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

The patients parent has requested reimbursement and prospective authorization and coverage for Hizentra 8 grams weekly infusions with supplies. This patient present with many recurrent infections and low immunoglobulin levels. The standard of care in this clinical setting includes treatment with intravenous immunoglobulin (IVIG) such as Hizentra. The records provided for review document that since starting treatment with Hizentra, the patient has experienced an improved quality of life. In this particular patient, with six months of treatment, there has been a significant benefit with decrease in provider office visits and he has been able to return to activities of daily living. Researchers described the use of IVIG for primary immunodeficiencies as being definitely beneficial. The authors noted that IVIG is increasingly recognized as a treatment of a variety of medical condition, not only for its ability to fight infection as a replacement therapy but also for its anti-inflammatory and immunomodulating effects. All told, Hizentra 8 grams weekly infusions with supplies were and are medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the medication at issue was and 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 subspecialty certification in pediatric 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

An enrollee has requested authorization and coverage for Brilinta 90 mg tablets. The submitted documentation supports that the requested medication is medically necessary. Records reflect that the patient had a recent acute coronary syndrome that was treated with coronary stent placement. In this setting, treatment with a more potent P2Y12 inhibitor, tigacrelor (Brilinta), has been shown to improve outcome over less potent P2Y12 inhibitors such as clopridogrel (Plavix). Treatment with Brilinta in this setting is reasonable, appropriate, and considered standard accepted practice in the medical community. Current guidelines endorsed by several national organizations also consider this therapy appropriate. Accordingly, Brilinta 90 mg tablets are medically necessary to treat the patients medical condition.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 cardiovascular disease, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Repatha SureClick 140 mg/mL pen injectors. The submitted documentation supports that the requested medication is medically necessary. The patient has established coronary artery disease and mild carotid artery disease in a context that is status post myocardial infarction and left anterior descending coronary artery stenting. The patient has been tried on simvastatin, rosuvastatin, and most recently atorvastatin at a medium/high dose which he could not tolerate owing to both myalgias and memory issues. The patient then self-discontinued this medication due to side effects. Using ezitimibe alone would not be effective in lowering the patients LDL level toward his goal level, given his established coronary artery disease. The patients records include documentation of a recent high LDL cholesterol level. Under these circumstances, the use of a PCSK9 inhibitor is medically reasonable, given the patients established coronary artery disease, his intolerance of multiple statin medications, and his poor control of his LDL cholesterol, which is not near his guideline directed goal. Accordingly, the requested Repatha SureClick 140 mg/mL pen injectors are medically necessary to treat the patients medical condition.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 cardiovascular disease, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patients parent has requested reimbursement for wilderness residential treatment center (RTC) services. Applying the CALOCUS guidelines, this patient had a low risk of harm. The medical records indicate that the patient was not actively suicidal at any time. There was no indication that the patient was aggressive at any time during treatment. The progress notes did not indicate any active suicidal ideation, self-harm behaviors, or homicidal ideation. The patient demonstrated mild functional impairment as she had mild issues with level of function due to relationship problems with her family. She did not exhibit any significant behavioral problems, mood symptoms, or anxiety symptoms according to the records. The patient had minor comorbidity with a history of substance use that affects her primary psychiatric issues. The patient did not exhibit withdrawal symptoms or express cravings or urges to use substances. There was no indication of substance use during the treatment program. The progress notes indicate the patient presented to the treatment center with a history of depression and anxiety, and difficulty with relationships with peers and family. The patients recovery environment was mildly stressful as there was no indication of an unsafe home environment. The patients recovery environment was supportive as the records reported the patients family was actively involved in treatment on a regular basis. The patient demonstrated moderate response to treatment. The providers indicated that the patient engaged well at the RTC and her symptoms were under good control. There was no description of any significant mood or anxiety symptoms. The patient reportedly demonstrated limited response to prior treatment. The patient was constructive in treatment and was described as cooperative with good insight into her needs. The records noted that the patient was cooperative in treatment and engaged in individual therapy and family sessions. The patients parent was constructive and worked actively with providers on a regular basis. This patients composite score correlates with intensive outpatient services. Given these findings, the wilderness RTC services provided were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Testopel 75 mg x 12 implantable pellets every four months. This patients medications include Dilaudid, Opana and Cymbalta, all of which are associated with decreased libido and erectile function. Alternate sources of pain management would improve the patients testosterone levels and potentially improve his symptoms. There is significant literature that testosterone replacement is warranted in cases of opioid-induced hypogonadism (Coluzzi, et al.). However, the patients records do not document the chronically low testosterone level that warrants replacement. Based on the available documentation, the requested Testopel 75 mg x 12 implantable pellets every four months are 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 urology 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 a 44-year-old female who has been diagnosed with ocular migraine headaches, allergic rhinitis, and left foot pain. The patient reported she had received four acupuncture sessions for the treatment of her ocular migraine headaches and left foot fracture with success. The patients foot pain was noted to be reduced by 25% and migraine headaches were less frequent due to treatment with acupuncture. The patient reported acupuncture had been helpful for the treatment of her migraine headaches, allergies, and left foot pain. The patient has requested authorization and coverage for acupuncture treatments. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether acupuncture treatments are medically necessary for the treatment of the patients medical condition. In this case, the patient reported acupuncture had been helpful for the treatment of her migraine headaches, allergies, and left foot pain. The medical evidence supports the requested services in this clinical setting. Therefore, acupuncture treatments are medically necessary for the 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 chiropractic care with expertise in acupuncture 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for eight treatments of chiropractic manipulation. Chiropractic manipulation has been demonstrated to be helpful for the management of a variety of conditions such as neck and back pain. Current medical literature includes studies and guidelines to support the use of chiropractic care to improve symptoms in patients with acute and chronic neck and back pain. This patient presents with left-sided upper back pain with intermittent numbness in the bilateral upper extremities. The data supports the requested eight chiropractic visits to achieve functional improvement. All told, the requested eight treatments of chiropractic manipulation are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Three of the three physician reviewers found the requested eight treatments of chiropractic manipulation are 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Medical professional reviewers 1, 2, and 3 are board certified chiropractors 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: The patient has requested authorization and coverage for Sensipar, or in the alternative, cinacalcet hydrochloride (HCL) 30 mg tablets. The signs and symptoms of primary hyperparathyroidism (PHPT) can be due to hypercalcemia, especially when the serum calcium is greater than 12 mg/dL, or if there is a rapid increase in serum calcium (Bilezikian). The symptoms of PHPT are more likely related to its key target organs. The treatment for symptomatic PHPT is parathyroidectomy (Marcocci and Cetani). In patients who are not considered candidates for surgery, but have a serum calcium greater than 1 mg/dL above normal or are symptomatic, pharmacological treatment may be indicated. Cinacalcet is a calcimimetic agent that can accomplish this goal by virtue of its property to bind to the calcium-sensing receptor. Cinacalcet is of benefit in patients with intractable primary hyperparathyroidism (Schwarz, et al.). This patient has intractable primary hyperparathyroidism with symptoms of organ involvement. She is unable to undergo parathyroidectomy, as she has had two prior surgeries and an adenoma was not localized on imaging. Based on the available documentation, the patient meets the U.S. Food and Drug Administration (FDA) approved indications for treatment with cinacalcet HCL. Moreover, the patient reports that she started treatment with the generic formulation, cinacalcet, and would like to continue treatment. The provider states that the patients history of broken femurs, new renal stone and significantly elevated blood levels support treatment with the generic formulation of Sensipar, cinacalcet HCL. For these reasons, cinacalcet HCL 30 mg tablets are 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 subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 49-year-old female who has been diagnosed with chronic idiopathic constipation. On an earlier date, the records noted that the patient was being treated with dicyclomine. Per the provider appeal form dated earlier this year, the patient has failed treatment with MiraLAX, Colace, senna, Metamucil, and Bentyl. The patient has requested authorization and coverage for Trulance. 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 Trulance is medically necessary for the treatment of the patients medical condition. Miner and colleagues performed a randomized, double-blinded, placebo-controlled phase III clinical trial assessing the efficacy and safety of plecanatide (Trulance). The authors noted that plecanatide significantly improved constipation and its related symptoms with a low rate of adverse events. Plecanatide has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic idiopathic constipation. In this case, the patient has been diagnosed with chronic idiopathic constipation and has failed treatment with MiraLAX, Colace, senna, Metamucil, and Bentyl. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested reimbursement for the DecisionDx Melanoma Assay. The enrollee was diagnosed with a malignant melanoma on her right inner thigh. Biopsy results showed the lesion was Clarks Level III, with a 0.35 millimeter Breslows depth. The DecisionDx Melanoma Assay report noted the lesions melanoma class was 1, with a sub-class of 1A. The class 1A signature is associated with the lowest risk of recurrence within five years. Based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this enrollee. The DecisionDX Melanoma assay is not known to be effective based on a lack of scientific evidence showing the results will accurately guide patient care and health outcomes. The physician reviewer found that he testing would not have been considered effective or useful in treatment planning. Literature notes professional societies do not currently recommend the use of the DecisionDx-Melanoma assay testing panel. Clinicians must understand how to interpret the results. Literature notes the difficulties in gleaning meaningful information from the studies as some studies have small sample sizes. In one study the sample size was 217; with 73,000 melanoma enrollees per year, a sample size of 400 is necessary to have a 95 percent confidence interval.  To properly utilize this testing procedure as the basis for diagnostic recommendations, a much larger trial is needed. Use of this diagnostic to advocate for more rigorous follow-up testing may increase anxiety without providing substantial benefit. The enrollee has a thin melanoma, the risk of metastasis is small, and no further testing is necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 61-year-old female who has been diagnosed with osteoarthritis of the right knee. On 8/19/19, the provider noted the patient had been treated with a right knee arthroscopy with partial meniscectomy and chondroplasty in January 2018 and a cortisone injection in June 2018. The provider noted the patient had previous success with an intra-articular Gel-One injection in September 2018. On 8/19/19, the patient reported intermittent right knee pain, stiffness, and swelling. The patient has requested authorization and coverage for Orthovisc (or any other recommended hyaluronic acid injection) for the right knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc (or any other recommended hyaluronic acid injection) for the right knee is medically necessary for the treatment of the patients medical condition. The physician reviewer found that the review of current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patients options are limited. She has tried and failed arthroscopic surgery and corticosteroid injections, with the alternative being a total knee arthroplasty. Furthermore, she had benefitted from prior viscosupplementation injections. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc (or any other recommended hyaluronic acid injection) for the right knee is medically necessary for this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections in the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive.As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the options are limited. The patient has tried and failed medications, corticosteroid injections, physical therapy, and arthroscopic surgery. The remaining treatment alternative is a total knee arthroplasty. Given these findings, the requested Euflexxa injections in the left knee are medically necessary for 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 orthopedic 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.