Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for transoral incisionless fundoplication with EsophyX device. Based on the records provided for review, this patient has not exhausted standard conservative therapies for the treatment of GERD. Specifically, there is a lack of documentation that the patient has attempted lifestyle modification or maximal medical therapy. Moreover, there is a lack of peer-reviewed medical literature or guidelines reporting that transoral incisionless fundoplication is superior at long-term follow-up when compared to other standard operative techniques such as Nissen fundoplication. All told, the requested transoral incisionless fundoplication with EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trulicity 1.5 mg/0.5 mL pen. The records provided for review demonstrate that this patients type 2 diabetes mellitus is poorly control with a hemoglobin A1C of 8.8% on a regimen of metformin with glimepiride. As recommended by the American Diabetes Association (ADA), a target hemoglobin A1C should be less than 7% to decrease the risk of vascular complications. The ADA also encourages diet management and weight loss for improved glycemic control. The patients records demonstrate that she lost two pounds with diet management and continued on metformin and glimepiride, and her hemoglobin A1C had improved to 7.4%. After initiating Januvia, which is a dipeptidyl peptidase 4 inhibitor (DPP4-i), this patients hemoglobin A1C increased to 7.7% with further decrease in her weight. Due to the rise in hemoglobin A1C, her provider recommended the addition of Trulicity to her current combination of metformin, glimepiride, and Januvia. Trulicity is a glucagon-like peptide-1 receptor agonist (GLP-1). According to the ADA, the current data have not established a clinical role for the combined use of a GLP-1 agonist and a DPP4-i in this clinical setting. Therefore, the requested Trulicity 1.5 mg/0.5 mL pen is not medically necessary for this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine 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 Lantus Solostar insulin pens (U-100 insulin 100 units/mL (3 mL) subcutaneous insulin pen). This patient was diagnosed with type 1 diabetes mellitus at age 23. The patient is currently using Lantus Solostar insulin via pen, but he has used Lantus insulin via the vial in the past. Lantus is a once daily, long-acting insulin analog specifically designed to provide basal insulin requirements. There are multiple ways to inject insulin, such as with a vial and syringe or by using a pen device. Although newer, pen devices offer several benefits over a vial and syringe including more accurate dosing, which is associated with improved patient adherence. Given this support, the requested Lantus Solostar insulin pens (U-100 insulin 100 units/mL (3 mL) subcutaneous insulin pen) 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco. The Centers for Disease Control and Prevention (CDC) guidelines state that, clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The Federation of State Medical Boards guidelines report that, continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. The records provided for review document that this patient sustained a non-displaced left tibial fracture. The provider advised that the patient does not need to be evaluated for acute or subacute pain. The provider also reported that the patient is not a good candidate for opioid therapy since the benefits of treatment do not outweigh the potential risks. The records reviewed do not include a current Controlled Substance Utilization Review and Evaluation and System (CURES) report demonstrating continued compliance with her opioid regimen. The CDC guidelines recommend providers to discontinue opioid therapy in patients where the risks outweigh the benefits. Accordingly, the requested Norco is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a positron emission tomography (PET) scan (CPT 78813) of the whole body.The submitted documentation supports that the requested services are medically necessary. The patient's pathology indicates adenocarcinoma of the cervix. Based on National Comprehensive Cancer Network (NCCN) Guidelines for imaging related to cervical cancer, positron emission tomographycomputed tomography (PET/CT) is the preferred imaging for initial work up of cervical cancer. Additionally, the patient has had extensive imaging in the recent period preceding her diagnosis, with most recent computed tomography (CT) imaging of the abdomen/pelvis on, and magnetic resonance imaging (MRI) of the abdomen. There would be no medical benefit to re-doing these imaging modalities, especially since PET/CT could be useful for demonstrating more advanced disease, including pelvic lymph node involvement. Additionally, radiotherapy is an option for adjuvant therapy, and PET/CT is a useful modality for radiation therapy planning. Therefore, the request for PET/CT for initial staging prior to surgery is medically necessary and accepted as a standard of care for initial imaging assessment for this patient for staging and possible therapy planning. Accordingly, the requested positron emission tomography (PET) scan (CPT 78813) of the whole body is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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 medical 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 10/325 (30 tablets/30 day supply) until hip surgery may be performed.In this case, the patient has advanced joint disease affecting the left hip, and she has been evaluated by two orthopedic surgeons who both recommended total hip replacement. The procedure has been postponed due to the COVID-19 pandemic. In the interim, the patient has tried and failed conservative care including ibuprofen, Tylenol, gabapentin, and activity modification which were advised by her treating provider. The patients current pain levels are reportedly 10 out of 10 on the Visual Analogue Scale (VAS), and the patients pain is adversely impacting her ability to perform her activities of daily living and her quality of life. The patient has requested one Norco tablet per day as needed for pain because non-opioid medications have failed to provide relief until she is able to have her surgery. CDC guidelines advise providers to explore non-opioid and non-pharmacologic treatment of pain as an initial step, however, when these measures fail to provide relief, they do not discourage the use of sensible prescribing of opioids to low risk individuals with documented pathology. CDC guidelines also acknowledge that the use of a short course of opioid therapy has been shown to be effective in managing pain, which is the situation in this case, since the medication is requested as a bridge until the patients joint surgery can be performed. Similarly, Federation of State Medical Boards guidelines also recommend opioid therapy for patients who are unresponsive to conservative care and in such cases to use the lowest possible dose, which is the case in this situation. The patient has end stage hip disease with pain scores rated as 10 out of 10 with impairment of her activities of daily living. In addition, ASIPP guidelines provide risk stratification for opioid dosing noting that the levels below 40 mg of morphine equivalents is low risk for adverse outcomes. Consistent with this guidance, the patient is requesting the equivalent of 10 mg daily. Under these circumstances, the requested medication, Norco 10/325 (30 tablets/30 day supply) until hip surgery may be performed, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty certification in pain 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 patients parent has requested authorization and coverage for 22 additional hours (total 40 hours) per week of direct applied behavioral analysis (ABA) therapy services (CPT 97153). Based on the guidelines set by the Behavior Analyst Certification Board (BACB), comprehensive ABA programs consisting of 30-40 hours per week treatment intensity are based on the clients response to treatment and current needs. Per the BACB, decreases in hours of therapy per week typically occur when a client has met a majority of the treatment goals and is moving toward discharge. This patients records document diagnoses of autism and ADHD. The patients current behavioral issues support an indication for treatment with ABA therapy services. The patients treatment plan highlights 21 goals. However, the patient has shown significant progress in nearly all of his goals. Based on the number of goals and the patients response to treatment and increase to 40 hours are not medically necessary, as the patient has made significant progress with much fewer hours from previous authorization periods. Additionally, the patient does not meet all of the criteria outlined in the medical necessity definition by Papatola and Lustig. The authors noted that, health-care services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on the presenting information, the patient does not meet criterion (c), as the level of treatment is not consistent with scientifically based guidelines regarding ABA services. The patient is noted to be engaged in low levels of maladaptive behaviors. For these reasons, the requested 22 additional hours (total 40 hours) per week of direct ABA therapy services (CPT 97153) are 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 a licensed B.C.B.A, board certified in psychology, 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 Xolair 300 mg administered every two weeks in the providers office. The records provided for review document that this patients medical history is significant for allergic rhinitis and severe persistent asthma. The patient has been treated with combination therapy consisting of inhaled corticosteroids and long-acting beta-agonists with fluticasone furoate and vilanterol. Severe asthma warrants aggressive and phenotype-specific management. The patients provider recommended anti-IgE biologic therapy with Xolair based on the allergic phenotype of his asthma, which resulted in significant improvement in asthma control. Xolair is U.S. Food and Drug Administration (FDA) approved for allergic-type asthma in patients who have failed combination inhaled corticosteroids and long-acting beta-agonists. Given the risk of serious allergic reaction, the standard of care is to give the injection in the providers office to enable monitoring of side effects. Treatment with Xolair is within the standard of care for the management of asthma in this patient. Therefore, the requested Xolair 300 mg administered every two weeks in the providers office is medically necessary for treatment of this patient. 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 internal medicine with subspecialty certifications in pulmonary disease and critical care 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

The patient has requested authorization and coverage for Trulance. Researchers reported plecanatide significantly improved constipation and its related symptoms with a low rate of adverse events. These results suggest that plecanatide will be a useful treatment option in the management of chronic idiopathic constipation (CIC). In this case, the patient reported ongoing constipation over three months, without a cause identified on clinical examination or colonoscopy, consistent with chronic idiopathic constipation. The patient reported that MiraLax, laxatives, stool softeners, and Amitiza were ineffective. The medical evidence supports the requested medication in this clinical setting. Therefore, Trulance 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: Overturned Decision of Health Plan

The patients parent has requested reimbursement for mental health residential treatment center (RTC) level of care services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The patient has a composite score which is consistent with medically monitored residence based services, such as RTC. Therefore, the mental health RTC services were medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 with subspecialty 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

The patient has requested reimbursement for ThyGeNEXT and ThyraMIR genetic testing of thyroid nodules provided by Interpace Diagnostics. Per the American Thyroid Association (ATA) guidelines, patients with thyroid nodules with atypia of undetermined significance (AUS) or FLUS cytology, repeat fine needle aspiration (FNA) or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Researchers reported that high sensitivity and specificity are obtained using the combination testing of ThyGeNEXT and ThyraMIR as demonstrated in two different studies that combined these tests for indeterminate thyroid nodules. The records provided for review document that the results of the genetic test were critical to determine whether to perform a total thyroidectomy versus observation. As this patient had a thyroid nodule with FLUS pathology results, the genetic testing was indicated to help establish whether the patients tumor was malignant and guide treatment decisions. All told, the ThyGeNEXT and ThyraMIR genetic testing of thyroid nodules provided by Interpace Diagnostics was medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Linzess 290 mcg capsules once daily. Linzess is indicated to restore colonic function in chronic constipation, and is U.S. Food and Drug Administration (FDA) approved for chronic constipation. Linzess has a different mechanism of action than osmotic laxatives and stimulant laxatives, and can be effective even when those agents have failed. In multicenter, randomized, blinded, placebo-controlled clinical trials, Linzess significantly increased weekly spontaneous bowel movements while reducing abdominal pain in patients with chronic constipation. A dose- ranging study tested Linzess doses of 290 mcg and 580 mcg daily for the treatment of chronic constipation and found them to be safe and effective. For this patients chronic constipation, Linzess dosed at 145 mcg daily was ineffective. Therefore, the requested Linzess 290 mcg capsules once daily 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 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.