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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for five doses of Supartz injections. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients knee pain. The submitted documentation supports the medical necessity of the requested medication regimen. Researchers conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. They reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Evidence based guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with significantly symptomatic osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature supports the use of hyaluronic acid injections for the treatment of pain in patients with osteoarthritis of the knee. This patient presents with chronic right knee pain and functional limitations in activities of daily living. The clinical examination findings are consistent with x-ray evidence of severe osteoarthritis with bone-on-bone findings of right knee osteoarthritis. The record indicates that reasonable conservative treatments have failed to provide adequate symptom relief. The medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. Therefore, the requested five doses of Supartz injections are 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for biofeedback services. Pelvic pain is a complex problem that is typically difficult to treat as the disease process is multifactorial without one specific etiology. Some common diagnoses include infection, endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis. Given the lack of work-up for this patients symptoms, it is difficult to ascertain if physical therapy is the best therapy for her symptoms. Depending on the patients ultimate diagnosis, different management options can be helpful.  The enrollee would likely benefit from counseling for PTSD and possibly sexual counseling for longstanding anorgasmia. In the absence of a thorough work-up of bladder/pelvic floor issues, the biofeedback services were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not and are 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Radicava infusion therapy. Findings: Radicava (edaravone) has been approved by the U.S. Food and Drug Administration (FDA) to treat patients with amyotrophic lateral sclerosis. Edaravone showed efficacy in a small subset of people with amyotrophic lateral sclerosis who met criteria identified in post-hoc analysis of a previous phase 3 study. This patient is likely to benefit from the use of Radicava. There is a lack of other available therapies for the treatment of this patients medical condition. Thus, Radicava infusion therapy is likely to be more effective than other treatment options. Final Result: Two of the three physician 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. In this case, the patients mental health professionals noted that it is not in the patients best interest at this time to be treated with opioids. In addition, the medical literature supports the use of alternatives to opioids for the treatment of this patient. In this patients case, there was no objective functional loss reported in the documentation when the patient was weaned off the opioids. Instead, there is documentation of being a danger to himself while on opioids. Furthermore, there is no objective treatment goals for pain and function noted for the requested medication. Also, in this case, not all non-opioid treatment options have been utilized. The records do not document that different types of behavior therapy have been exhausted despite significant research to support its use. Finally, not all non-opioid medications classes have been optimized or tried. For these reasons, Norco is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin 10 mg/2 mL pen. The patients height is more than 2.5 standard deviations below the mean for age and gender. In addition, all known systemic causes of short stature have been ruled out. Based on the patients bone age and height assessment, their estimated final adult height is approximately 57 inches. This height prediction is more than 2.5 standard deviations below the mean. The U.S. Food and Drug Administration (FDA) has approved a trial of growth hormone therapy in patients with idiopathic short stature who have an adult predicted height less than 59 inches. This patient meets FDA criteria for a trial of growth hormone therapy for idiopathic short stature. Thus, the requested Nutropin AQ Nuspin 10 mg/2 mL pen is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 53-year-old female enrollee has requested reimbursement for the Guardant360 molecular profiling test using circulating tumor DNA. Guardant360 testing offers a comprehensive panel of molecular genetic markers on an individual patients tumor in an attempt to identify markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network (NCCN) guidelines, it has not been determined if molecular markers are useful in treatment determination. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. Per the NCCN guidelines for glioblastoma, radiation therapy with temazolomide and alternating electric field therapy is considered the current standard of care. Thus, therapy is not directed by genomic alterations. Accordingly, the Guardant360 molecular profiling test using circulating tumor DNA was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the Guardant360 molecular profiling test using circulating tumor DNA was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services. The records indicate that this patient continued to show moderate post-acute withdrawal symptoms. However, the patient was not provided with any detoxification medications. The patient was not a danger to self or others, nor was the patient aggressive or violent. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the RTC level of care. The patients cognitive impairment due to the previous encephalopathy did not require supervision, and it did not interfere with self-care. The patient was not manic or psychotic. The patient had no biomedical complications, and was psychiatrically stable to the extent that they did not need a 24-hour facility to render the remainder of their care. The patients medication management and medication assisted treatment could have been performed in an ambulatory setting. The patient was motivated and appeared to be working the program. The patient was cooperative and participating in the treatment plan. Moreover, the patients emotional stressors did not require them to be treated or monitored in RTC setting. From the date of denial forward, there were no further changes in that they continued to report high levels of cravings, and using dreams. Thus, the RTC services provided were not medically necessary for treatment of this patients medical condition. 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 with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Xifaxan. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients irritable bowel syndrome with diarrhea. The submitted documentation supports the medical necessity of the requested medication. This patient has irritable bowel syndrome, diarrhea-predominant (IBS-D). Xifaxan has been proven to be safe and effective in randomized placebo-controlled trials for IBS-D. The American College of Gastroenterology guidelines for the treatment of irritable bowel syndrome state that Xifaxan is effective. Additionally, this patient has small intestinal bacterial overgrowth. Xifaxan has been shown to be highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief.  Per the medical evidence, this medication has greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones, such as ciprofloxacin. The results are sustained for several weeks after treatment. The formulary alternative would not address small intestinal bacterial overgrowth. For these reasons, Xifaxan 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for an ultraviolet light home therapy device. There are many ways to treat chronic plaque psoriasis if topical steroids are not an option due to contraindication, ineffectiveness, or side effects. Phototherapy is one way to treat psoriasis and can be safe and efficacious. There are also several other standard therapies such as medications including methotrexate and Humira. In this case, there is no evidence to suggest that a home phototherapy unit will be more beneficial than any other standard psoriasis treatment. According to the documentation, the patient does not have a serious physical condition that prevents him from going to in-office phototherapy. Given these findings, the requested ultraviolet light home therapy device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested ultraviolet light home therapy device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested device 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:  One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in dermatology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued speech therapy and continued occupational therapy. The medical records provided for review do not document that this patient has an impairment in articulation of speech or oral motor function aspects of speech which would warrant coverage of speech therapy services. The patient endorses that her ultimate goal has to been to freely communicate her thoughts, concerns, needs and wants across social and emotional dynamics. However, these communication goals are considered social in nature. In addition, many adults with autism spectrum disorder prefer talk therapy. Moreover, the patient does not have any documented deficits that require treatment with formal occupational therapy. All told, the requested continued speech therapy and continued occupational therapy are not medically necessary for treatment of this 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 physical medicine and rehabilitation 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: A 23-year-old transgender enrollee has requested authorization and coverage for weekly individual therapy sessions with a therapist who utilizes attachment based narrative therapy with a psychodynamic approach, which includes guided imagery and hypnosis. Researchers state that psychotherapy is an integral part of patients treatment. Further medical literatures note there is evidence that individuals with chronic, complex mental illness seem to improve with long-term psychodynamic psychotherapy and that a greater number of sessions is associated with better outcome.  There is support for a psychodynamic component of therapy for adult patients with major depressive disorder. The use of hypnosis is also being used here as an aspect of the patients overall therapy with benefit to date. Therefore, weekly individual therapy sessions with a therapist who utilizes attachment based narrative therapy with a psychodynamic approach, which includes guided imagery and hypnosis is medically necessary for treatment of the patients medical condition.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 psychiatry with expertise in gender dysphoria 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: A patient has requested authorization and coverage for Humira 20 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients plaque psoriasis. The submitted documentation supports the medical necessity of the requested medication. skin disease, which typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients who are moderately or severely affected by the disease. Approximately 20 percent of patients have severe psoriasis, necessitating systemic drugs such as acitretin, methotrexate, cyclosporin A or the newer biologic agents. Up to 30 percent of psoriatic patients develop psoriatic arthritis (also known as psoriatic arthropathy), a type of inflammatory arthritis. Humira (adalimumab) is a fully human tumor necrosis factor-alpha monoclonal antibody approved for the treatment of rheumatoid arthritis, which is also used in treating other conditions, including psoriasis and psoriatic arthritis. Open prospective studies and randomized controlled trials have shown the short-term efficacy of adalimumab in psoriatic arthritis and psoriasis. There is sufficient support for the requested medication in this clinical setting. Humira has been approved by the U.S. Food and Drug Administration for the treatment of moderate to severe chronic plaque psoriasis. The approval was based on the results of two trials that showed marked improvement in skin condition. Therefore, Humira 20 mg 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 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.