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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sumatriptan 100 mg 30 quantity. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic migraine.Findings:  Chronic migraine, as defined by the International Headache Society Classification of Headache Disorders, are migraine headaches greater than 15 days per month for greater than three months, and the headache is not attributable to another disorder. Per the documentation provided, the patients migraines are consistent with the International Headache Societys definition of chronic migraine. Treatment of chronic migraines should be centered around prophylactic therapy and lifestyle modification with limitation of acute headache medications.  Chronic use of acute migraine therapies predisposes a patient to medication overuse headache. There is evidence to suggest the effectiveness of a large number of medications including, but not limited to, topiramate, onabotulinumtoxinA, propranolol, amitriptyline, valproic acid, gabapentin, memantine, zonisamide, and candesartan. Medication overuse headache describes a headache occurring 15 or more days a month and developing as a result of overuse of acute headache medications for an extended period of time.  Triptan overuse is one of the most common causes of medication overuse headache. There is a lack of evidence supporting daily use of sumatriptan at the requested quantity for management of migraines.  Additionally, there is good evidence to suggest that overuse of this medication can lead to additional disease process.  In sum, sumatriptan 100 mg, 30 quantity for the management of chronic migraines has not been demonstrated as medically necessary.Final Result: The reviewer has determined that the requested medication quantity 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Crinone 8% gel. The Health Plan has denied this request indicating that the requested medication is not considered investigational for treatment of the enrollee who is in her first trimester of pregnancy. Findings:  The medical literature does not support the superior efficacy of the requested medication in this clinical setting. Supplemental vaginal progesterone therapy is not routinely prescribed for women with recurrent pregnancy loss (RPL) once a pregnancy has been established. Treatment with vaginal progesterone therapy has not been shown to increase live birth rate. Although there are other smaller studies with variable results, these studies are include small sample size, poor methodology, and variable preparations of progesterone. Current guidelines from the American Society for Reproductive Medicine are based on the large randomized trial that do not support supplemental vaginal progesterone therapy for the treatment of recurrent pregnancy loss once a pregnancy has been established. For these reasons, Crinone 8% gel is not likely to be superior to other methods of treating this patients medical condition.Final Result: All three reviewers have determined the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  All three reviewers are board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ injections for treatment of the enrollees short stature. Findings:  The physician reviewer found that The patients height and weight decelerated simultaneously, a pattern that is not consistent with growth hormone deficiency and is more likely to be related to decreased caloric intake and/or constitutional delay. The patients height is not greater than two standard deviations below the mean for age and gender. His bone age is not delayed, and IGF-1 level is not low. The provider noted a predicted adult height of 54. However, based on the patients bone age and height measurement, the estimated final adult height is approximately 68 inches using the Bayley-Pinneau method. This is a normal adult height that is appropriate for the genetic potential and not consistent with growth hormone deficiency. Growth hormone stimulation testing has poor specificity for the diagnosis of growth hormone deficiency, particularly in an unprimed child who is pre-pubertal or in early puberty. Thus, low growth hormone levels in response to stimulation testing cannot be taken as sole evidence of growth hormone deficiency. All told, Nutropin AQ injections are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification 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: An enrollee has requested authorization and coverage for total hip replacement of the right hip. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees right hip pain.In this patients case, evidence based peer-reviewed literature have been met for the requested services. The patient has chronic right hip pain that did not respond to conservative treatment or arthroscopy with debridement and chondroplasty. At the time of surgery, the provider found evidence of grade III and grade IV chondromalacia. According to the records, postoperative improvement was temporary and the patient continues to be in pain that interferes with activities with activities of daily living. There is objective evidence of limitation of motion consistent with the degree of osteoarthritis found at the time of surgery. The data indicates that results from a total hip replacement are very good. While the patients body mass index (BMI) is slightly over the recommended criteria, this is not a contraindication to the requested surgery. A review of the literature supports the surgical procedure for a total hip in this clinical setting. As such, total hip replacement of the right hip has been demonstrated as medically necessary for the treatment of this patients hip pain. Final Result: The reviewer determined the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified orthopedic surgery and 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 GeneSight Psychotropics. The submitted documentation fails to demonstrate the medical necessity of the requested services. Per the literature, there is a lack of evidence demonstrating improved health outcomes due to genetic testing. There is a paucity of head-to-head comparisons proving that genetic studies are of clinical benefit. There are some circumstances that genetic testing is done for safety reasons. This would be the case for a patient who is starting carbamazepine. The test would be for HLA-B*1502 allele to test for possible Stevens-Johnson syndrome and toxic epidermal necrolysis. The patient is not currently on carbamazepine, and the documentation did not report that this is a consideration. Therefore, GeneSight Psychotropics is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Durezol. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients cystoid macular edema. The submitted documentation supports the medical necessity of the requested medication. This patient has a history of chronic uveitis and cystoid macular edema responsive to high potency steroids. Given the severe nature of this patients condition, requiring high potency steroids to treat the inflammation, it is medically necessary to continue this class of medication until the inflammation has decreased enough to switch to an alternative or lower potency treatment. It would not be medically reasonable to switch to a lower potency steroid or nonsteroidal anti-inflammatory drugs during active inflammation, when current treatment is effective in decreasing inflammation. There is sufficient support for the requested medication in this clinical setting. Therefore, Durezol 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 ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested has requested authorization and coverage for small bowel capsule endoscopy. The Health Plan has denied this request indicating that the requested service is not medically necessary for evaluation of the patients gastrointestinal bleeding. The submitted documentation supports the medical necessity of the requested service. Current medical literature supports the medical necessity of small bowel capsule endoscopy. This patient has had overt gastrointestinal bleeding, and upper endoscopy and colonoscopy were unrevealing. The American Gastroenterological Association guidelines recommend video capsule endoscopy to evaluate patients with evidence of gastrointestinal bleeding when upper endoscopy and colonoscopy do not provide an explanation. The American Society for Gastrointestinal Endoscopy guidelines also recommend capsule endoscopy for investigation of gastrointestinal bleeding. As upper endoscopy and colonoscopy have not ruled out a small bowel source for bleeding, the medical literature supports the use of capsule endoscopy in this case. Finally, the patients symptoms are consistent with possible Crohns disease. Wireless capsule endoscopy is a useful test for the diagnosis of Crohns disease when other tests have been negative. For these reasons, small bowel capsule endoscopy is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested evaluation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for array-based evaluation of multiple molecular probes test and the advanced lipoprotein testing for evaluation of the enrollee who has a history of coronary heart disease.  Findings:  The physician reviewers found that The American College of Cardiology/American Heart Association Task Force on Practice ACC/AHA guidelines do not support the use of the advanced lipoprotein analysis over standard lipid measurements. Despite some researchers advocating for use of the advanced lipoprotein analysis, ACC guidelines do not support the use of advanced lipid testing. Rather, their guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. Accordingly, the array-based evaluation of multiple molecular probes test and the advanced lipoprotein testing  were not likely to be superior to the available standard lipid profile for evaluating this patients medical condition.  Final Result: All three reviewers have determined the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in in internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty. Findings:  Two of the three physician reviewers found the data supports the short-term and long-term benefits of bronchial thermoplasty for select patients. In this case, the patient has allergic asthma that appears to be only partially controlled. He is on an aggressive regimen, but this is ultimately incomplete. Prior to pursuing bronchial thermoplasty, a trial of an anti-muscarinic agent is appropriate. These medications have been demonstrated to be efficacious in the management of asthma in this setting. The data supporting the efficacy of biologics in asthma is strong, and the records do not document that the patient exhausted this line of treatment. Further, he may also benefit from low-dose intermittent azithromycin to improve control of his asthma. In sum, bronchial thermoplasty is not likely to be of greater benefit than other treatment options. 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 sub-specialty certification in pulmonary disease 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: An enrollee has requested authorization and coverage of diazepam, Adderall, and Ritalin titration therapy for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that Ritalin and Adderall are schedule II medications. These medications are highly controlled and regulated by the U.S. Drug Enforcement and Administration (DEA) and their use require frequent follow up. The records indicate that this patient had not followed up with his provider, which would be eight to nine months from the requested fill date. This length of follow up is not considered standard of care while prescribing schedule II medications. Therefore, it is appropriate and the standard of care for the provider to require face to face follow up prior to continuing schedule II medications. Moreover, switching medications from Ritalin to Adderall without a visit is not considered standard of care. There has been no opportunity to discuss the risks and/or benefits of these medications with his provider. In addition, a mental status examination has not been performed prior to prescribing. It is also not the standard of care to switch from Ritalin to Adderall with only an electronic communication. If the patient is exhibiting behaviors such as frequent early refill requests, it is appropriate to deny these early refill requests. This is also recommended by the DEA. Regarding the patients request for diazepam, the patient has not been prescribed diazepam since June. The patient was also taking a different benzodiazepine (Ambien). It is not the standard of care to combine benzodiazepines. This would have to be discussed at a visit. In this clinical setting, it was appropriate for the provider to deny refilling diazepam, when an evaluation has not been performed for several months. Therefore, Ritalin, Adderall, and diazepam, without appropriate follow up and evaluation, have not been demonstrated as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for pembrolizumab (Keytruda) infusions. Findings:  The physician reviewer found that multiple myeloma is a plasma cell neoplasm with many systemic complications including anemia, hypercalcemia, bony lytic lesions, and renal failure. Multi-agent chemotherapy is the mainstay of treatment and is often consolidated with autologous hematopoietic stem cell transplant. By 2017, this patients provider recommended a combination regimen with pembrolizumab, pomalidomide, and dexamethasone that has been demonstrated to be safe and effective in myeloma patients. The U.S. Food and Drug Administration (FDA) has approved Keytruda for metastatic solid tumors that have been identified as microsatellite instability high. However, the FDA has not approved Keytruda multiple myeloma. For these reasons, the Keytruda infusions provided was not and 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 Keytruda infusions provided was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certifications in medical oncology and hematology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.According to the  guidelines issued by the American Association for the Study of Liver Diseases  and the Infectious Diseases Society of America all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive  patients should be treated , based on a 98% cure rate in the  guidelines cite data showing reduced survival with delayed treatment For these reasons, Epclusa for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified 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. Findings:  The physician reviewer found that