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 a 28 day supply (240 pills) of Norco. Findings:  The physician reviewer found that there is a lack of support for the medical necessity of the requested medication in this clinical setting. Chronic pain that has no hope for a cure is considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. In the documentation available for review, not all non-opioid treatment options have been utilized. There was no mention of behavior therapy despite much research to support its use. The medical literature recommends consideration of alternatives to opioids as well as to be weaned to a lower dose of opioids or weaned off the medications entirely. In this patients case, there is a lack of objective treatment goals for pain and function for the requested medication. The records indicate that tolerance has taken place since the start of the narcotics. The medical evidence shows that dose escalation is not a long term plan but a short term plan for the treatment of tolerance. Simply adding more pure mu agonists will, for a short while, take care of the symptoms of mu agonist saturation. However, down regulation will transpire and then the patient is back to where they started in terms of their perception in pain. Moreover, not all non-opioid medications classes have been optimized or tried. Finally, continuation of opioid medications, prescribed at higher doses without proper treatment for the opioid use sets this patient up for higher morbidity and mortality. For all these reasons, 28 day supply (240 pills) of Norco is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with 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: An enrollee has reimbursement for infraumbilical panniculectomy and release of infraumbilical abdominal scar procedure. Findings:  The physician reviewer found that the medical documentation supports the services at issue in this clinical setting. Studies found the following, The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms  This patient has evidence of a symptomatic overhanging lower abdominal pannus, for which she underwent a panniculectomy.  She had a previous c-section complicated by wound healing problems that required healing by secondary intention.  Her c-section scar was noted to be painful and adherent to the abdominal wall.  In addition, she had evidence of chronic rashes associated with the lower abdominal pannus that was overhanging.  Although the photographs do not show evidence of a significantly enlarged abdominal pannus, there is sufficient overhang consistent with her functional complaint of chronic rashes.  Her examination details are consistent with this chronic problem. In addition, she had a documented complication to a previous medically necessary procedure. As such, reasonable attempts to correct her medical condition should be considered medically necessary. Therefore, based on the documentation and the photographs provided, infraumbilical panniculectomy and release of infraumbilical abdominal scar procedure performed were medically necessary for treatment of this patient. With regard to the patients body structure, the submitted documentation does demonstrate that this patient had an abnormal structure of the body. The patients lower abdominal overhang as well as a symptomatic indented c-section scar was an abnormal occurrence. Moreover, previous surgeries (c-section and obesity treatment with bariatric surgery) were the cause of the abnormal presentation. The surgery performed was to relieve her functional problems of chronic rashes and scar pain. Finally, the surgery provided more than a minimal improvement in the appearance 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 plastic 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 enrollee has requested reimbursement for the allergy or toxicity (IgG food sensitivity) testing. Findings:  The physician reviewers found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The American College of Allergy, Asthma and Immunology recommends that suspected food allergies should first be assessed by maintaining a food and symptom diet on standardized exclusion diets, combined in select cases with challenge testing. Similarly, the Mayo Clinics standard of care approach states that there is no standard test used to confirm or rule out a food allergy and a diagnosis hinges on the combined analysis of reported symptoms, physical examination, food diary, skin prick testing, response to elimination diets, assessment of psychologic factors, and as a final arbiter IgE antibodies with or without an oral food challenge. Based on the documentation submitted for review and national guidelines, the allergy or toxicity (IgG food sensitivity) testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing at issue was 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: Two physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. One physician reviewer is board certified in allergy and immunology and is 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The representative of an enrollee has requested reimbursement for air and ground ambulance services. Findings:  The physician reviewer found that acute leukemias and their treatment are major emergencies in internal medicine. The standard of care is to use multi-agent chemotherapy followed by allogeneic hematopoietic stem cell transplant for patients with matched bone marrow. In this case, the patient was treated with the CALGB 9111 protocol, which involves remission induction, intensification, followed by maintenance. After induction, she achieved a complete remission by bone marrow exam. On subsequent relapses she received blinatumumab and CAR-T therapy at UW. All of her other care was at UCSF. She was received at UCSF after discharge from UW as an inpatient with palliative care. Her active medical issues prevented her from being treated as an outpatient. Furthermore, her transplant was performed at UCSF and those providers were familiar with her case. The social infrastructure is an essential component of palliative care. Air transport as used in this case was medically appropriate and necessary for this patients care. As such, the air and ground ambulance services provided were medically necessary for treatment of the patients medical condition. 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 physician reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and hematology 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 Cialis 5 mg. Findings:  The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. The documentation provided indicates that this patient has tried multiple therapies for treatment of his BPH symptoms but his nocturia is still bothersome. The patient reported to his provider that he has worsening lower urinary tract symptoms for over five years. Cialis is considered an acceptable alternative for treatment of BPH symptoms.  As such, Cialis 5 mg is medically necessary for treatment of this 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene tests (BRCA and PTEN). Findings:  The physician reviewers found that the standard of care in patients with Ashkenazi descent and breast cancer is to test for BRCA mutations. In this patients case, there is evidence that she meets the criteria for BRCA gene testing. However, there is no evidence in the documentation provided to support testing for PTEN in any patients including Ashkenazi Jewish descent without suggestive features for Cowden syndrome. PTEN mutation analysis (e.g., Cowden syndrome, hamartoma tumor syndrome) may be considered when there is a suspected or known clinical diagnosis of Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome (BRR) or when there is a known family history of a PTEN mutation. The medical record submitted is not indicative of any of these clinical features.  For these reasons, the BRCA gene test performed was likely to have been superior over the standard modalities available for the evaluation of this patient. However, the PTEN gene test performed was not likely to have been more effective than the other options available for evaluation of this patient. Final Result: 2 of 3 reviewers determined that a portion of the services at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 reimbursement for residential treatment center services. Findings:  The physician reviewer found that a portion of the residential treatment center services provided were medically necessary for treatment of the patients behavioral health condition, but not thereafter. The patient had post-acute withdrawal symptoms including severe insomnia. He verbalized the desire to leave so he could use in order to sleep, placing him at imminent risk for relapse. He was depressed and anxious, but no psychotropic medications were started. He was externally motivated, but he had little insight. He participated in groups and meetings, and his Suboxone taper had completed and he was sleeping better. He was working on steps and had a temporary sponsor. As of the date of service identified, the patient could have been treated at a lower level of care. Thus, a portion of the services at issue were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The physician reviewer is board certified in psychiatry with sub-specialty certification in addiction 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: An enrollee has requested authorization and coverage for Lyrica 50 mg capsules for treatment of the enrollees pain. Findings: The physician reviewer found that Lyrica has well-documented efficacy and safety for treating neuropathic pain, which is what the patient is describing.  She had significant side effects from a trial of gabapentin and does not have an indication for a trial of duloxetine. The medical evidence supports the requested medication in this clinical setting. 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 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: An female enrollee has requested authorization and coverage for Mekinist for treatment of the enrollees adenoid cystic carcinoma. Findings: The physician reviewer found that adenoid cystic carcinomas are rare cancers usually arising from the salivary glands presenting as oropharyngeal masses, although metastatic presentations have been described.  The tumors can be slow growing, but have a high propensity for recurrence. Mekinist is a newly inhibitor of MEK kinases approved for use in metastatic melanoma with mutant BRAF.  The MEK kinases are within the same pathway as RAS and BRAF. Thus, it is mechanistically appealing to apply Mekinist to tumors with constitutive RAS signaling, such as the tumor in this patients case. A phase I trial in a study showed that Mekinist was tolerated at 2 mg twice daily with responses in patients with diverse cancers.  Recently, it has become important to identify mutations that may be amenable to targeted therapy.  In another study, they performed a study of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to the progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage.  There is sufficient support for the requested medication in this patients case. 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 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of one-on-one applied behavioral analysis (ABA) therapy and 17 hours per month of supervision provided for treatment of the autism. Findings: The physician reviewer found that the peer-reviewed literature demonstrates the correlation between treatment outcomes and treatment intensity for children with autism. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. The patient continues to have issues with noncompliance, tantrum behaviors, elopement, screaming, non-response, and vocal stereotypy. Furthermore, the patients maladaptive behaviors have increased over the last six months. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 168 hours per week of home health care services for treatment of the enrollees Werdnig-Hoffman disease, idiopathic scoliosis, respirator dependent and gastrostomy tube (G-tube) status. Findings:  The physician reviewer found that Werdnig and Hoffman disease is a disorder of progressive muscular weakness beginning in infancy characterized by loss of anterior horn cells. Home care nurses provide specialty care to adult and pediatric patients with medically complex needs. The most complicated patients require the use of a ventilator in order to maintain adequate breathing. Patients with this level of need require a competent nurse with current knowledge of and experience with the latest medical technology. In this case, the patient requires 24-hours per day nursing care as he is ventilator dependent, requires frequent repositioning, G-tube feedings, medication administration, and ongoing active skin care. He also needs repositioning every two to three hours, skin assessments, medication management, and help with transfers. Given the patients medical condition there is potential for decompensation which is likely to occur with a decrease in home health services. 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a magnetic resonance imaging (MRI) for evaluation of the enrollees bilateral knee pain status post strain and bilateral patella subluxation. Findings: The physician reviewer found that the records do not show red flags to indicate immediate MRI on either knee prior to an attempt at conservative management including physical therapy. There is no evidence of fracture, effusion or instability of a major ligament such as the anterior cruciate ligament on physical examination. Conservative treatment including a regimen of physical therapy may improve the patients symptoms. Final Result: The reviewer determined that the requested diagnostic procedure is 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for the continuation of 64.5 hours per month of one-on-one applied behavioral analysis (ABA) therapy and 10.8 hours per month of supervision provided for treatment of autism. Findings: The physician reviewer found that the Health Plan has authorized 43 hours per month (11 hours per week) of one-on-one ABA and eight hours per month of supervision, which is less than what has been provided in the past. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. In this case, the patient continues to demonstrate low to moderately low adaptive skillsets as measured across multiple domains. The patient also requires a high level of support to complete activities of daily living and does not problem solve independently. While the patient has met his behavior goals, he continues to work on communication, daily living, socialization and safety goals. The patient continues to struggle with stopping at the curb and looking both ways before crossing the street and completing purchasing routines. Failure to master these skills puts the patient at an increased risk for injury. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.