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

Nature of Statutory Criteria/ Case Summary: The enrollee has requested authorization and coverage for weight loss surgery involving CPT code 43644 (laparoscopy, surgical, gastric restrictive procedure with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm of less), CPT code 43846 (Gastric restrictive procedure, with gastric bypass, for morbid obesity, with short limb (less than 100 cm) Roux-en-Y gastroenterostomy and two days of inpatient acute hospitalization. The health plan has denied this request as not medically necessary. A review of the records indicates this enrollee was evaluated by her surgeon for gastric bypass weight loss surgery. She previously weighed 215 pounds but had reduced her weight to 193 pounds using a professionally monitored weight loss program with exercise. Her co-morbidities, potentially associated with morbid obesity, are obstructive sleep apnea (OSA), gastroesophageal reflux disease, osteoarthritis of the knees and lumbar disc disease. Her body mass index (BMI) had been equal or greater than 35. She also had a psychiatric evaluation done and successfully completed a professionally monitored weight loss program. The enrollee wanted to proceed with a Roux-en-Y gastric bypass weight loss surgery proposed by her surgeon. According to the medical literature, a consensus panel indicated that bariatric surgery is appropriate for all patients with a BMI (kg/m2) greater than 40 and for patients with a BMI between 35 to 40 with associated co-morbid conditions. Bariatric/metabolic surgery is currently the only effective long-term treatment for morbid obesity and obesity-related diseases, such as diabetes, heart disease, hypertension, obstructive sleep apnea and dyslipidemia. Bariatric/metabolic surgery has also been shown to significantly reduce the incidence of diabetes and cancer and prolong life when compared to non-surgical therapies. The records show this patient has life threatening comorbidities, including obstructive sleep apnea. The patient has shown compliance with the required weight loss and exercise program. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the Acessa procedure, laparoscopy and surgical ablation of uterine fibroids with an out-of-network provider. The health plan denied this request as experimental/investigational. A review of the records indicates this enrollee has uterine fibroids. Her medical history includes a significantly irregular menstrual cycle due to perimenopause and a benign endometrial biopsy. A magnetic resonance imaging (MRI) revealed she has a uterine fibroid measuring 11 centimeters (cm) by 9.8 cm by 8.9 cm that occupies the majority of her uterus. Of note, her entire uterus measured 13 cm by 11 cm by 11 cm. The enrollee was treated with the medication, ulipristal, for an unspecified duration of time. It improved her overall pain, but it caused mood side effects. The enrollee had a consultation with interventional radiology, and she was not interested in proceeding with a uterine artery embolization (UAE). Although the Acessa system is approved for treatment of uterine fibroids, it is not evident this would be an appropriate treatment modality for this enrollee. Studies are limited to use of the system in patients with fibroids measuring up to 10 cm. The size of the dominant fibroid of 11cm in this enrollees uterus falls outside of the studied size range, as noted in her most recent MRI. More clinical studies are needed to support the safe and effective treatment of this procedure in patients with a large fibroid burden.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 Obstetrics and Gynecology 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:  The enrollee has requested reimbursement for residential treatment center services. Review of the medical records indicates the patient has a history of substance abuse, underwent detoxification and was admitted to a residential treatment center. She experienced headaches, anxiety, panic, overeating, fear based thought patterns, avoidance behaviors, anger, depression, fatigue, and difficulty concentrating. She was committed to recovery and trying to develop a sober support system and find a sponsor. She was working on confronting her denial. She had anxiety, cravings, using dreams, worthlessness, depression, insomnia, headache, panic, worries about her finances and her living situation, and maintaining sobriety with her cravings and anxiety. She worked on coping skills, awareness and knowledge of unhealthy dynamics. The medical literature indicates that residential treatment is primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. Residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse. In this case, the patient was considered in need of 24 hour residential treatment, as she had continued alcohol use, despite negative consequences. She suffered financial and medical consequences and was isolated from friends and family. She still needed 24 hour treatment during this time period. It was not likely that she could remain abstinent outside of a 24 hour therapeutic structured and supervised residential treatment setting in order to work on improving coping skills, identify relapse triggers, and deal with cravings and anxiety. She was started on Naltrexone during this time to better deal with cravings. She came from an inpatient detoxification treatment and required further inpatient treatment to work on these issues and give her the best chance of abstinence. Final Result: The reviewer determined that the requested therapy was 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Invokana. Sodium-glucose cotransporter 2 (SGLT2) inhibitors, such as Invokana, are U.S. Food and Drug Administration (FDA) approved to be used in type 2 diabetes, but not type 1 diabetes. A few small studies in type 1 diabetes have shown benefits of SGLT2 class of medication on improving glycemic control, lower insulin dosing and weight loss. In 2017, short-term phase II trials and 24-week phase III trials provided initial support for the use of SGLT2 inhibitors in type 1 diabetes. However, longer-term clinical trials and observational cohort studies are needed to determine the overall benefits and potential adverse effects of SGLT2 therapy in type 1 diabetes. There is also an increased risk of fungal infections and reports of diabetic ketoacidosis associated with use of SGLT2 inhibitors in patients with type 1 diabetes. Currently, there is a paucity of large scale randomized clinical trials of SGLT2 inhibitors in type 1 diabetes establishing the benefits and safety of this therapeutic regimen. As standard proven therapies remain available for treatment of this patients type 1 diabetes, the requested Invokana 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 Invokana 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 Invokana is not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism 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

An enrollee has requested authorization and coverage for Dupixent. The submitted documentation supports the medical necessity of the requested medication. This patient tried and failed topical medications as well as oral steroids. Per the submitted documentation, a treatment trial with tacrolimus ointment was ineffective. Dupixent is the only U.S. Food and Drug Administration (FDA) approved biologic for atopic dermatitis. There is no other FDA approved biologic therapy, and there is no step therapy associated with biologic use for atopic dermatitis. In the setting of moderate to severe atopic dermatitis, the use of Dupixent is medically appropriate when topical medications are ineffective. Therefore, Dupixent 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Dexcom G6 continuous glucose monitoring system (CGMS). Per the current consensus statement from the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE), the choice of diabetes therapies must be individualized based on the specific attributes of each patient and the available medications. Medication attributes that affect this choice include: antihyperglycemic efficacy; mechanism of action; risk of inducing hypoglycemia; risk of weight gain; other adverse effects; tolerability; ease of use; likely adherence; and safety or risk reduction in heart, kidney, or liver disease. Minimizing the risk of both severe and non-severe hypoglycemia is a priority. Self-monitoring of blood glucose is necessary in all patients taking insulin, with increased frequency of monitoring recommended for patients taking meal-time insulin. One safety measure for prevention of hypoglycemia is the use of a CGMS that provides real-time glucose data and alarms for hyperglycemic and hypoglycemic events. A 2019 meta-analysis by Ida and colleagues found that, compared with the self-monitoring blood glucose group, the CGMS group exhibited significantly lower hemoglobin A1c levels. This patient has diabetes mellitus type 2 with severe insulin resistance and multiple complications. He is being managed with continuous insulin infusion pump therapy, which requires the patient to make decisions based on glucose levels. This places the patient at risk for glucose fluctuations and hypoglycemia. In addition, he has neuropathy, nephropathy, sleep apnea and heart disease, which increases his risk of hypoglycemia. The real-time Dexcom G6 CGMS will likely decrease the patients episodes of hyperglycemia and hypoglycemia. Further, the Dexcom G6 includes a new alert that is triggered when an algorithm predicts that an estimated glucose value, allowing patients more time to act to avoid hypoglycemia. Therefore, the requested device, the Dexcom G6 CGMS is medically necessary to improve the management and control of this patients diabetes mellitus.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 internal medicine with subspecialty certification in diabetes, endocrinology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage with an out of network provider for a tolerance induction therapy program. The health plan denied this request as experimental/investigational. Findings:  The three physician reviewers found that a review of the medical records indicates this patient has been treated in a tolerance induction therapy program due to his diagnosis of food allergies. His food allergies include nuts, eggs, coconut and soy. The tolerance induction therapy program involves increasing the patients diet, as tolerated, and incorporating a food strategy, treatment food and food challenges. The enrollees treating physician, indicated the tolerance induction therapy program is different from oral immunotherapy and all other desensitization programs. Graduates are able to tolerate large and infrequent doses of their allergens, which allow them to maintain a normal diet without restriction or fear of a reaction. According to the medical literature, the standard of care is to avoid foods and have the administration of emergency medication upon exposure.  The fundamental strategy of oral immunotherapy is to mitigate adverse immune responses to allergenic food proteins through repeated exposure. The reduced reactivity to food allergens often results, but the establishment of sustained immune unresponsiveness or of a permanent resolution is not certain.  As a result, further studies are needed in this area. 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 Allergy and Immunology 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: The enrollee has requested authorization and coverage for anastrozole.Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.  Aromatase inhibitors, such as anastrozole, offer effective and convenient aromatase inhibition, which correlates well with decreases in the levels of plasma estrogens. Testosterone replacement therapy is indicated when an enrollee has low testosterone. Anastrozole has been used for the treatment of male hypogonadism. Anastrozole increases testosterone levels by lowering serum estradiol (E2) levels and increasing gonadotropin levels. When used with clomiphene, anastrozole has been shown to be safe and effective to use in hypogonadal men to promote fertility. Anastrozole also has been shown to aid in sustaining the therapeutic testosterone levels in men undergoing testosterone pellet treatments. In addition, there is adequate support for use of anastrozole therapy to treat patients with hypogonadism. The records suggest that the provider recommended anastrozole to decrease the enrollees plasma estrogens in conjunction with testosterone replacement therapy. Given these findings, the requested anastrozole is medically necessary for the treatment of this enrollee.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology 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

The patient has requested authorization and coverage for Noxafil DR 100 mg. Coccidioidomycosis, more commonly referred to as Valley fever, can cause severe symptoms including fever, night sweats and weight loss to fatigue, chest pain and cough. Pneumonia and disseminated disease can also occur. In the medical literature, colleagues noted that Valley fever remains difficult to treat, especially when patients have not responded to therapy with drugs that were recommended in treatment guidelines. The authors found that the success rate suggests that oral posaconazole should be considered as an important agent for the treatment of refractory coccidioidomycosis. This patients persistent right lower lung mass not reportedly improved despite treatment with Diflucan. Given this support, the requested Noxafil DR 100 mg is supported as 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 internal medicine with subspecialty certification in pulmonary 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for custom foot orthotics. After careful review of the enclosed information and the pertinent guidelines and medical literature, the requested custom foot orthotics for this patient are medically necessary. The patients physical evaluation during the medical visit documented significant biomechanical changes to his feet. Specifically, the patient is noted to have a rear foot valgus, compensating forefoot varus, and a hypermobile first ray, which all lead to painful contracted second toes bilaterally. The provider recommended that the patient be fitted with custom foot orthotics to hold his feet in a proper biomechanical position allowing for reduction of foot pain. Custom foot orthotics will also defer further improper pull of muscles and tendons leading to a more significant hammertoe. Therefore, the requested custom foot orthotics are 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 podiatry 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 patient is a female diagnosed with asthma, type 2 diabetes, fibromyalgia, hallux valgus with bunions, and chronic low back pain with bilateral sciatica. The patient reported that she was unable to walk to a bus stop and was unable to sit on a bus for prolonged periods of time due to back pain. The patient underwent a functional mobility assessment. The patient was able to ambulate in her home without the use of a walker. She has a history of using a four-wheeled walker with a seat for ambulating longer distances in the community. The patients home was not wheelchair accessible. The patients upper and lower extremity strength was noted to be within functional limits. Her sitting and standing balance was intact. There was no history of falls. The patient has requested coverage for a power operated vehicle (motorized scooter). The Health Plan denied the request and reported the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a power operated vehicle (motorized scooter) is medically necessary for treatment of the patients medical condition. In this case, the record does not document functional mobility limitations that impair the patients ability to participate in her activities of daily living (ADL), and there is no mobility limitation that is not correctable by cane or walker. The patient can ambulate in her home with or without a walker and historically has used a four-wheeled walker for ambulating longer distances in the community.  There is no described absence of upper extremity function preventing the self-propelling of a manual wheelchair to perform her ADLs. The medical evidence does not support the requested equipment in this clinical setting. Therefore, the requested power operated vehicle (motorized scooter) 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 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.