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

Nature of Statutory Criteria/Case Summary:The patient has circadian rhythm sleep disorder, specifically non-24-hour sleep wake disorder. The medical records stated that the patient has a history of problems related to sleep initiation and management. Prior pharmacotherapy used for the patients condition included Silenor and alprazolam. The patient has requested coverage for Hetloiz. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Hetloiz is medically necessary for the treatment of the patients medical condition. The medical records provided for review do not support that this patient has a diagnosis of non-24-hour sleep wake disorder (non-24) as defined by current diagnostic standards. The practice guidelines do not support the use of Hetloiz in any circadian rhythm disorder. Further, there is more evidence to support the use of timed melatonin for treatment of non-24 versus Hetloiz. The available studies on Hetlioz have included patients in the blind population. While the U.S. Food and Drug Administration (FDA) granted approval for Hetloiz for non-24, this approval was not based on a body of published evidence. The current published evidence on the efficacy of Hetloiz is limited to its use in the blind patient population. Use of Hetloiz in the sighted population is not considered to be within the accepted standard of care. In this setting, Hetlioz is not medically necessary for this patient. Final Result: The reviewer determined that the requested service 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 neurology with subspecialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee is requesting authorization and coverage for a durable dental mouth guard. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device. The current literature recommends that a dental provider evaluate patients for adequate periodontal health and an absence of temporomandibular joint problems prior to use of an oral appliance. This is due to the potential side effects of oral appliance therapy, which include temporomandibular joint problems and tooth mobility.  The medical records do not document that such an evaluation took place. Thus, the provision of an oral appliance would not be consistent with the generally accepted standards of care in this clinical setting. There is a lack of support for the requested device in this patients case. Therefore, the requested durable dental mouth guard is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 neurology with sub-specialty certification in sleep 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 patients parent has requested reimbursement and prospective authorization and coverage for past in-home nursing services, and future in-home nursing services for up to 16 hours per day. Although dated, the Committee on Children with Disabilities continues to guide treatment decisions in the disabled pediatric population. The guidelines noted that the overarching goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensivehealth care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities. Further, children with special needs frequently require equipment at home to allow for safe and effective care. Such equipment may facilitate feeding and eating, toileting, bathing, safe sleeping, and mobility, as well as offer opportunities to achieve functional skills. This patient has a number of medical issues associated with her genetic condition. Her skilled nursing needs require 24-hour attention to monitor her airway, breathing, positioning, and feeding. During the day, it is reasonable to expect her family to provide for her needs, including the intermittent gastrostomy feedings and medication administration. However, at night, she receives continuous feedings. It is not reasonable to expect the family to continue bedside diligence overnight. Therefore, skilled nursing services were and are medically necessary for 12 hours per night, seven nights per week. Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certification in pediatric critical care 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 with a history of short stature. The patients height is less than 2 standard deviations (SDs) below the normal range for age and gender, and she is noted to have poor growth velocity. A prescription drug form reported the patient is consistently below the first percentile at -2.27 SDs below the mean. The provider has recommended treatment with growth hormone therapy. At issue in this case is whether Nutropin AQ NuSpin is medically necessary for treatment of this patient.The submitted documentation supports the medical necessity of the requested medication. Idiopathic short stature (ISS) is defined by a height below -2 SDs below the mean without findings of disease or pathology that can explain short stature. Growth hormone is approved by the U.S. Food and Drug Administration (FDA) for children with ISS whose current height is below -2.25 SDs below the mean, in whom the predicted adult height is unlikely to fall within the normal range, and the epiphyses are not closed. This patient has poor growth velocity of 3.82 cm per year, and her predicted adult final height of 152.4 cm based on her skeletal age is much shorter than her target mid parental height of 170.3 cm and lower than normal female in society of 154 cm. Her birth history, past medical history, and family history rule out constitutional delay of growth, puberty, and familial short stature. Her laboratory studies have been normal, which rule out other causes of short stature, including chronic medical conditions, hormone deficiencies, genetic conditions, medication use, and poor nutrition. Her insulin like growth factor (IGF-1) was also normal, indicating she does not have growth hormone deficiency. Given these findings, the requested Nutropin AQ NuSpin is medically necessary for 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 pediatrics with expertise in pediatric endocrinology 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 is diagnosed with major depressive disorder. The patient failed treatment with escitalopram, fluoxetine, and duloxetine. The patient was also treated with lamotrigine, Adderall, and armodafinil. The provider noted the patient is an ultra-rapid metabolizer and requires a higher dose of medication for efficacy. At issue in this case is whether Viibryd 40mg is medically necessary for the treatment of the patients medical condition. Viibryd is an effective antidepressant for the treatment of major depressive disorder. The records provided for review document that this patient has been stable on Viibryd 40mg. Prior treatment has included escitalopram, fluoxetine, duloxetine, lamotrigine, Adderall, and armodafinil. Further, he does not have any contraindications for treatment with Viibryd. The medical evidence supports treatment with Viibryd, at the requested dose, in this clinical setting. Therefore, Viibryd 40mg is medically necessary for the treatment of this patients major depressive disorder.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 psychiatry and geriatric 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 patient has requested authorization and coverage for a positron emission tomography (PET) with computed tomography (CT) for attenuation. PET/CT is the preferred imaging test to evaluate a patient with a history of multiple areas of tumor involving the abdomen and pelvis including the peritoneum in the setting of prior surgery. The therapy this patient has received in the past requires a scan showing metabolic activity in all areas of interest in order to assess the degree of residual tumor. The measurement of the standardized uptake value (SUV) on PET/CT increases the accuracy with which to evaluate tumor stability or progression. Since the PET scan will be fused with a CT at the same time, the patient will not need a conventional CT scan. The PET/CT will be compared to prior similar studies, which will make the assessment of tumor activity more reliable than with conventional CT alone. Given these findings, the requested PET scan with CT for attenuation is supported as medically necessary for further evaluation and treatment of this patients medical condition. 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 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

Patients symptoms include scaling, hyperpigmentation in the upper and lower extremities and achy, painful joints.  Previous therapy has included methotrexate, betamethasone, fluocinonide, ketoconazole, and naproxen. The patient is also taking lefunomide 10mg daily with good relief of his arthritis and skin complaints. The patient had knee pain that worsened with activity. Physical examination findings on 11/30/18 revealed scaling on the right forearm, left elbow, and knees, with hyperpigmented areas. Crepitus of the patella was noted and knee range of motion was decreased. At issue in this case is whether Otezla 30mg is medically necessary for the treatment of this patients medical condition. Current literature supports the use of conventional and biologic agents, including anti-tumor necrosis factor (TNF) agents over the use of targeted synthetic biologics such as Otezla for the treatment of psoriatic arthritis. Otezla should be reserved for patients unable to take disease-modifying antirheumatic drugs, which have proven safety and efficacy. Otezla is an orally administered phosphodiesterase-4 inhibitor available for the treatment of psoriatic arthritis, but it is not currently known to be disease modifying. In this case, the patients medical records indicate a history of plaque psoriatic arthritis. The record demonstrated that the patient had good control of arthritis and no active synovitis on history or examination while on leflunomide and naproxen. Minimal skin disease was noted. The patient has no history of failure or U.S. Food and Drug Administration (FDA) recognized contraindications to biological disease-modifying antirheumatic drugs. The records fail to demonstrate any contraindications to tumor necrosis factor inhibitor (TNFi) agents. The medical evidence does not support the requested medication in this clinical setting. Therefore, Otezla 30mg is not medically necessary for the treatment of this patient.   Final Result: The reviewer determined that the requested service 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 certifications in allergy and immunology and rheumatology 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 diagnosis of thoracic and lumbar segmental dysfunction. She has a long history of chronic upper and lower back pain. She was reportedly diagnosed with scoliosis as a child and hurt her back. She has been receiving therapy, chiropractic, and acupuncture. She reports that chiropractic care improves her symptoms and enables her to perform activities of daily living. Her provider states that chiropractic care helps the patient maintain functional capacity. She has been receiving chiropractic services about 20 times a year. She reports that when she is not seen, her pain level increases and she has difficulty with daily activities.The patient is receiving chiropractic care as maintenance therapy, which is defined as a treatment plan that seeks to prevent disease, promote health, and prolong or enhance the quality of life; or therapy is that is performed to maintain or prevent deterioration of a chronic condition. Despite the claimant stating that she benefits from treatment, there is no new injury and she is receiving maintenance care. When further clinical improvement cannot reasonably be expected from continuous ongoing care, the chiropractic treatment becomes supportive rather than corrective in nature. As in this case, continued chiropractic treatment is considered maintenance therapy and is not medically necessary.Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a board certified chiropractor and licensed in oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with palmar hyperhidrosis. The patient described that the sweating of his hands is intolerable and interferes with his ability to perform activities of daily living. Physical examination revealed that his skin was normal in temperature, turgor, and texture. No prior treatments have reportedly been tried for his palmar hyperhidrosis. Studies found that because of the potential complications of Botox injections in the palmar region, it is not considered first-line therapy for the management of palmar hyperhidrosis. Other potential treatments for hyperhidrosis such as over-the-counter antiperspirants, prescription strength or clinical strength antiperspirants, iontophoresis, or oral medications, have not reportedly been tried. The physical examination indicated that the patients skin was of normal temperature, turgor and texture and there was no documentation of increased moisture on the patients skin. Based on these reasons, the requested Botox injections are not medically necessary for treatment of this patients medical condition.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 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: The patient has requested authorization and coverage for Lyrica 50 mg. In the medical literature recently conducted a review of Lyrica for neuropathic pain in adults concluded that studies showed limited evidence of benefit in neuropathic back pain or sciatica, neuropathic cancer pain, or polyneuropathy. In addition, the North American Spine Society (NASS) guidelines concluded that there is insufficient evidence to make a recommendation for or against the use of gabapentin in the treatment of lumbar disc herniation with radiculopathy. In this case, the patient has reported low back pain with radiation into the right lower extremity consistent with the diagnosis of sciatica. A lumbar magnetic resonance imaging (MRI) revealed L5-S1 degenerative disc disease with partial right lateral recess stenosis which correlates with her clinical symptoms. She has tried and failed physical therapy due to pain. The providers notes state that her treatment has consisted of medication management with Lyrica, Naproxen, Percocet, Norco, Lidoderm patches, tizanidine and gabapentin. The providers notes do not state that the patient has tried and failed neuropathic agents from other drug classes including anticonvulsants and tricyclic acid medications. The patient reports that in early 2018 she was started on Lyrica 50 mg three times a day and found this to be helpful in managing her sciatic pain. However, based on the current medical literature, there is limited evidence to support the use of Lyrica for the treatment of sciatic pain. Accordingly, the requested Lyrica 50 mg is not medically necessary for treatment of this 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Repatha SureClick Auto-Injector. Findings:  The physician reviewer found that this patient has established coronary artery disease (CAD) and his goal LDL should be 70. He is on maximally tolerated statin therapy of rosuvastatin at 20 mg. His Lpa is elevated and he is being referred for Repatha therapy to lower LDL further and also to lower Lpa. Clinical notes specifically reference lowering the patients lipoprotein (A) (Lpa), which is the reason given for not adding ezetimibe, as this would not significantly lower his Lpa. Although the patients Lpa may be used as an additional risk factor to assess the need for statin therapy under current American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, and there is some data that PCSK-9 inhibitors are effective at lowering Lpa, the current data is limited and short-term. Further, the current ACC/AHA clinical guidelines do not currently target Lpa lowering as a goal for therapy. In addition, Lpa levels have not been shown to affect recurrent ischemic events in patients after acute coronary syndromes. The ACC/AHA guidelines recommend LDL lowering to a goal of 70 in patients with established disease, using both maximally tolerated statin therapy and ezetimibe in combination. If the patients LDL goal is not reached with this combination therapy, PCSK-9 inhibitors can then be considered for use to lower LDL to goal of less than 70. This patients records do not document an adequate trial of multi-drug therapy with maximal statin and ezetimibe, prior to consideration of Repatha SureClick. All told, the requested Repatha SureClick is not supported as medically necessary for treatment of this 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 internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology 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.