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

Nature of Statutory Criteria/ Case Summary:  According to the records, the enrollee went to the urgent care center complaining of psoriasis all over her body with the exception of her face, neck, and chest .  She reported the sites had not improved, had flared and were itchy.  It was noted her whole upper body had healed well and she had been applying betamethasone and calcipotriene to her legs.  However, her legs were starting to become itchy and the physician noted scattered, small, psoriatic, annular, clustered plaques to her shins. This was a new flare due to stopping Otezla.  It was recommended she continue utilizing Otezla and follow-up. According to a review of the record, there are effective, safe alternatives that have not been trialed. The health plan indicates Otezla is medically necessary if the enrollee has attempted therapy with preferred alternative drugs for the treatment of psoriasis (methotrexate, cyclosporine, or acitretin and then two of the following drugs: Cosentyx, Enbrel, or Humira). The enrollee has a history of plaque psoriasis. She has tried betamethasone and calcipotriene with minimal benefit. She has a history of psoriatic arthropathy with pain in her achilles and lateral foot. The enrollee has a contraindication to acitretin. However, the enrollee has no documented contraindications to the use of cyclosporine, Cosentyx, Enbrel or Humira. Current peer reviewed literature supports the use of the preferred medication to Otezla. study's found biologics are highly effective treatments for moderate-severe psoriasis with a high percentage of patients achieving 75% improvement in Psoriasis. However, psoriasis is a chronic disease and long-term efficacy is critical. When comparing medications at one year, response rates among the initial treatment groups were best with secukinumab (Cosentyx) and worst with apremilast (Otezla). In initial responders who received one year of continuous treatment, maintenance was best with adalimumab (Humira) and worst with apremilast (Otezla).There has been robust clinical data demonstrating the efficacy of the preferred alternative, Humira (adalimumab). Adalimumab efficacy was well maintained over more than three years of continuous therapy for patients with sustained initial Psoriasis Area and Severity Index.   Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested authorization and coverage for speech and language therapy. A review of the records indicates the enrollee was diagnosed with speech delay, specifically developmental expressive language disorder after an Early Intervention in-home evaluation. At the time of evaluation, he was not saying any words and was communicating through gestures and vocalizations. At the end of the evaluation, the impression was that the enrollee had a significant delay in his language expression skills. His hearing is normal and his social skills are also normal for age. Speech and language intervention was recommended with the goal of being able to communicate his wants and needs, add 50 new words to his vocabulary and begin to use 2 and 3-word phrases. The enrollee was assessed using an accepted behavioral assessment battery of language development specifically for his age group.  (Rosetti) The Rosetti assesses a variety of language and developmental skills, including social skills, attachment, play, expressive and receptive language skills.  The enrollee was able to participate in all parts of testing and performed at age-appropriate levels in all areas with the exception of expressive language, in which he was shown to be at the 9-12 month range.  This represents a 6-9 month delay, which is significant.  Expressive language disorder is categorized as a disability, and without intervention has been linked to issues with literacy /emerging reading skills.  At this point, the enrollee can only express his wants/needs by gesture and facial expression.  As his thoughts and needs become more complex, this will become even more inadequate as a form of primary communication.  Given his overall development, he has good prognosis to bring his language skills to age-appropriate levels with a skills speech-language pathologist.  Final Result: The reviewer determined that the requested speech and language therapy is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in Speech-Language Pathologyand 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  According to the records, the enrollee is requesting consultation with a dermatologist. Internal medicine notes indicate the enrollee has hormonal acne treated with medicated face wash that over-dried her skin and a skin lesion on her face. A referred dermatologist documented jawline inflammatory papules and pustules and scars distributed on her face. Prescribed were Retin-A micro topical gel, spironolactone, and clindamycin 1% lotion. A follow-up visit noted that spironolactone made her nauseous and topical treatment was fine, but she was still having breakouts. Acne was improved, but still present and prescribed was the antibiotic, Doxycycline. On the next visit, her acne was the same, skin was almost clear. Prescribed was Aczone 7.5% topical gel and Retin-A Micro gel was continued.  The enrollee contacted her primary care physician stating her acne treatment was not working and the health plan denied follow up care with the dermatologist. The health plan advised the treatment she needs is in the scope of her primary medical doctor. The dermatologist has training in treatment of the multiplicity of skin conditions, including acne. Dermatologists generally prescribe and manage the acne treatment regimen the enrollee has been using for her hormonal acne.  According to the medical literature, hormones and androgens play an important role in the pathogenesis of acne.  Multiple hormonal modulators are available for treatment of acne and expert knowledge of the efficacies and side effects is vital. Dermatologists specialize in the care of this enrollees condition and by training have more knowledge of treatment options. Thus, consultation by a dermatologist is appropriate. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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 Tylenol 3. The Centers for Disease Control and Prevention (CDC) guidelines for use of opioids for chronic pain state that providers should evaluate the benefits and harms of continued therapy with patients every three months or more frequently. The CDC noted further, that when the benefits do not outweigh harms of continued opioid therapy, providers should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The 2017 Federation of State Medical Boards guidelines state that continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. In this case, the patient has been prescribed Tylenol 3 for chronic pain related to his Kaposi sarcoma and neuropathy. It is noted that he was informed that his recent urine drug screen was positive for methamphetamine. The providers assessment was that opioids were no longer a good option to treat the patients chronic pain due to the risks of treatment outweighing any potential benefits. His provider recommended Gabapentin and Motrin for his pain, and participation in a chemical dependency program. Based on the guidelines from the CDC and the Federation of State Medical Boards, the requested Tylenol 3 is not medically necessary for treatment of this patients chronic pain. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a hypoglossal nerve stimulator.Findings:  Two of the three physician reviewers found that there is sufficient support for the requested device in this clinical setting. The records document obstructive sleep apnea. The patient has not been able to tolerate continuous positive airway pressure therapy. The Inspire device has been approved by the U.S. Food and Drug Administration for the treatment of obstructive sleep apnea. The provider has reported that the patient is not an appropriate candidate for oral appliance therapy. The medical evidence supports the requested device in this patients case. Therefore, the requested hypoglossal nerve stimulator is likely to be superior over other treatment options. Final Result: The reviewers determined that the requested device is 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: Physician reviewers 1, 2 and 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lyrica 50 mg, three times a day. Findings:  The physician reviewer found that treatment with Lyrica was beneficial in the past. However, the records do not specify how Lyrica helped the patient. There is no description in the progress notes to support an indication for Lyrica. The patient is on several anxiety medications. The progress notes do not indicate that the patients anxiety is the focus of treatment. The documentation suggests that his functional impairment and problematic symptoms are due to his psychosis. The progress notes indicate the patients target treatment goals are psychotic symptoms, consisting of delusions, and sleep disturbances affecting his interpersonal relationships. Lyrica has U.S. Food and Drug Administration (FDA) approval for diabetic neuropathic pain, post herpetic neuralgia, fibromyalgia, partial onset seizures, and spinal cord pain. Lyrica is not indicated to treat delusions or psychosis (Martin, et al; Griebeler, et al). Furthermore, Lyrica does not have FDA approved indications for any of the patients current documented diagnoses. Therefore, Lyrica 50 mg, three times a day, is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 enrollees parent has requested  coverage for Nutramigen baby formula. A review of the records indicates the enrollee is growing well and gaining weight. Formula is noted to be Nutramigen 4 ounces very two to three hours. There is no documentation of allergies or rashes. Growth and development is appropriate. A referral request was for EF Ped Hydrolyzed/Amino Acid for symptoms of clay like stool, formula concern. Physician indicates tried Nutramigen and doing well, will refer for formula. A prescription by the provider was for Nutramigen. Per addendum, the mother indicated the enrollee gets a rash with Gentlease and Reguline.  According to the medical literature, the majority of children with cow milk protein allergy have one or more symptoms involving one or more organ systems, mainly the gastrointestinal tract and/or skin. If a cow milk protein allergy is suspected in a patient by a history and examination, then strict allergen avoidance is initiated. Typically a food challenge is recommended to confirm the diagnosis, provided that symptoms are not life-threatening.  For infants with a true cow milk protein allergy, a trial of an extensively hydrolyzed formula is recommended. There is insufficient evidence in the records of a milk protein allergy or failure to thrive. It was specifically documented that the enrollee had been gaining weight well and had no blood in her stool. There also was no documentation in the two physical examinations provided that supports the enrollee had a milk protein allergy. There were only two sentences in the addendum to the office visits, which recounted the parents report of a rash without a medical professionals confirmation of the nature or appearance of the rash. A rash may be a symptom of a milk protein allergy, but the medical reports do not demonstrate the cause of the enrollees rash here. A rash may also occur in a variety of non-allergic settings in infants. The medical literature indicates a milk challenge should be performed in non-life-threatening cases to confirm the diagnosis. It does not appear this had been done here. In addition, it is noted in the record that the enrollee was consuming Gentlease formula alongside Nutramigen, without rash documented in these notes.Final Result: The reviewer determined that the service at issue is not medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician reviewer is board certified in Pediatric Gastroenterologyand 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested coverage for Fasenra injection. A review of the records indicates this patient has a medical history of eosinophilic asthma, chronic eosinophilic pneumonia, chronic sinusitis, and vocal cord dysfunction. She has respiratory insufficiency that progressed. She has been experiencing shortness of breath, wheezing, and low oxygen saturations despite nebulizer treatments, steroids, and inhalers. Her provider recommended therapy with Benralizumab Fasenra, which could be expected to reduce the steroid dependence and toxicity and likely reduce her need for healthcare use. The patient stated that her saturations of oxygen were in the high 80s despite nebulizer treatments every two hours with ipratropium, and cromolyn, and Xopenex, along with use of prednisone.   She indicates she was given sample Fasenra injections, after which her wheezing resolved and shortness of breath and oxygen saturations improved.  The patient had a diagnosis of eosinophilic asthma and had benefit with use of the medication, as she was able to breathe better.  The medical literature did not indicate that a patient must trial Nucala prior to the use of Fasenra.  Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Pulmonology 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 similar medical condition.Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Laparoscopic Anti-Reflux Procedure Utilizing LINX Reflux Management System. According to the medical literature, experience with the LINX Reflux Management System confirms the initial safety profile that led to FDA approval of the device. The LINX results in long-term gastroesophageal reflux disease (GERD) control based on symptomatic outcomes, proton pump inhibitor utilization, and pH studies. The current medical literature shows LINX results in similar objective control of GERD, symptom resolution, and improved quality of life. LINX, by the medical literature, has less of the common side effects from which fundoplication patients often suffer and results in improvement in health outcomes.Final Result: Three of the three reviewers determined that the requested service was likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Surgery 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for foot inserts (Foot, Insert, Removable, Molded to PT model, UCB Type, Berkley Shell  Code L3000). The health plan has denied this request as not medically necessary.  A review of the records indicates the enrollee was seen for follow-up of long-term right foot pain.  He reported that he had done well with orthoses, but he needed a new pair as the previous orthotics had worn out.  The use of orthotics had helped him avoid surgery.  Physical examination of the right foot demonstrated mild local edema to the plantar/central forefoot, mild tenderness of the second metatarsal head plantarly with direct pressure, flexor contractures of the second and third toes with medial deviation at the metacarpophalangeal (MP) joints, as well as dorsal subluxation of the second MP joint.  As the enrollee continued to do well and was not interested in surgical correction, updated custom functional orthoses were recommended.  According to current peer-reviewed medical literature, when hammertoes cause significant pain or interfere with gait, surgical correction is required. For less severe symptomatic cases, hammer toe pads, buddy taping, shoes with a roomy toe box, and various orthotics and forefoot padding may offer some pain relief.  The initial treatment for metatarsalgia consists of metatarsal pads.  If metatarsal pads are ineffective, small observational studies suggest that customized orthotics designed to unload the distal metatarsals and distribute plantar pressure more evenly substantially reduce pain and allow patients to increase their walking.  Surgical referral is a last resort for metatarsalgia.  The enrollee has chronic foot pain, metatarsalgia, and hammertoe.  Supporting examination findings included edema to the plantar/central forefoot, tenderness of the second metatarsal head, and contractures of the second third toes.  The enrollee reported significant benefit with prior use of orthotics.  Custom orthotics have helped him avoid surgical intervention, but his orthoses had worn out.  As per the medical literature, custom orthotics are effective in the treatment of metatarsalgia. Therefore, the requested foot inserts (Foot, Insert, Removable, Molded to PT model, UCB Type, Berkley Shell  Code L3000) are considered medically necessary to treat the patient's condition.  Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the patients condition. Credentials/Qualifications: The physician reviewer is board certified in Podiatry 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 similar medical condition.