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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for reoperation with reduction of the cerebellar tonsil and possible partial posterior fossa cranioplasty. The records provided for review document that this patient underwent Chiari decompression in December 2018, but her symptoms have continued to worsen. The patients postoperative imaging shows tonsillar decent of 25 mm. Following a thorough evaluation, the patients providers have recommended reoperation. Arnautovic and colleagues noted that a Chiari malformation type 1 is a hindbrain disorder associated with elongation of the cerebellar tonsils, which descend below the foramen magnum into the spinal canal. Clinical symptoms mainly develop from alterations in cerebrospinal fluid flow at the foramen magnum and the common subsequent development of syringomyelia. On review of the current medical literature, the authors noted that syringomyelia was resolved or improved in 78% of patients following surgical interventions including posterior fossa magnum decompression and tonsillar resection. This patients providers have planned a repeat operation to reduce her tonsils and possibly perform posterior fossa cranioplasty. The requested reoperation for this patients persistent symptoms after initial Chiari decompression is appropriate and consistent with the current medical literature. Therefore, the requested reoperation with reduction of the cerebellar tonsil and possible partial posterior fossa cranioplasty 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 neurological 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for bloodwork services. This patients records document a history of anaphylactic reaction to peanuts, eggs, milk and dairy products. The provider noted that the patient has been diagnosed with allergic rhinitis, asthma, eczema, and reactive airway disease. The patients provider has recommended treatment in an oral immunotherapy, or tolerance induction program. As part of the treatment protocol, the provider recommended specific bloodwork including IGA, IgG, IgM and IgE, as well as IgG subclasses, immunoassay for analyte other than infectious agent antibody and complete blood count with differential. Also requested is allergen specific IgG, IgE, and urticaria induced basophil activation testing. Based on current peer-reviewed medical literature, there is a lack of support for the bloodwork and tolerance induction program planned for this patient. Although oral food desensitization has reportedly been achieved in the majority of patients in randomized controlled studies, few patients successfully develop tolerance or sustained unresponsiveness. Overall, there is a lack of support for the requested treatment protocol in lieu of allergen avoidance and availability of an epinephrine autoinjector. Given these findings, the requested bloodwork services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested bloodwork services are not likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology with subspecialty certification in pediatrics and is 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for sublingual immunotherapy and/or food tolerance induction. This patient presents with a history of food allergies and dermatitis due to ingested food. The patients provider has recommended treatment with oral immunotherapy. Currently, the American Academy of Allergy, Asthma, and Immunology (AAAAI) does not recommend oral immunotherapy as a standard of care treatment for patients with food allergies due to uncertainty whether the potential therapeutic benefits outweigh the risks of treatment. Although several studies have reported positive outcomes, according to the AAAAI, the interventions and endpoints used in clinical trials are too inconsistent to establish oral immunotherapy as superior to allergen avoidance. Furthermore, there is significant potential for adverse events including oropharyngeal, respiratory, and gastrointestinal symptoms. Therefore, the requested sublingual immunotherapy and/or food tolerance induction is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested sublingual immunotherapy and/or food tolerance induction 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 reviewer 1 is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology with subspecialty certification in pediatrics and is 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: 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 combination of Opdivo (nivolumab) with Yervoy (ipilimumab) every three weeks. This patient presents with recurrent malignant neoplasm of parotid gland status post right parotidectomy and adjuvant radiotherapy, repeat resection in with myocutaneous flap placement and adjuvant therapy. A recent computed tomography (CT) of the soft tissue of the neck revealed a 13 mm enhancing lesion, and evidence of extensive locoregional disease recurrent along the anterior and posterior margins of the flap, with index lesions. The patient was started on a regimen of Yervoy and Opdivo, which has been shown to yield a positive response in specific types of cancer, such as melanoma. However, there is a paucity of medical literature or guidelines reporting on the long-term safety and efficacy of the regimen consisting of Yervoy and Opdivo in the treatment of salivary gland cancer. Therefore, the combination of Opdivo (nivolumab) with Yervoy (ipilimumab) every three weeks forward was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the combination of Opdivo (nivolumab) with Yervoy (ipilimumab) every three weeks forward 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 medication regimen at issue was not and 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology and is 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 Androderm 2 mg/24-hour transdermal patch.Male hypogonadism is a clinical syndrome that results from failure of the testis to produce physiological levels of testosterone (androgen deficiency) and the normal number of spermatozoa caused by disruption of one or more levels of the hypothalamicpituitarygonadal (HPG) axis. Low testosterone can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue (Dandona, P., and Rosenberg, M.). For these reasons, many physicians treat patients with hypogonadism when their testosterone level is less than 350 ng/dl. The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored 3 to 6 months after initiation of treatment in order to assure that the patients testosterone level is optimal, and the dose of testosterone replacement therapy should be adjusted accordingly (Rivas, A., et al.). In this case, the patient has a diagnosis of hypogonadotropic hypogonadism and suffers from sleep apnea, depression, low energy and low libido. The patient has declined transdermal gel out of a concern for the risk of transference to his daughters. Under these circumstances, the requested medication, Androderm 2 mg/24-hour transdermal patch, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in endocrinology, diabetes, 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 electromyography (EMG) and nerve conduction study (NCS) (CPT codes 95886 and 95913). The records provided for review demonstrate that this patient has a history of migraine, cervicalgia, dizziness, and paresthesia of skin. She has been treated with topiramate and trazodone, which she was unable to tolerate, per the providers reports. The provider has recommended evaluation with EMG and NCS to determine whether the patient has any evidence of active denervation. Per Li and Tavee, although NCS is an important part of a patients electrodiagnostic examination, the diagnosis of radiculopathy rests mainly on the needle electrode examination findings. This supports the utility of both NCS and EMG in this clinical setting. Performing EMG with NCS will help determine whether the patient requires further radiological imaging or neurosurgical intervention. For these reasons, the requested EMG and NCS (CPT codes 95886 and 95913) are medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tertiary level of care services. As noted in the medical literature, hidradenitis suppurativa can profoundly affect a patients quality of life. Severity is based on clinical appearance as well as impact on quality of life. According to the U.S. and Canadian Hidradenitis Suppurativa Foundations, management is complex and requires balancing medical and surgical treatment options in addition to managing the psychosocial and medical conditions that go along with this disease (Alikhan, et al.). The records provided for review document that this patient has been treated for hidradenitis suppurativa with oral antibiotics, antimicrobial washes, acitretin, Humira, and most recently with Remicade. He has a history of hospitalization for superinfection of his chronic wounds and he required education for wound care. He has been referred to plastic surgery for scarring. Based on these facts, the patients condition is severe, and he meets the criteria for treatment at a higher level of care. He has severe disease that requires surgical, dermatological, pain management, and wound care, which will be best managed and provided at a tertiary care facility. The patient requires higher level of care than a community level provider. Accordingly, the requested tertiary level of care services are 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 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 omalizumab (Xolair). The current peer-reviewed medical literature has demonstrated that Xolair can provide improvement in symptoms in mast cell activation syndrome patients. Lemal and colleagues reported that Xolair is a useful therapeutic option to control mast cell-mediator symptoms and displays a favorable safety profile. Similarly, Molderings and colleagues found that Xolair can lessen the intensity of the symptoms of systemic mast cell activation disease. Given this patients attempts at treatment with oral cromolyn, doxepin, montelukast, methylprednisone, and imatinib, the requested six month trial of Xolair is appropriate. Therefore, the requested omalizumab (Xolair) 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 allergy and  immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco medication. On determining when to initiate or continue opioids for chronic pain, researchers report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The authors further note, Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Federation of State Medical Boards (FSMB) strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has a right labral tear requiring arthroscopic surgery, which was delayed by abnormal lab results. Due to her upcoming surgery, her provider has recommended a topical compound cream, along with Motrin and naproxen for pain management, and did not recommend opioid therapy due to concerns regarding dependence and increased difficulty with postoperative pain management. The patient has been treated with a cortisone injection into the shoulder, along with physical therapy yielding small benefits. Given that this patient is being treated in a manner consistent with current medical literature, the requested medication is not medically indicated. Therefore, Norco medication is 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for RTC level of care services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to continued suicidal ideation, with a history of a past suicide attempt, and substance use.  In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to conflict with parents and weight loss while at the RTC. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance abuse.In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to stress related to family conflict. With regard to level of support of the recovery environment, the records support a score of 2 due to the parents participation in family therapy and treatment planning.In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, due to lack of improvement in mood, anxiety, and substance abuse and recurrence of weight loss despite prior inpatient hospitalization, outpatient therapy, medication trials, and six weeks of PHP treatment. With regard to treatment acceptance and engagement, the records support a score of 2. The patient was cooperative in her treatment at the RTC. Thus, the patient has a total score of 20. The harm risk score of 4 supports care at Level 5, medically monitored residence-based services. This is consistent with the level of care that the patient received and is receiving at the residential treatment center. Therefore, RTC level of care services were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 psychiatry with sub-specialty 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.