression, and other interstitial lung conditions not well depicted on chest radiography (Ferguson and Berkowitz). There is no need for use of intravenous (IV) contrast with the CT imaging. Given these findings, the requested CT scan of the chest is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. Based on the available documentation and current medical literature, proton radiation therapy is not considered the standard of care for this patients recurrent invasive squamous cell carcinoma. The American Society for Radiation Oncology (ASTRO) does not support the use of proton radiation therapy for management of pelvic malignancies outside the context of a prospective clinical trial. Currently, there are insufficient high quality clinical trials demonstrating improved health outcomes with use of proton beam radiation therapy in this setting. The standard of care remains intensity modulated radiation therapy for treatment of this patients recurrent disease. Therefore, the requested PBRT is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services 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 radiation 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: The patients parent has requested authorization and coverage for Xolair 300 mg every two weeks for six months administered in the doctors office. This patient has a history of poorly controlled allergic rhinitis and mild persistent asthma. Based on current data and U.S. Food and Drug Administration (FDA) approval, Xolair is not indicated for the treatment of allergic rhinitis or mild persistent asthma. Xolair is supported for the treatment of moderate to severe persistent asthma uncontrolled on inhaler therapy. The records provided for review document that treatment with inhaled corticosteroids has adequately controlled this patients asthma. For these reasons, the requested Xolair 300 mg every two weeks for six months, administered in the doctors office, is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication and services 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 internal medicine with subspecialty certification 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for omeprazole DR 40 mg capsule. Since proton pump inhibitors do not correct the underlying pathophysiological motor abnormalities responsible for reflux, ongoing treatment at a sufficient dose is appropriate to maintain remission in patients with gastroesophageal reflux disease (GERD). Insufficient acid suppression can result in complications. Multiple studies show superior healing of erosive esophagitis with omeprazole 40 mg daily dosing rather than 20 mg daily. This patient has GERD and erosive esophagitis. Her symptoms are partially due to mechanical defects in esophageal motility. The records document that the patient has not experienced sufficient control with omeprazole 20 mg daily. Her provider recommended an increase in dosing to 40 mg, which is consistent with the current guidelines and medical literature. Given this support, the requested omeprazole DR 40 mg capsule is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 subspecialty 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 Qualitest brand hydrocodone/acetaminophen (Norco) 10/325 mg, 10 per day (300 per month).The patient has a long-standing history of chronic pain and has been on 10 Norco tablets daily to manage her pain for the past six years. She has x-ray proven osteoarthritis of her hands and feet, but the work up for connective tissue disease by her PCP was negative. Her Rheumatologist has advised her to follow up with her PCP and Pain Management. Her PCP has expressed concern regarding the quantity of tablets being used daily and offered a conservative tapering plan of her medications beginning with an allowance of 8.5 tablets daily with a decrease of one-half tablets per month in conjunction with Pain Management treatment. The patient has declined this offer and is requesting 10 tablets daily of Qualitest brand hydrocodone/acetaminophen only. The most recent European best practices guidelines from 2017 clearly state that chronic opioid therapy is not indicated for fibromyalgia, and this recommendation came with a strong consensus. Furthermore, the consumption of 10 Norco tablets daily carries with it a significant acetaminophen burden of over 3000 mg a day. The current best practices guidelines recommend that patients keep their daily acetaminophen consumption to under 2000 mg a day. Accordingly, the requested Qualitest brand hydrocodone/acetaminophen (Norco) 10/325 mg, quantity of 10 per day (300 per month), is not medically necessary to treat the patients medical condition.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 subspecialty 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: The patient has requested authorization and coverage for Aubagio tablets. The American Academy of Neurology (AAN) practice guidelines for disease-modifying therapies (DMTs) for adults with multiple sclerosis states that a change in therapy injection fatigue or injection-related pain or discomfort may be a common reason for poor adherence. Clinicians should discuss a change to non-injectable or less frequently injectable DMTs in people with MS who report intolerable discomfort with the injections or in those who report injection fatigue on injectable DMTs. According to the AAN, there are reports of progressive multifocal leukoencephalopathy (PML) with the use of both Gilenya and Tecfidera. The U.S. Food and Drug Administration (FDA) has approved Aubagio for the treatment of relapsing-remitting MS at 14 mg dose once daily. A review of a study compared the efficacy and safety of oral agents for the treatment of relapsing-remitting MS. The authors reported that clinical trials of Aubagio showed efficient annualized relapse rate and disability progression outcomes comparable to first-line drugs. This patient has relapsing remitting MS with symptoms of injection fatigue and side effects related to weekly injections with Avonex. Per the AAN practice guidelines, it is appropriate to switch to a non-injectable DMT. Two of the formulary alternatives, Copaxone and Extavia, are injectable DMTs and would not be appropriate for this patient. Gilenya and Tecfidera are oral DMTs but are not recommended given the patients JC virus seropositive status and risk for PML. Given these findings, the requested Aubagio tablets are 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel. Acthar Gel is U.S. Food and Drug Administration (FDA) approved therapy for the management of nephrotic syndrome (NS). Acthar Gel is not FDA approved or supported in the current medical literature for use as first-line therapy. Based on current data, Acthar Gel is reserved for patients with refractory NS. Madan and colleagues concluded that, Acthar gel may meet an important treatment need in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. This patient has NS that has not adequately responded to first-line therapy with corticosteroids. For these reasons, the requested Acthar Gel is medically necessary for 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 subspecialty certification in nephrology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.