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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for inpatient mental health treatment services provided and reimbursement and authorization and coverage for residential mental health treatment services. Findings: The physician reviewer found that based on the available documentation, the inpatient mental health treatment services provided and residential mental health treatment services provided and forward were not and are not medically necessary for treatment of this patients medical condition. The patient was calm and cooperative and she was participating in groups. The patient had conditional suicidal ideations, but  did not have a plan. The patient did not have any homicidal ideation. The patient had been observed for many days and did not demonstrate any self-harming behaviors. The patient was compliant with medications and her family has been supportive. The patient did not have any psychosis, mania, delusions, hallucinations, or agitation. The patient mentioned many times that the patient felt ready to go home and wished to continue her treatment in a less restrictive environment. Consistent with current guidelines, the patient did not meet the criteria for continued inpatient hospitalization or residential treatment center care. The patient continued to require treatment, but this could have been done in a less restrictive environment such as in a partial hospitalization program. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for continued substance use disorder intensive outpatient program treatment and prospective authorization and coverage for admission to a substance use disorder transitional intensive outpatient program, three days a week, four hours per day for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that there is a lack of support for the services at issue in this patients case.  This patient had a low risk of harm as she denied any suicidal thoughts or plans, although she would occasionally have transient suicidal thoughts.  She did not have any prior suicide attempts.  The patient had a significant comorbidity of her ongoing substance use despite negative consequences.  The records noted that she has a supportive mother.  The patient is motivated for change and has been attending and participating in treatment.  She has a positive attitude toward recovery and treatment.  Based on the submitted documentation, the patient could be treated in a lower level of care.  In this patients case, treatment in an outpatient setting through a community 12-step program with the help of a sponsor is medically appropriate.  All told, continued substance use disorder intensive outpatient program treatment and admission to a substance use disorder transitional intensive outpatient program, three days a week, four hours per day were not and are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent Pen 7.5 mg/mL injector for treatment of the enrollees hypercholesterolemia. Findings:  The physician reviewer found that the records provided for review demonstrate that this patient meets the U.S. Food and Drug Administration (FDA) indications for use of Praluent. As noted by the FDA, Praluent is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease, who require additional lowering of LDL cholesterol. The documentation includes evidence that this patient has not responded to multiple statins. Further, the patient has an elevated LDL and meets the accepted criteria for familial heterozygous hypercholesterolemia. This is a reasonable conclusion that this patient has heterozygous familial hypercholesterolemia. Given this patients elevated LDL despite attempts with statin treatment and strong family history of heart disease, the requested Praluent Pen 7.5 mg/mL injector is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that 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 cardiovascular 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 Saxenda for treatment of the enrollees obesity. Findings:  The physician reviewer found that pharmacotherapy can be added to lifestyle interventions in patients with a BMI of 30 kg/m2 or greater regardless of health history or patients with a BMI of greater 27 kg/m2 and one additional cardiovascular risk factor, such as diabetes, hypertension, or hyperlipidemia. The U.S. Food and Drug Administration (FDA) approval of Saxenda followed several randomized controlled trials demonstrating its safety and efficacy in obese or overweight patients. This patient meets the criteria for the addition of an anti-obesity pharmacological agent as his BMI is over 30 kg/m2, he has comorbidities including hyperlipidemia, metabolic syndrome, and sleep apnea, and has not lost weight with diet. His provider has prescribed Saxenda. He already has responded to Saxenda with a weight loss of 10 pounds. Since treatment should be made available early in the disease to prevent irreparable complications, the requested Saxenda is supported as medically necessary for treatment of this patients obesity. 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 endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG).Findings:  The physician reviewer found that this patient has been diagnosed as having CIDP, and has been treated once with IVIG with a report of improvement. She then subsequently worsened. This clinical picture is consistent with a sensorimotor neuropathy, and CIDP is one of the more common causes of asymmetric weakness of the upper and lower extremities. The EMG reports are the providers impression only, and none of the actual data is included for review. Clinically, it is likely that this patient has CIDP, but given the lack of appropriate laboratory testing for an immune related neuropathy, lack of spinal fluid analysis indicating elevated protein, and the lack of actual EMG tracings, the diagnosis is not fully confirmed. Given these findings, IVIG is medically necessary and should be approved for one treatment with follow-up with a neuromuscular specialist to determine if the patient has another etiology for CIDP. Final Result: The reviewer determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast magnetic resonance imaging (MRI). Findings:  Two physician reviewers found that the patient has a family history of breast cancer with her mother, who was diagnosed at age 48. A breast MRI was performed on 9/11/15 which was negative. Currently, the patient is requesting a breast magnetic resonance imaging (MRI), which she noted has been used in the past for her breast examinations. The patient requests authorization and coverage for breast MRI. The Health Plan denied the request noting that this test is investigational for evaluation of this patient. The medical evidence supports the requested services in this patients case. One study shows, Addition of MRI to mammography for screening BRCA1/2 mutation carriers age  50 years improves screening sensitivity by a magnitude similar to that observed in younger women. Limiting screening MRI in BRCA1/2 carriers age  50 years should be reconsidered. Moreover, another study performed by another study noted the following findings, Screening with both MRI and mammography might rule out cancerous lesions better than mammography alone in women who are known or likely to have an inherited predisposition to breast cancer. The data supports a key role for screening MRI in women who have an increased risk of breast cancer. Final Result: Two reviewers determined that the requested service is 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: All three physician reviewers 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 and Foundation One genetic testing for treatment of the enrollees metastatic breast cancer. Findings:  Two physician reviewers found that as noted in the medical literature, Foundation One testing is an assay that explores the mutations or gene over-expressions of an individual patients cancer cell to help guide providers to the most specific treatment for that cancer. However, there is a lack of convincing evidence that the assay adds to decision making ability beyond standard testing. There are a variety of non-randomized trials exploring the value of molecular profiling that have as been unconvincing of the value of this approach. One randomized trial did not demonstrate value of the assay in selecting therapy. A recent report also raised doubts about the use of these assays. Thus, the use of the Foundation One assay is not supported for use in this patients evaluation and treatment. With regard to the requested Opdivo, which is one of a new class of drugs, the checkpoint inhibitors, which act by unblocking the patients native T cells so that they may attack the cancer. There is data that these therapies are effective in certain cancers, such as lung cancer, melanoma, and bladder cancer. However, there is a lack of data of its usefulness in breast cancer. All told, the requested Opdivo injections and Foundation One genetic testing are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The 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 genetic tests: Bloom syndrome, dihydrolipoamide dehydrogenase deficiency, familial hyperinsulinism, Fanconi anemia C, Gaucher disease, glycogen storage disease type 1A, Joubert syndrome, maple syrup urine disease, mucolipidosis type IV, nemaline myopathy, Niemann-Pick disease, spinal muscular atrophy, Usher syndrome type IF, Usher syndrome type III and Walker-Warburg syndrome for evaluation of the enrollee who underwent prenatal genetic testing. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity for a portion of the services at issue in this clinical setting. The American Congress of Obstetricians and Gynecologists (ACOG), notes that certain disease conditions are more prevalent in individuals of Eastern European Jewish descent. In this patients case, both she and her husband are of Ashkenazi Jewish descent. The ACOG Committee Opinion recommends the following, Carrier screening for Tay-Sachs disease (TSD), Canavan disease, cystic fibrosis, and familial dysautonomia should be offered to Ashkenazi Jewish individuals before conception or during early pregnancy. ACOG also specifies that Preconception and prenatal screening for spinal muscular atrophy (SMA) is not recommended in the general population at this time. The services at issue involved screening for Bloom syndrome, dihydrolipoamide dehydrogenase deficiency, familial hyperinsulinism, Fanconi anemia C, Gaucher disease, glycogen storage disease type 1A, Joubert syndrome, maple syrup urine disease, mucolipidosis type IV, nemaline myopathy, Niemann-Pick disease, spinal muscular atrophy, Usher syndrome type IF, Usher syndrome type III and Walker-Warburg syndrome. In this patients case, only spinal muscular atrophy and Walker-Warburg syndrome were not medically indicated. As such, the genetic tests performed for Bloom syndrome, dihydrolipoamide dehydrogenase deficiency, familial hyperinsulinism, Fanconi anemia C, Gaucher disease, glycogen storage disease type 1A, Joubert syndrome, maple syrup urine disease, mucolipidosis type IV, nemaline myopathy, Niemann-Pick disease, Usher syndrome type IF, and Usher syndrome type III were medically necessary. However, the genetic tests for spinal muscular atrophy and Walker-Warburg syndrome were not medically necessary for evaluation of this patient. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal and fetal 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis. Findings:  Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Final Result: Two reviewers determined that the diagnostic procedure at issue was 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: All three physician reviewers 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostatic urethral lift implant (Urolift) for treatment of the enrollee who has a history of enlarged prostate with lower urinary tract symptoms, chronic prostatitis and benign prostatic hyperplasia (BPH). Findings:  The 3 physician reviewers found that the patient is a male who presented to his provider with a history of lower urinary tract symptoms. He was diagnosed with benign prostatic hyperplasia (BPH). The patient was prescribed finasteride and Rapaflo to improve his symptoms. However, the patient reported that the medications have provided some relief but his symptoms still persist. The patient has requested authorization and coverage for prostatic urethral lift implant (Urolift). The Health Plan denied the requested procedure. The Health Plan stated that the requested procedure is investigational for the treatment of this patients medical condition.The prostatic urethral lift (Urolift) system is a novel, minimally invasive approach to treating BPH that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials including prospective sham-controlled randomized studies have shown that the Urolift system is safe and effective in relieving lower urinary tract symptoms due to BPH without significantly compromising sexual function.  Maintained outcomes have been reported at 24-month follow-up. Compared with transurethral resection of the prostate (TURP) and laser photoselective vaporization of the prostate (PVP), the Urolift system is a minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time. In light of recent studies documenting the clinical effectiveness of this procedure, as well as the support of this procedure by organizations such as the American Urological Association, the use of the Urolift is clinically appropriate in this patients case. All told, the requested Urolift procedure is likely to be more beneficial for treatment of this patients BPH than any available standard therapy. Final Result: The 3 reviewers determined that the requested procedure 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: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Prolia (denosumab). Findings:  The physician reviewer found that The records indicate that this patient is unable to tolerate oral bisphosphonates due to gastrointestinal upset and pain. However, given this patients medical history, the current guidelines recommends class IV bisphosphonates (zolendronic acid) as the preferred agent when oral bisphosphonates are not tolerated. Prolia is a recommended alternative for women at high risk for fracture, or who have difficulty with the dosing requirements of oral bisphosphonates. Prolia is also preferred for those patients who wish to avoid intravenous bisphosphonates due to side effects, or those who have chronic kidney disease. In this patients case, the records do not indicate she has a history of chronic kidney disease or a contraindication to Reclast. While this patient has a reported family history of allergy to Reclast, the records do not document a personal history of allergy with Reclast.  Moreover, there are no long term safety data for Prolia, at this time. Bisphosphonates, on the other hand, have been used for many years and are considered standard or the preferred therapy.  Therefore, Reclast would be considered the preferred therapy in this case given the patients normal renal function, and the medications efficacy, based on long term safety profile. For these reasons, Prolia is not medically indicated 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 internal medicine with sub-specialty certification in rheumatology 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.