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 Trintellix, 40 mg per day. Studies have found that vortioxetine was significantly more effective in response and remission than placebo for acute treatment of major depressive disorder. There has been no evidence of a dose effect for vortioxetine with the exception of adverse effects. The 20 mg per day dose was approved as the target dose by the U.S. Food & Drug Administration (FDA) because it was the only dose with at least two trials showing efficacy in the U.S. population. The efficacy and safety of doses above 20 mg per day have not been evaluated in controlled clinical trials. While there is no evidence to suggest that higher doses of the medication would result in a reduction of depressive symptoms, there have been no studies looking at higher doses of vortioxetine.In this case, the patient reported subjective improvement in his depressive symptoms with a dose of 40 mg per day of the drug. Although there is no research data to suggest benefit from this dose, some patients will respond differently to the dose of an antidepressant. Many psychiatrists in clinical practice will dose antidepressants at doses higher than the FDA recommended dose, should their patients report a positive response. Given that this patient has a lengthy psychiatric history with episodes of severe mood lability and functional decline, he poses a high risk of decompensation with a reduction in vortioxetine. Should his mood decline with a lower dose, he is at risk of both relapsing on alcohol and requiring a higher level of care such as an IOP or even inpatient level of care. Given the risk of worsening symptoms with a reduction in dose, maintenance on the 40 mg dose is reasonable and consistent with clinical practice. Under these circumstances, Trintellix, 40 mg per day, is 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 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 skilled nursing facility (SNF) services. Based on the records provided for review, the requested SNF services are not medically necessary for treatment of this patient. The patient ambulated 100 feet x 2 with stand by assistance and a two-wheeled walker. She required standby assistance for toileting and transfers as well as supervision for lower body dressing. She was then ambulating 125 feet x 2 with a two-wheeled walker while on oxygen at two liters. She then ambulated 175 feet with supervision and a two-wheeled walker. She transferred with supervision and a two-wheeled walker while on oxygen at two liters. The documentation does not demonstrate that the patient requires skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse. The patient does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. The patients current functional level does not require ongoing SNF level skilled therapy services or skilled therapy services on a daily basis. All told, the requested SNF services are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular 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 patient has requested authorization and coverage for Envarsus XR 0.75 mg two tablets daily, Envarsus XR 1 mg three tablets in the morning, and Envarsus XR 4 mg one tablet in the morning. This patients history is concerning for recurring antibody mediated rejection (AMR) in light of infection and non-adherence with treatment. The patient is at extremely high risk of losing his allograft. The provider recommended that the patient switch from a twice-daily medication to Envarsus to encourage compliance with once-daily dosing. Researchers concluded that, once daily Envarsus has shown improved pharmacokinetic properties, rapid achievement of therapeutic trough levels, consistent exposure, non-inferior efficacy and similar safety, with lower tacrolimus dose than other tacrolimus formulations. Given this support, the requested Envarsus XR 0.75 mg two tablets daily, Envarsus XR 1 mg three tablets in the morning, and Envarsus XR 4 mg one tablet in the morning, is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 surgery with expertise in transplant 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for whole body positron emission tomography with computed tomography (PET/CT) for attenuation (CPT code 78816). Fibromyxoid sarcoma often displays aggressive and malignant behavior with high rates of local recurrence and metastases. PET/CT is sensitive for the detection of metastatic disease. Due to fibromyxoid sarcomas relatively benign histology, the neoplasm also demonstrates decreased sensitivity to chemoradiation therapy. Therefore, prompt detection of metastatic disease is critical for appropriate patient care. According to the American College of Radiology (ACR) appropriateness criteria, PET/CT may be appropriate depending on individual patient circumstances (Roberts, et al.). PET/CT has been emerging as a primary tool for diagnosing metastatic disease in many musculoskeletal tumors. This patient has known positive margins. Considering the high and atypical metastatic potential of fibromyxoid sarcoma and the patients young age, PET/CT is appropriate. PET/CT would change the management of this patient especially if the imaging reveals distant metastases. Therefore, the requested whole body PET/CT (CPT code 78816) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested whole body PET/CT (CPT code 78816) is 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 likely to be more beneficial for evaluation 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 diagnostic radiology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nivolumab (Opdivo) injections (CPT code J9299) 292.5 mg intravenous (IV) every 14 days for six cycles. The patient is not eligible for U.S. Food and Drug Administration (FDA) standard approved use of Opdivo, as he has microsatellite stable disease (Smith and Desai). The FDA supports treatment with Opdivo for patients with microsatellite instability-high or mismatch repair deficient metastatic colorectal cancer that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan. This patient has the standard care option of regorafenib for treatment of microsatellite stable disease. The recommendation for the combination of regorafenib with Opdivo is based on recent data from the phase 1b results of the REGONIVO trial. The authors found that the combination of regorafenib 80 mg plus Opdivo showed encouraging anti-tumor activity. However, the authors concluded that these findings warrant further studies in a larger cohort. In the absence of data demonstrating superior health outcomes with use of Opdivo in this clinical setting, the requested regimen is not appropriate for treatment of this patient. All told, the requested Opdivo injections (CPT code J9299) 292.5 mg IV every 14 days for six cycles 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 Opdivo injections (CPT code J9299) 292.5 mg IV every 14 days for six cycles 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 medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Rituxan infusion treatment. Standard therapy for relapsing remitting multiple sclerosis includes a number of disease-modifying therapy (DMT) options approved by the Food and Drug Administration (FDA) for the long-term treatment of relapsing remitting multiple sclerosis. Rituxan is a monoclonal antibody directed against the CD20 antigen on B-lymphocytes that causes B cell reduction. In an observational study of 494 patients diagnosed with relapsing remitting multiple sclerosis, Rituxan was associated with a lower discontinuation rate compared with other disease modifying therapies. Per the American Academy of Neurology (AAN) practice guidelines, patients with multiple sclerosis who are stable on DMT should continue their current DMT unless the patient and physician decide a trial off therapy is warranted. In this case, the patient has multiple sclerosis with evidence of lesions in the brain and cervical spine cord and JC virus positivity. Based on the current peer-reviewed medical literature, Rituxan is comparable to other disease modifying therapies. This patient has cervical cord lesions which can cause disability if her disease progresses. She has been treated with Rituxan for the past three years. The records document that the patient has been stable with no reported clinical progression of disease while on Rituxan. For these reasons, the requested Rituxan infusion treatment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Rituxan infusion treatment is 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: Physician reviewers 1, 2, and 3 are board certified in neurology 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

The patient has requested authorization and coverage for Freestyle Libre Sensors for glucose monitoring. The Freestyle Libre is a continuous glucose monitor (CGM) that is useful for diabetic patients for improving safety with frequent hypoglycemic events or with hypoglycemic unawareness. The device allows blood sugar readings to be obtained on an ongoing basis. With this information, the patient is allowed to adjust insulin dosages either prandially or at bedtime to avoid hypoglycemic events. Latent autoimmune diabetes in adult (LADA) is a type of diabetes that generally does not require insulin at diagnosis but may progress to insulin dependence in the future. In this case, the patient has LADA. No hypoglycemic events have been recorded and she has not been started on prandial insulin. She does have a history of chorioretinitis, but the records do not document the extent of the disease, or that the patient is unable to use a finger stick glucometer. Given these findings, Freestyle Libre Sensors for glucose monitoring are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medical supplies are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with expertise in endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patients parent has requested authorization and coverage for stroller canopy shade. According to the records provided for review, this patient does not have a medical condition exacerbated by sun exposure. The patients skin examination has been normal as documented by her medical providers. A medical stroller shade is not recommended for patients with cerebral palsy unlike other durable medical devices used in order to best prepare for potential functional or developmental needs based on the expected development of the patient. There is a lack of scientific evidence or a quality medical studies demonstrating that a stroller shade is of benefit for management of patients with cerebral palsy. For these reasons, the requested stroller canopy shade is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for Genetic cancer screening performed by Myriad Genetic Laboratories.  The myRisk test includes a panel of genes important for determining the etiology of breast and ovarian cancers. The myRisk gene panel is a standard evaluation tool used to analyze genetic causes of breast and ovarian cancer. These cancers have multifactorial causes encoded by several genes, and represents an example of a polygenic etiology. Even if the patient does not meet the criteria for each individual gene, the power of all genes combined is more informative than each gene alone. The genetic cancer performed by Myriad Genetic Laboratories was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in genetics and is actively practicing. Physician reviewer 2 is board certified in genetics and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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

An enrollee has requested authorization and coverage for the medication Taltz Autoinjector.Medical literature supports the use of the requested medication in this case. Taltz (ixekizumab) was approved by the U.S. Food and Drug Administration (FDA) in 2016 for the treatment of moderate-to-severe plaque psoriasis. Ixekizumab has been shown to be effective in the treatment of other types of psoriasis, including palmoplantar, erythrodermic, and generalized pustular psoriasis as well as nails affected by psoriasis. Ixekizumab is well tolerated by patients, with the most common adverse events being injection site reaction and infections such as nasopharyngitis and upper respiratory tract infections.In this case, the patient has extensive plaque psoriasis that has been reported to be non-responsive to first line medications. The patient has been using Taltz and has noted great improvement. Taltz (ixekizumab) represents a very promising therapy, providing an alternative mechanism of action with high efficacy and safety profiles, sustained total skin clearance, and rapid onset of effect to psoriasis patients who previously failed or experienced an inadequate response to systemic therapies, such as this patient. Under these circumstances, Taltz Autoinjector, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the 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

The enrollee is requesting authorization and coverage for the medication Saxenda, 3 mg/0.5 mL (18 mg/3 mL). This enrollee has an elevated body mass index. She has a medical history of hypertension, hyperlipidemia, and impaired fasting glucose. Her internal medicine physician reports the enrollee has been trying diet and exercise since, but has gained weight. Her physician indicated the enrollee has lost a few pounds since starting Saxenda, and was motivated for her exercise program. A governmental body reports Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adults with an initial body mass index of 30, or a body mass index of 27 if the person has at least one weight-related comorbid condition, such as hypertension, type 2 diabetes mellitus, or dyslipidemia. A study showed 3.0 milligrams of liraglutide (Saxenda), in addition to diet and exercise, was associated with reduced body weight. This enrollee has tried diet and exercise. She has a history of hypertension, hyperlipidemia and impaired glucose tolerance. The enrollees body mass index is above 30; therefore, she qualifies for Saxenda.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 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 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 Proton Beam Radiation Therapy, 30 treatments given twice daily for a total of 60 concurrent treatments.The medical literature does not support that the requested services are medically necessary in this setting. The ASTRO Model Policy for Proton Beam Therapy does not support the use of proton beam radiation therapy in the management of potentially resectable head and neck malignancies outside the context of a prospective clinical trial. In this case, the patient has recurrent oropharyngeal cancer. At this time, there are insufficient high quality clinical outcomes published to permit definitive conclusions regarding the relative safety and efficacy of proton radiotherapy in the setting of oropharyngeal cancer, as compared to standard of care photon-based radiotherapy. Accordingly, the requested proton beam radiation therapy, 30 treatments given twice daily for a total of 60 concurrent treatments, is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in radiation 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.