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

The patient has requested authorization and coverage for Norco. This patient has acute presentation of non-specific low back pain, with reports of weakness in the lower extremities. MRI studies of the lumbar spine showed degenerative changes affecting the L5-S1 region of the spine without high grade spinal canal narrowing. The patients provider recommended a physical therapy program and referred the patient to pain management. In this case, non-pharmacologic treatments have not been exhausted and a specific cause of the patients low back pain has not been identified. The current CDC guidelines do not recommend the prescribing of opioid therapy for acute non-specific back pain due to a lack of evidence of benefit combined with risks of dependence, sedation, interruptions of sleep, and gastrointestinal upset. Based upon the medical records available for review and the current medical guidelines, the request for Norco 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 anesthesiology with subspecialty certification 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an enrollee has requested authorization and coverage for Functional Formularies Nourish. The patient has tried and failed Elecare, Elecare Jr., and Kate Farms Pediatric Peptide. It can be used for meal replacement or to supplement, for both oral and enteral use. It meets the dietary restrictions of the six-food elimination diet. Records reflect that the patient has tried samples of Nourish and has responded well, with decreased symptoms and improved weight gain. Functional Formularies Nourish treats the patients eosinophilic esophagitis, prevents complications from the disease, and promotes weight gain and growth. The requested Functional Formularies Nourish therefore promotes the health of the patient, prolongs life, and prevents the progression of her health condition. Accordingly, the requested Functional Formularies Nourish is medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested product is medically necessary to treat the patients condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics, with subspecialty certification in pediatric critical care 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

The patient has requested authorization and coverage for applied behavior analysis (ABA) services of 60 hours per week at 2:1 ratio, 10 hours per month of mid-level supervision, and 120 hours per month of high-level supervision, in the alternative ABA services of 60 hours per week at a 2:1 ratio, 38 hours per month of mid-level supervision, and 12 hours per month of high-level supervision. The Behavior Analyst Certification Board (BACB) outlines that, many variables, including the number, complexity, and intensity of behavioral targets and the clients own response to treatment help determine which model is most appropriate. A targeted assessment and treatment in a center-based model, by providers specifically trained to treat challenging behavior, is preferable to in-home ABA services. The BACB noted that autistic patients demonstrating severe destructive behavior disorders might require treatment in more intensive settings, such as specialized intensive-outpatient, day- treatment, residential, or inpatient programs. The patients caregiver reports that the 60 hours per week of 2:1 ABA therapy is appropriate. However, the patient and caregiver have not made progress with this intensity, challenging behaviors have increased, and multiple discharges have ensued. Overall, the records do not demonstrate that the home is an optimal treatment setting, as it has exacerbated the patients symptoms. All told, the requested ABA services of 60 hours per week at 2:1 ratio, 10 hours per month of mid-level supervision, and 120 hours per month of high-level supervision, in the alternative ABA services of 60 hours per week at a 2:1 ratio, 38 hours per month of mid-level supervision, and 12 hours per month of high-level supervision are not medically necessary for 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 a licensed B.C.B.A, 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: Overturned Decision of Health Plan

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (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. Given the findings, the RTC level of care services provided were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Diazepam (Valium) 2 mg (30 tablets/30 day supply). The enrollee has low back pain, muscle spasms, obstructive chronic bronchitis without exacerbation, and a history of spinal surgeries. The enrollee reports she has taken Vicodin, Naproxyn, Mobic, Tramadol, Gabapentin, Prozac, and Baclofen. The enrollees physician has prescribed the medication diazepam (Valium) 2 milligrams for a 30-day supply. In addition to the aforementioned history, this enrollee is morbidly obese. The enrollee reports she has taken Vicodin, Naproxyn, Mobic, Tramadol, Gabapentin, Prozac, and Baclofen. She had an adverse reaction to Flexeril, reporting it caused her to lose consciousness. Literature advised caution when prescribing Valium to those who concomitantly use other sedatives. Literature also warned of the dangers of dependence and respiratory arrest in persons with obstructive sleep apnea, which is almost universally present in morbidly obese persons.  The formulary alternatives are not scheduled drugs and have similar efficacy.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for Intermittent Theta Burst Stimulation/Transcranial Magnetic Stimulation, 2 times per week, 5 sessions per day.Transcranial Magnetic Stimulation (TMS) therapy is currently approved for treating patients who are suffering from the acute phase of major depressive disorder (MDD). TMS is not currently approved for the treatment of bipolar disorder, based on consensus statements and lack of clinical trials demonstrating efficacy. While there have been some small studies to explore the use of TMS in bipolar disorder, they have not shown statistically significant remission rates. There are also ongoing studies investigating the use of TMS for the depressed phase of bipolar affective disorder (BPAD), but they have not yet demonstrated evidence that would support the use of TMS for bipolar disorder. In this case, the patient has been diagnosed with bipolar 2 disorder and anxiety. Despite the fact that the patient reports subjective improvement, the patient does not have a diagnosis of major depressive disorder, for which TMS is currently approved. TMS is also not currently approved for the treatment of bipolar disorder, the patients diagnosis. Under these circumstances, Intermittent Theta Burst Stimulation/Transcranial Magnetic Stimulation, 2 times per week, 5 sessions per day, was not, and is not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgical implantation of an upper airway stimulation device for the hypoglossal nerve (CPT 64568 and 0466T). The records provided for review support a diagnosis of obstructive sleep apnea (OSA). The patients drug induced sleep endoscopy (DISE) showed no concentric collapse at velum and primarily anterior posterior collapse with 100% collapse at the velum in the anteroposterior direction. There was significant improvement of the airway with jaw thrust. The patient has not been able to tolerate the CPAP device. The Inspire device is a U.S. Food and Drug Administration (FDA) approved device for the treatment of OSA device. The patient is a candidate for the Inspire device given his intolerance to CPAP, anterior posterior collapse, no central apnea, and body mass index (BMI) of 29.28 kg/m2. The patients jaw thrust significantly improved the airway and there is no concentric collapse. Thus, the patient will benefit from the surgery. Accordingly, the requested surgical implantation of an upper airway stimulation device for the hypoglossal nerve (CPT 64568 and 0466T) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested surgical implantation of an upper airway stimulation device for the hypoglossal nerve (CPT 64568 and 0466T) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Acessa laparoscopic radiofrequency ablation procedure. Researchers concluded that, laparoscopic radiofrequency ablation therapy is efficacious for small-sized and non-pedunculated symptomatic uterine fibroids. Based on this review, this patient is not a suitable candidate for the Acessa laparoscopic radiofrequency ablation procedure. The patients fibroid is pedunculated and measures 6.9 x 4.8 x 7.1 cm. In addition, the patient previously underwent magnetic resonance guided treatment of her myomas, and there is a lack of data demonstrating that subsequent radiofrequency in this clinical setting is safe and effective. The patient has heavy bleeding and symptoms related to her fibroid uterus. Palpation of the myoma causes pain. The patients heavy bleeding is likely related to the submucosal fibroid. Myomectomy would address the pedunculated fibroid, while hysteroscopic myomectomy can be used to remove the submucosal fibroid. The patient has indicated that she would like to preserve her fertility, and the Acessa procedure is not recommended if a pregnancy is planned. In addition, Acessa is not suitable for pedunculated fibroids. Accordingly, the requested Acessa laparoscopic radiofrequency ablation procedure (CPT 58674) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Acessa laparoscopic radiofrequency ablation procedure (CPT 58674) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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

The patient has requested authorization and coverage for pregabalin capsules 25 mg. The U.S. Food and Drug Administration (FDA) approved indications for pregabalin include neuropathic pain associated with diabetic peripheral neuropathy, post-herpetic neuralgia, adult patients with partial onset seizures, fibromyalgia, and neuropathic pain associated with spinal cord injury. Medical literature studies showed limited evidence of benefit in neuropathic back pain or sciatica, neuropathic cancer pain, or polyneuropathy. The North American Spine Society (NASS) guidelines for diagnosis and treatment of lumbar disc herniation with radiculopathy concluded that there is insufficient evidence to make a recommendation for or against the use of gabapentin in the treatment of lumbar disc herniation with radiculopathy. This patient presents with acute on chronic low back pain radiating into the right leg suggestive of lumbar radiculopathy. The records do not document a trial of a duloxetine or venlafaxine, which have been shown to be effective for neuropathic pain. Overall, there is insufficient evidence in the peer-reviewed medical literature to support the use of pregabalin for lumbar radiculopathy. Therefore, the requested pregabalin capsules 25 mg 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 anesthesiology with subspecialty certification 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for HP Acthar Gel 80 Units twice a day (BID) for three months and then HP Acthar Gel 40 Units BID for three months. Acthar Gel is U.S. Food and Drug Administration (FDA) approved for the management of nephrotic syndrome. Acthar Gel is supported as safe and effective for patients who are refractory or intolerant of the typical agents used as first- and second-line therapies. Researchers found that Acthar Gel may meet an important treatment need in patients with treatment-resistant nephrotic syndrome in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. This patient has exhausted many standard treatments. She has advanced disease is at high risk for further progression. Given the support in the medical literature, the requested HP Acthar Gel 80 Units BID for three months and then HP Acthar Gel 40 Units BID for three months is medically necessary for 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 subspecialty certification in nephrology 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 atherectomy. The documentation supports the medical necessity of the requested services in this case. The patient has a history of diabetes and tissue loss involving the right foot. Given that the patient is symptomatic, has a history of a diabetic foot ulcer and has significant bilateral evidence of flow limiting stenosis, he is an appropriate candidate for intervention. In a diabetic patient with even marginally abnormal ABIs, a foot ulcer, and known lower extremity arterial occlusive disease, atherectomy is medically appropriate. There is sufficient support for the requested services in this clinical setting. Therefore, the requested atherectomy is 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 surgery with subspecialty certification in vascular 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the medication Relizorb cartridges (immobilized lipase). The enrollee has cystic fibrosis and exocrine pancreatic insufficiency. She had a lung transplant. She eats two meals per day and she is fed by a gastrostomy tube overnight. She takes the medication Relizorb cartridges (immobilized lipase) and her physician reports that this medication is for absorption of the patients overnight feeds. Her body mass index remains within normal limits. Her physician reports that she strongly recommends Relizorb to help the patient maintain adequate energy and protein stores that are essential to adaptive immune response, graft survival rate, and quality of life. This patient has advanced cystic fibrosis (CF) with high nutritional needs given the energy requirements associated with her condition, her bilateral lung transplantations, her infections and her maldigestion associated with her exocrine pancreatic insufficiency. This particular patient would benefit from the use of Relizorb during her nighttime tube feeds. The use of Relizorb is approved by the Food and Drug Administration (FDA) in children and is supported by studies to be safe and effective thereby elevating the use of this device to standard of care. Therefore, the medication Relizorb cartridges (immobilized lipase) is medically necessary to treat the patients medical condition. 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 pediatric 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: This is a patient with a diagnosis of glioblastoma. The patient had treatment with a surgical resection of the tumor, surgery with gamma knife, radiation, and chemotherapy. The patient showed progression of the disease after being on a clinical trial. The provider is requesting Keytruda medication. At issue is whether the Keytruda (pembrolizumab) is medically necessary to treat the patients medical condition. At this time, there is insufficient clinical literature support for the use of Keytruda for the diagnosis of glioblastoma. Researchers reported an observational study for the use of pembrolizumab in recurrent high-grade glioma, which showed that in those patients with glioblastoma, all reported progressive disease with the use of Keytruda. Another finding reported a clinical trial of pembrolizumab in recurrent glioblastoma with the conclusion that there is insufficient response and the majority of glioblastoma patients. The current National Comprehensive Cancer Network Guidelines (2020) does not list pembrolizumab as a recommended treatment option for glioblastoma.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 oncology 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.