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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Jardiance 25 mg tablets. Findings:  The physician reviewer found that Jardiance is SGLT-2 agonist agent that has been U.S. Food and Drug Administration (FDA) approved for management of type 2 diabetes. Starting SGLT-2 inhibitor is helpful to improve glycemic control in patients with established type 2 diabetes. SGLT-2 agent therapy can also be started at any stage of the disease as long as the patient does not have significant renal disease. Dual therapy with metformin and SGLT-2 inhibitor is recommended by the American Association of Clinical Endocrinologists (AACE) for management of type 2 diabetes. Per the clinical documentation provided, this patient was recently started on metformin therapy without substantial improvement in his type 2 diabetes. His renal function is adequate to support Jardiance therapy. For these reasons, the requested Jardiance 25 mg tablets is 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left knee magnetic resonance imaging (MRI) for evaluation of the enrollees left knee pain. Findings:  The physician reviewer found that this patient has had no x-rays of his symptomatic knee and has not undergone an adequate trial of physical therapy. While his legs have documented atrophy there are no physical signs documented to provide medical necessity for MRI prior to repeat x-rays and a trial of physical therapy. In this patient with severe atrophy, physical therapy is likely to be of little or no benefit as he is apparently wheelchair bound. Repeat x-rays may be of benefit for orthopedic evaluation as well as for analysis of patellofemoral changes. The examination was only two views by report which means a sunrise view of the patellofemoral joint was not included and according to the patients appeal letter he has severe patellofemoral crepitus. Thus, while the patient does not meet the medical necessity criteria for MRI which includes recent x-rays and physical therapy, repeat x-rays may provide enough information to support an indication for MRI even absent a trial of physical therapy. However, based on the current available documentation, the requested MRI of the left knee is not supported as medically necessary for evaluation of this patients knee pain. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture/acupressure, once per week, trigger point injections, medial branch blocks (MBBs), subacromial bursa injections, Percocet 10 mg, three times per day, oxycodone-acetaminophen 10-325 mg, every eight hours, pentoxifylline XR 400 mg, twice per day, Flexeril 10 mg, as needed, once per day, Neurontin 300 mg, three times per day, and Lyrica 50 mg, every 12 hours. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services and requested medications. This patient has requested an array of therapies without proper clinical basis and against clinical practice guidelines. He has several red flags which make prescribing chronic opiates problematic. These include the use of cannabis, a past history of alcohol abuse, and a history of depression. In this setting, there is a lack of support for medication management with opiates and benzodiazepines. Additionally, therapeutic plans which include injections should be ordered by medical providers. The documentation does not indicate that the requested injections have been recommended by the patients providers. Thus, the records do not support the medical necessity of the requested injections in this setting. With regards to MBBs and acupuncture, there is no note from his last primary care provider or last pain management provider recommending either of these interventions. There are a lack of physical examination findings that support facet joint syndrome. In sum, the requested acupuncture/acupressure, once per week, trigger point injections, MBBs, subacromial bursa injections, Percocet 10 mg, three times per day, oxycodone-acetaminophen 10-325 mg, every eight hours, pentoxifylline XR 400 mg, twice per day, Flexeril 10 mg, as needed, once per day, Neurontin 300 mg, three times per day, and Lyrica 50 mg, every 12 hours are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services and requested medications 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acute cognitive rehabilitation center services for treatment of the enrollees middle cerebral artery (MCA) cerebrovascular accident (CVA). Findings:  The physician reviewer found that a review of the literature and the patients medical records reveal that the request for admission to a specialized inpatient cognitive rehabilitation center is not medically necessary. Although patients recovering from stroke may benefit from an acute inpatient rehabilitation admission, the documentation does not demonstrate that the patient has the medical complexity that requires the continued intensive physician and nursing support that is present in an acute inpatient rehabilitation facility. The patient currently appears medically stable per documentation. A review of the current medical literature indicates that the effect of time spent in rehabilitation post-stroke has been explored extensively but without clear conclusions. The effect of increased time spent in rehabilitation on ADLs is also uncertain. The literature reveals that multiple studies on stroke rehabilitation do not all make a recommendation for treatment duration. Furthermore, there have been several randomized controlled trials that have studied cognitive rehabilitation and addressed immediate effects on standardized psychobehavioral tests. However, few studies have assessed the durability of treatment effects or relevance to everyday functioning. Although the documentation reveals that he may benefit from additional physical and occupational therapy as well as speech therapy for cognitive dysfunction, there is no evidence that a more intensive rehabilitation program of six hours a day is medically necessary. Thus, the requested acute cognitive rehabilitation center services are not supported as 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 with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 15 pills per month of Cialis for treatment of the enrollees erectile dysfunction. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. This patient has a history of erectile dysfunction following pelvic fracture. His provider has recommended Cialis. The patient has requested coverage for 15 pills per month of Cialis. The Health Plan has approved coverage for six pills per months as an alternative. The use of six tablets per month is an appropriate supply for the treatment of this patients medical condition. The records do not support the medical necessity of the requested medication quantity in this patients case. All told, the requested 15 pills per month of Cialis are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient epilepsy monitoring for treatment of the enrollees seizures. Findings:  The physician reviewer found that it is currently considered the standard of care by most providers and supported by the medical literature to admit a patient in this clinical setting for long-term EEG monitoring and evaluation. This patient carried a suspected, but not confirmed, diagnosis of intractable epilepsy. In addition, she was not tolerating her current anti-epileptic drugs. In this case, it is important to determine the correct diagnosis as this would guide management. Accordingly, the inpatient epilepsy monitoring services provided were medically necessary for treatment of the patients medical condition. Final Result: The physician reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in internal medicine with sub-specialty certification 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Pushtronex 420 mg/3.5 mL wearable injector for treatment of the enrollee, who has a history of hyperlipidemia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has dyslipidemia and significantly increased coronary risk, but no documented cardiovascular disease. There is a lack of documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia.  These diagnoses require not only elevated low-density lipoprotein (LDL) levels that significantly exceed 180 mg/dL, but also a combination of physical examination findings (arcus cornealis, tendon xanthomas), a strong family history of coronary disease, and documented genetic defects related to cholesterol metabolism, according to published criteria. Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL cholesterol. The documentation does not support that the patient fits either of these criteria. PCSK9 inhibitors have not been studied in other patient populations, such as in this clinical setting. Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Therefore, the requested Repatha Pushtronex 420 mg/3.5 mL wearable injector is not medically necessary for the treatment of this patient. Final Review: 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 cardiovascular disease 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 valganciclovir HCl (Valcyte) 900 mg twice a day (until cytomegalovirus is negative for two weeks), then 900 mg once a day for three months. Findings:  The physician reviewer found that Cytomegalovirus is the most significant opportunistic pathogen affecting liver transplant recipients, and it produces diverse clinical manifestations and significant morbidity and mortality. It is life-threatening disease in liver transplant patients and can cause organ rejection. Per guidelines from the American Association for the Study of Liver Disease (AASLD) and American Society for Transplantation, cytomegalovirus can cause viremia. Treatment should be started whenever recipients are symptomatic in the setting of viremia, and continue until both symptoms and viremia are resolved. The recommended dose is 900 mg twice daily for a minimum of two weeks, and until viremia and symptoms are resolved. There is a lack of recommended alternatives for treatment of active cytomegalovirus in patients with liver transplant. The current medical evidence supports the requested medication regimen in this clinical setting. For these reasons, valganciclovir HCl (Valcyte) 900 mg twice a day (until cytomegalovirus is negative for two weeks), then 900 mg once a day for three months is medically necessary for the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for epinephrine auto injector. Findings:  The physician reviewer found that candidates for immunotherapy are patients whose symptoms are not controlled adequately by medication and avoidance. The allergy immunotherapy practice parameter recommends that at the onset of immunotherapy, patients should be counseled on the possibility of immediate and delayed systemic reactions. Accordingly, the decision to prescribe epinephrine auto injectors to patients receiving immunotherapy should be at the providers discretion. Patients should remain in the providers medical clinic for at least 30 minutes after receiving an injection, but longer waits are reasonable, as directed by the provider. Some providers might request that patients who are considered at increased risk of a serious systemic reaction outside of the medical clinic carry injectable epinephrine. These patients should be instructed in the use of epinephrine to treat a systemic reaction that occurs after they leave their providers office or other location where the injection was administered. In addition, biphasic anaphylactic reactions are characterized by complete clinical resolution of initial symptoms followed by onset of late phase symptoms, usually within 24 hours. The literature indicates that biphasic anaphylactic reactions are reported to occur 1% to 20% of the time and that biphasic reactions occur in 10% and 23% from immunotherapy reactions. As such, the use of more than one dose of epinephrine auto injector would be crucial. Based on the documentation provided, epinephrine auto injector would be indicated in this patient. Therefore, authorization and coverage for epinephrine auto injector 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 allergy and immunology 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 rifaximin (Xifaxan). Findings:  The physician reviewer found that the use of Xifaxan is supported by current medical literature for both pouchitis and prophylaxis of hepatic encephalopathy. A meta-analysis of nine studies, including three randomized controlled trials, has demonstrated that antibiotic use is associated with a significant improvement in pouchitis compared to placebo or other treatment. Antibiotic-dependent pouchitis often requires chronic antibiotic therapy. In a study of 51 patients with antibiotic-dependent pouchitis, Xifaxan was used as long-term maintenance therapy after proctocolectomy with ileo-anal pouch. One study in 16 patients with antibiotic- and probiotic-refractory pouchitis demonstrated 81% of patients achieved remission with Xifaxan. Based on current medical literature, Xifaxan is effective for treatment of pouchitis. In this case, the patient has failed the alternatives ciprofloxacin and metronidazole multiple times. Xifaxan can also be used for prophylaxis of hepatic encephalopathy in this case, and its use is supported by studies demonstrating the efficacy of Xifaxan without concurrent use of lactulose. The formulary alternative lactulose is effective for hepatic encephalopathy prophylaxis, but is not useful for the treatment of pouchitis. For these reasons, the request for Xifaxan is supported as medically necessary for the treatment of this patients pouchitis and for hepatic encephalopathy prophylaxis. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tilt table testing and referral to a geneticist. Findings:  The physician reviewer found that with regard to genetic testing for Ehlers Danlos, this is not medically necessary. Ehlers Danlos is a rare (1 in 100,000 to 250,000 people) autosomal dominant disease of collagen synthesis. The disease involves skin, viscera, joints, and blood vessels. In this case, there is no family history of Ehlers Danlos reported. The patient has no vascular disease or other typical manifestations of Ehlers Danlos. In addition, the patient has been evaluated by rheumatology and who did not feel the patient to have any rheumatologic disease. In sum, genetic testing is not medically necessary for the evaluation of this patient medical condition. Final Result: The reviewer determined that a portion of the requested services is 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 internal medicine with sub-specialty certification in cardiovascular disease and clinical cardiac electrophysiology 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.