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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Euflexxa injections. Findings:  The physician reviewer found that the enrollee has a history of bilateral knee pain and instability of the patella as well as subluxations and pain rated between 0/10 and 8/10.  Patella grind and patella apprehension are both positive.  Imaging is negative on x-rays for joint space narrowing. An MRI showed an anterior cruciate ligament (ACL) tear on the right knee, mild chondromalacia and patella alta.  An MRI of the left knee showed a degenerative meniscus tear and mild cartilage loss. Treatments for her patella instability include activity modification, and steroid injections.  She reports this has helped her, as has her physical therapy treatments.  The physical therapist recommended the enrollee stop physical therapy (PT) although she had made improvements, because she still had patella tracking issues consistent with her prior exams and history of patella instability. Euflexxa injections were recommended for pain relief with a determination of whether her knee pain is coming from cartilage loss or knee instability.  She was also assessed for meniscus debridement and underwent a partial medial meniscectomy of the left knee. Review of the record indicates this enrollees case is complicated by underlying anatomic challenges including a right knee ACL tear, left knee meniscus injury, and bilateral patella instability.  While there is some evidence of cartilage loss, there seem to be more sources of pain rather than early arthritis in this enrollee.  According to the medical literature, in general, the use of hyaluronic acid is not supported due to the fact that most studies do not show superiority over other treatments, including placebo.  According to the American Academy of Orthopedic Surgeons (AAOS), Euflexxa injections are not recommended for patients with symptomatic osteoarthritis of the knee and have not shown substantial improvement over a placebo treatment.  While it is noted that Euflexxa is US Food and Drug Administration (FDA)-approved for use in the treatment of osteoarthritis of the knee, current medical literature does not support use secondary to a lack of efficacy within the published medical literature.  The literature does not support the use of hyaluronic acid injections in symptomatic osteoarthritis of the knee.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedics and orthopedic sports 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 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 speech therapy. While the patient appears to have plateaued in his speech therapy progress, it is important to note that significant delays in expressive and receptive skills persist. Direct one-to-one intervention with a speech language therapist (SLT) can be effective for all areas of language for older children with developmental language disorders. Thus, direct SLT services should be available for school-aged children with developmental language disorders, including older children and adolescents with pervasive difficulties. It is also important to note that empirical evidence suggests that early interventions for children with developmental disabilities can promote greater achievement of functional potential. Consequently, there is a growing demand for rehabilitation services, beginning early, which encompass strategies of prevention, remediation and compensation to maximize a patients function in all activities. Therefore, speech therapy services are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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 Crohns Disease of the large and small bowel.  Her symptoms include loose stool with intermittent streaks of blood, abdominal bloating, gassiness, nausea, and constipation, in between flare-ups.  She is followed by a gastroenterologist and has tried and failed oral steroids, as well as oral and rectal mesalamines, and Linzess.  She also tried Remicade, which resulted in some mucosal healing, but she developed a drug reaction and psoriasis, so she is unable to take any other anti-tumor necrosis factor medications. The medication was then changed to intravenous (IV) infusion of Stelara, with which she did well, but continued to have gastrointestinal inflammation on the standard eight week dosing.  She has elevated calprotectin levels and a colonoscopy showed some new inflammation. Due to this and increasing calprotectin levels, her physician is now recommending that her Stelara injections be increased to every four weeks to achieve the same degree of clinical, lab, and endoscopic remission that was seen initially. The health plan denied the injection of Stelara 90mg/ml at a dosing of every four weeks as not medically necessary. They indicate the use of Stelara every four weeks as maintenance is not supported or appropriate, and that there is no literature support or FDA indication for the use of Stelara at a dosing of every four weeks. The medical literature indicates that in  a cohort of patients studied to determine the relationship between trough levels of ustekinumab (Stelara), and clinical response during the maintenance phase, patients received 90 mg every four or eight weeks.  A recent presentation of data was in regard to optimization of Stelara to recapture response. The study analyzed patients with active Crohns disease who had their dose escalated from 90 mg every eight weeks to 90 mg every four weeks because of loss of response or inadequate response.   More than half the patients recaptured response after optimization. Therefore, based on very recent data, it has been shown that shortening the interval to four weeks has been used to optimize efficacy of Stelara. 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or 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 magnetic resonance imaging (MRI) of the lumbar spine. The current medical evidence supports the requested services in this clinical setting. According to the American College of Radiology, in the setting of low back pain and low velocity trauma, MRI of the lumbar spine is the usually appropriate examination. In this case, the patient has had chronic back pain and a history of low velocity trauma.  Any possible ligamentous injury would be occult on radiographs. Occult fracture or disc pathology would only be demonstrated on MRI. Therefore, MRI of the lumbar spine is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 authorization and coverage for five-day inpatient dihydroergotamine (DHE) infusions. The submitted documentation supports the medical necessity of the requested services. This patient has refractory NDPH. He has been treated with numerous prophylactic medications, without resolution of his headaches. Beta-blockers are contraindicated, and multiple acute abortive medications for headache have been tried. There are several published studies documenting the efficacy of inpatient administration of DHE infusion given over several days in the treatment of refractory NDPH and status migrainosus. A study included 32 consecutive pediatric patients with refractory status migrainosus who received inpatient treatment with intravenous DHE. The authors noted upon discharge, 74.4% of the patients were headache-free. The authors concluded that DHE is very effective in treating and aborting an episode of status migraine and should be offered to children and adolescent patients who have failed their usual abortive therapy to prevent further severe disability that mainly affects their schooling and social activities. Therefore, five-day inpatient DHE infusions are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for partial hospitalization program (PHP) services. Applying the Community Psychiatrists Level of Care Utilization System to determine the necessary and appropriate level of care for adults, this patient does not meet the criteria for PHP services. The patient has a composite score of 10. This correlates with treatment in a community-based outpatient clinic setting. Therefore, PHP services are not medically necessary for the 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 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 residential treatment center services. The American Society of Addiction Medicine (ASAM) has established a series of six dimensions to create a holistic, biopsychosocial assessment of an individual to be used for service planning and treatment across all services and levels of care. The six dimensions are: dimension 1) acute intoxication and/or withdrawal potential; dimension 2) biomedical conditions and complications; dimension 3) emotional, behavioral, or cognitive conditions and complications; dimension 4) readiness to change; dimension 5) relapse, continued use or continued problem potential; and dimension 6) recovery/living environment. The American Society of Addiction Medicine criteria for level of placement can be applied to this patients presentation to help determine the appropriate level of care. In this patients case, the records do not document that the patient met dimension 1 (acute intoxication and/or withdrawal potential) or dimension 2 (biomedical condition and complications). In order to meet ASAM criteria for the residential treatment level of care for adults, the patients presentation must meet all six criteria. Therefore, residential treatment center services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry 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 Linzess. The patient has diagnoses of diverticulosis in the entire colon, external and internal hemorrhoids, and a normal ileum, epigastric pain, and chronic idiopathic constipation. The American Gastroenterological Association Medical Position Statement on Constipation states that the first line of therapy should be an osmotic agent, followed by another type of laxative, such as a stimulant laxative. Linzess has been approved by the U.S. Food and Drug Administration (FDA) for chronic constipation. Clinical trials showed Linzess significantly increased weekly spontaneous bowel movements and complete spontaneous bowel movements while reducing abdominal pain. Linzess is not specifically a laxative. It has a different mechanism of action than osmotic laxatives and can be effective even if agents such as laxatives and fiber have failed. In this case, the patient has failed treatment with an osmotic laxative, a stimulant laxative, and a bulk-forming laxative. Medical evidence supports the requested medication in this clinical setting. Therefore, Linzess is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The enrollee has requested authorization and coverage for Tremfya 100mg/ml injections. According to the medical record, the enrollee was initially seen by a dermatologist complaining of a rash on his body that was not responding to Benadryl or cortisone cream. He was diagnosed with psoriasis vulgaris with 50% of body surface area involvement including his arms, legs, feet, back, and buttocks. He was not a good candidate for Methotrexate or Soriatane due to their effects on the liver. In addition, the enrollee is unable to go to the office for ultraviolet therapy. A Quantiferon TB gold test was negative. He was given a sample injection of Tremfya with plans for his next injection in four weeks. He also used topical steroids. At follow-up, his psoriasis has improved to one percent body surface area involvement. His physician has recommended continued treatment due to his significant response to therapy. The health plan indicates the requested medication, Tremfya 100mg/ml injection is not medically necessary for treatment of the enrollees medical condition. Per the health plan, it has not been determined the enrollee has tried methotrexate, cyclosporine, and acitretin. They will not cover Tremfya until the enrollee has tried two other treatments first, including Enbrel, Humira and Cosentyx. They may also cover Tremfya if there is physician documentation as to why the enrollee cannot take the other medication. National consensus guidelines advocate for the use of biologics after first-line therapy has failed. Humira, Enbrel, and Cosentyx are all Food and Drug Administration (FDA) approved for the treatment of plaque psoriasis. In fact, Humira has amassed the longest published safety data of any drug FDA approved medication for the treatment of plaque psoriasis since 2008. There are insufficient head to head trials showing superiority of Tremfya to the other biologics. Current medical literature does not support the use of Tremfya over the available formulary alternatives. The record indicates the enrollee has tried and failed topical steroids. However, there is insufficient documentation of the enrollees trial and failure of methotrexate, cyclosporine, acitretin, Enbrel, Humira, and Cosentyx. The records do not document reasons why the preferred medications cannot be used. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Retacrit (epoetin alfa-epbx) or Epogen/Procrit (epoetin alfa). Guidelines for the treatment of hemochromatosis recommend iron removal until the ferritin has fallen to 50-100 ug/L. In this case, the patients ferritin level exceeds the treatment goal despite treatment with phlebotomy and iron chelation. In addition, the patient requires treatment of iron overload to reverse cardiomyopathy. Iron removal can at least partially reverse cardiomyopathy due to iron overload. The use of erythropoietin to support hemoglobin levels during sequential phlebotomy has been effective in multiple studies. For these reasons, Retacrit (epoetin alfa-epbx) or Epogen/Procrit (epoetin alfa) was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A. enrollee has requested reimbursement for genetic testing services (Prenatal Noonan Spectrum Disorder Panel).Findings:  Two of the three physician reviewers found Noonan syndrome is an inherited condition characterized by short stature, congenital heart defect, and variable developmental delay. Other findings include broad or webbed neck, cryptorchidism, varied coagulation defects, and ocular abnormalities. Congenital heart disease occurs in 50% to 80% of individuals with this condition. Pulmonary valve stenosis, often with dysplasia, is the most common heart defect. Hypertrophic cardiomyopathy may be present at birth or develop in infancy or childhood. Other structural defects include atrial and ventricular septal defects, branch pulmonary artery stenosis, and tetralogy of Fallot. Due to the potential severity of Noonan syndrome, genetic testing should be offered to women carrying fetuses with cystic hygroma. In sum, genetic testing services (Prenatal Noonan Spectrum Disorder Panel) were likely to have been superior over other methods of evaluating this patient. 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 clinical genetics and genomics and is actively practicing. Physician reviewers 2 and 3 are board certified in clinical biochemical genetics 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: The patient has requested reimbursement for genetic testing (hemochromatosis DNA mutation analysis). This patient presented with an elevated ferritin level. His provider recommended genetic testing to rule out hereditary hemochromatosis (HH). One study noted that although low serum ferritin levels indicate reduced iron stores, raised serum ferritin levels are due to multiple etiologies. Current guidelines recommend a simple iron panel in this clinical setting. An iron transferrin saturation (TSAT) of 45% or higher is consistent with a genetic iron overload disorder. If the TSAT is below 45%, this rules out HH. This finding stands in the face of an elevated ferritin. In this case, the patients TSAT was 11%, which is within the normal range. Thus, the genetic testing (hemochromatosis DNA mutation analysis) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three physician reviewers determined that the services at issue were 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:  The three physician reviewers are board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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.