Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for irinotecan and bevacizumab. The National Comprehensive Cancer Network (NCCN) guidelines do not include irinotecan and bevacizumab in their recommendations for the treatment of this patients metastatic cholangiocarcinoma. In addition, the combination of infusional 5-fluorouracil (5-FU) with irinotecan and bevacizumab produced some responses in five of 13 patients. However, this is not the same regimen requested for this patient, as infusional 5-FU is not included. Further, the current data is from small studies with limited follow-up. Given these findings, the requested irinotecan and bevacizumab are 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 irinotecan and bevacizumab 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 medication regimen 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty 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:  The enrollee is requesting authorization and coverage for pimecrolimus cream, 1%. The patient has chronic dryness on the scalp that has spread to her face and nose. Her physician instructed her to continue using Eucerin cream for her eczema and to stop using ketoconazole cream. The dermatologist noted erythematous patches on her front hairline, behind her ear, on her nose and at the distal thigh. Protopic was prescribed with consideration for a biopsy if the condition did not improve. Mid-to-high potency topical corticosteroids are inappropriate for use on the face due to the adverse effects of atrophy. Use near the eye poses an increased risk of cataracts and glaucoma. The medical literature indicates pimecrolimus cream is classified as a calcineurin inhibitor. It is a newer formulation used for the treatment of acute flares and for maintenance therapy of atopic dermatitis. Pimecrolimus has the potency of a mild corticosteroid cream, but without the side effects of corticosteroids, such as thinning of the skin. This allows daily treatment for longer periods. Topical calcineurin inhibitors can also be used as a proactive treatment. Patients treated with pimecrolimus saw a reversal of skin thinning of the neck and head, and a reduction in lesions. Pimecrolimus provides a safe alternative to topical corticosteroids, particularly for sensitive skin sites, such as the head and neck. Pimecrolimus was initially approved in the United States in 2001. Pimecrolimus was selected for further development due to its favorable anti-inflammatory properties, skin-selective properties, and overall safety profile. Pimecrolimus may be a preferable alternative in some clinical scenarios, such as when steroids have been ineffective or the condition is located on areas of sensitive skin.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting reimbursement for partial hospitalization program (PHP) level of care services and intensive outpatient program (IOP) level of care services. The enrollee has a history of opioid use, beginning at age 18 after wisdom tooth extraction and ankle surgery. He also reported current heroin use (smoking), daily cannabis use since age 15; sedative use, i.e., 2 milligram of Xanax four times per day; and Norco use since shoulder surgery. The enrollee reported he would use heroin for two weeks, stop due to finances, and experience withdrawal symptoms. He reported a long-standing history of severe anxiety and a sleep pattern of one to two hours per night. The enrollee stated he experienced heart palpitations and sweating due to drug use. He reported a history of depression and five suicide attempts between the ages of 17 and 21. The recommendation was for admission to the partial hospitalization program, with a transition to an intensive outpatient program. The enrollee entered treatment. He developed an understanding of the causes of his anxiety and worked to identify three positive emotions he would like to experience on a daily basis. He developed an understanding about how thoughts, feelings and behaviors are connected. He learned to identify maladaptive, negative thoughts and how to replace them with positive, adaptive thoughts. He used smart recovery coping skills to manage and engage in at least two positive daily activities that promote growth and success. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. The enrollees composite LOCUS score correlates with low intensity, community-based services; which can be either a partial hospitalization program or an intensive outpatient program.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for the medication, Tretinoin cream 0.1%. The enrollee has chloasma (melasma). She has been receiving chemotherapy for metastatic breast cancer and the dark patches have worsened since treatment began. The enrollee started Tretinoin cream, 0.05. The provider is now requesting Tretinoin cream, 0.1%. The enrollee indicates she has been coping with this condition for four years. She has dark spots and raised areas on both sides of her face, causing unbearable itching. The enrollee has tried over-the-counter treatments but reports nothing works. Literature describes melasma as a pigmentary disorder with an unclear cause, with numerous treatment options and high recurrence rates. Literature indicates melasma is a problem in the mechanisms that control skin pigmentation. As a result, excess pigment is produced.  The treatment goal is to decrease pigment production and increase elimination. The standard treatment regimen for melasma consists of first-line therapy as a topical treatment with a hydroquinone and a retinoidbased product for a minimum of three months, with the addition of oral tranexamic acid if no contraindication is present. Secondline treatment is noted as laser therapy. Thirdline therapy would be the addition of chemical peels to the above treatments. These examples of first-line, second-line and third-line therapies do not include tretinoin as monotherapy, which is what this enrollee is requesting. Based on the medical literature on topical treatment, the requested treatment is for individuals who acquired this skin condition from UV light and does not account for other correctable factors, such as hypothyroidism or a medication side effect. 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 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 patients parent has requested authorization and coverage for social skills training and center-based applied behavioral analysis (ABA) services. Based on the presenting information, center-based ABA services are medically necessary, while the social skills services are not medically necessary for this patient. Center based ABA services meet the definition of medical necessity outlined by Papatola and Lustig. In this case, the patient meets the criteria for ABA treatment, which focuses on the patients deficiencies. In addition, ABA is having the strongest evidence-base supporting its efficacy for the treatment for autism. Moreover, ABA rendered in home setting has not led to adequate progress of the patient. Given this information and his low assessment scores, a clinic setting is appropriate. However, the patient does not yet possess the prerequisite skills to participate and advance in social skills training sessions. Considering these factors, the requested center-based ABA services are medically necessary, but social skills training is not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is a licensed BCBA, is board certified in psychology, 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 HP Acthar Gel. Although Acthar Gel is U.S. Food and Drug Administration (FDA) approved for the treatment of psoriatic arthritis, the current literature with respect to the long-term safety and efficacy is not well established. Acthar Gel is intended as a bridge therapy for use until maintenance therapy starts to work. Acthar Gel is not supported as a long-term maintenance therapy to replace alternative therapies. Although this patient has tried and failed to adequately respond to multiple prior therapies, the records do not document that the patient has been treated with Imuran, Cyclosporine, Cimzia, or Remicade. Additionally, HP Acthar Gel carries the same potential corticotrophin side effects as steroids including hypertension and worsening diabetes mellitus. This patient has hypertension and diabetes mellitus with glucose values up to 333 mg/dL. All told, the requested HP Acthar Gel is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for the medications, Percocet, 5mg, at a frequency of eight (8) pills per day, and Norco, 10mg, at a frequency of six (6) pills per day. The enrollee has lumbar radiculopathy. He has a history of lumbar fusion, myofascial tender points and osteoarthritis. It is aggravated by activity and relieved with pain medications, ice, and heat. He underwent a right knee steroid injection, bilateral lumbar medial branch blocks with poor response, a lumbar epidural steroid injection without relief, bilateral L5-S1 transforaminal epidural steroid injections, and sacroiliac joint injections with minimal relief. The enrollee was recommended for the chronic pain level 2 program, but he is not interested in doing these classes at this time. Regulatory agency guidelines describe opioid prescribing as part of a comprehensive, multidisciplinary, multimodal treatment plan in which enrollees are assessed and closely monitored. Due to the addictive risk of opioids, the agency recommends benefits and harms be evaluated within one month of prescribing, and every three months thereafter, to reevaluate the medical necessity for opioid use. Based on this enrollee's medical records, the enrollee refused clinician recommended evaluations including the lumbar spine magnetic resonance imaging scan to assess the pain severity. This point is important, because a magnetic resonance imaging scan can help determine if there is a new source of pain. If this is the case, prescribing an opiate will be masking the pain and prevent the potential workup needed to discover the problem that is at the root of this pain. Medical records indicate the enrollee is not interested in a multidisciplinary, multimodal treatment plan and is only interested in opioids at this time. Given that opioids in this case would not be part of a multimodal pain treatment plan, the medical necessity is not substantiated.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care. including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, a review of the patients records indicates that the patient was not in substantial withdrawal-related distress. There are no significant biomedical conditions or continued substance use reported to satisfy dimension 2. The patient does not meet the criterion for dimension 3, as he has PTSD and depression, but he does not require 24-hour support to control behavioral impulses or substance use. For dimension 4, the patient has expressed a willingness to change. However, he has limited insight regarding his need for continuing care. Dimensions 5 and 6 are met as the records document that the patient continues to endorse addiction symptoms including craving. Further, the patient has expressed that his substance use history has caused a strain on his relationship with his family, leaving him with limited social supports. Based on these findings, the RTC level of care services were not and are not medically necessary for 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 with subspecialty 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:  The enrollee is requesting authorization and coverage for the medication, Orencia. The enrollee has long-standing, erosive, undertreated, seropositive, class III/IV rheumatoid arthritis, and secondary knee osteoarthritis with large effusions. Her inflammatory markers have been very high, with a Vectra score of 74, showing high disease activity. The enrollee failed leflunomide, and developed mouth sores with methotrexate. She underwent knee aspiration and a steroid injection. She continues to have intermittent pain and swelling in the knees. She does not sleep well due to pain. After a discussion with her rheumatologist, the enrollee preferred to trial treatment with Orencia, instead of triple oral therapy with methotrexate, hydroxychloroquine, and sulfasalazine. Literature notes tumor necrosis factor-inhibitors still represent the first biologic after conventional synthetic disease-modifying anti-rheumatic drug. Literature shows all biologics, including tumor necrosis factor blockers and abatacept, are similarly effective on a long-term basis. A professional society guideline recommends tumor necrosis factor-inhibitors or a non-tumor necrosis factor-inhibitor biologic; with or without methotrexate, and in no order of preference, rather than continuing disease-modifying anti-rheumatic drug monotherapy alone. Orencia is a non-tumor necrosis factor-inhibitor biologic. This enrollee has documented rheumatoid arthritis.  She has already failed methotrexate.  Records show her symptoms continue and she has inflammatory arthropathy involving the knees. In this enrollees circumstances, Orencia is an appropriate therapeutic option.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 55-year-old female who has been diagnosed with osteoporosis. A dual-energy x-ray absorptiometry (DEXA) scan showed a spine L1-4 T-score of -3.0, a left femoral neck T-score of -2.5, and a right femoral neck T-score of -2.5. A couple years later, a DEXA scan showed a spine L1-4 score of -2.4, a left femoral neck T-score of -2.3 and a right femoral neck score of -2.5. Another DEXA scan was taken a year after, showing a spine L1-4 T-score of -2.6, a right femoral neck T-score of -2.3 and a left femoral neck T-score of -2.4. Records also noted that the patient had a history of breast cancer that was treated with tamoxifen for several years. The patient had received treatment with Zometa for three years and discontinued therapy approximately 1.5 to two years ago. The provider noted the patient had been treated with zoledronic acid, without improvement in her bone density. The patient has requested authorization and coverage for Prolia. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Prolia is medically necessary for the treatment of the patients medical condition. Prolia is indicated for the treatment of osteoporosis in postmenopausal women who are at high risk of bone fracture. The medical evidence supports the requested medication in this clinical setting. Therefore, Prolia 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 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.