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

The patient has requested reimbursement for a loop recorder (implantable ambulatory event monitor). Although this patient has a remote history of lone atrial fibrillation secondary to alcohol intake, he has no high-risk symptoms such as syncope, and there is no report of a stroke or transient ischemic attack. The patients symptoms of transient dizziness and premature ventricular contractions (PVCs) occurred in the setting of normal left ventricle function. The patient underwent placement of a loop recorder for evaluation of his symptoms. There is adequate data to support an indication for implantable loop recorder devices in the evaluation of patients with cryptogenic stroke, post atrial fibrillation ablation to monitor effectiveness, or for patients with persistent and repeated palpitations, syncope, or near syncope when external monitoring has been unrevealing. In this instance, the patient presented with transient symptoms of dizziness with no atrial fibrillation when evaluated in the emergency department, with a remote history of lone atrial fibrillation associated with alcohol intake many years prior. Given the patients minimal symptoms and lack of high-risk features, external monitoring with an auto-triggered or patient-activated event recorder, or a patch-type monitor, was appropriate for initial evaluation. In this clinical situation, an implantable loop recorder as an initial evaluation was not medically necessary prior to external monitor evaluation. Therefore, the loop recorder (implantable ambulatory event monitor) was not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS).Findings:  The physician reviewer found that this patient has a long documented history of treatment-resistant depression. Despite adequate trials of multiple medications as well as ongoing evidence-based psychotherapy, the patient continues to experience refractory depression, which has significantly interfered with her ability to function. The patient previously noted substantial symptomatic improvement with a past course of TMS. Given the treatment refractory nature of this patients major depressive disorder, numerous trials of alternative treatments for her condition, and only positive response to a course of TMS, the medical literature supports a repeated course of TMS (McClintock, et al.). Moreover, the requested TMS is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the requested TMS 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patients parent has requested authorization and coverage for five hours per week of intervention using the PLAY project intervention model. The Council of Autism Service Providers guidelines on ABA treatment of autism spectrum disorder note that for an individualized ABA treatment plan, a developmentally appropriate ABA assessment process must identify strengths and weaknesses across domains and potential barriers to progress. Papatola and Lustig report that ABA services should be consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research. Solomon and colleagues report that PLAY project therapy is based on a developmental, individual differences, and relationship-based (DIR) theoretical framework, operationalizing DIR through a structured approach that includes coaching, modeling, and video feedback. However, there is an overall lack of research on DIR based therapies to establish its efficacy. Current evidence-based practices for the management of patients with autism do not include PLAY project therapy or DIR- based therapies. In this clinical setting, given the limited evidence in current medical literature on the effectiveness of PLAY project therapy, the requested services are not medically indicated. In this patients case, five hours per week of intervention using the PLAY project intervention model are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, five hours per week of intervention using the PLAY project intervention model are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for  chemotherapy with immunotherapy (Carboplatin, Abraxane, and Keytruda). The National Comprehensive Cancer Network (NCCN) has broad recommendations for chemotherapy regimens used in the treatment of patients with metastatic adenocarcinoma of the lung. The NCCN guidelines include various combinations, such as treatment with a carboplatin in combination with a taxane. The guideline noted that Abraxane can generally be substituted for another taxane. In addition, there is support for treatment with pembrolizumab when there is no contraindication. In this patient, there is no evidence of a contraindication treatment with pembrolizumab. Furthermore, the patients assay for PDL-1 was 10-15%, which provides further indication that pembrolizumab will be effective. An overall an analysis of NCCN guidelines suggest that the requested medication regimen meets guideline criteria and is likely to be more beneficial as any other treatment. Therefore, the requested chemotherapy with immunotherapy (Carboplatin, Abraxane, and Keytruda) 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 chemotherapy with immunotherapy (Carboplatin, Abraxane, and Keytruda) 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 medication regimen is 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 reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in hematology and is 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

The patient has requested authorization and coverage for a glucose monitor. Many patients monitor their blood glucose levels at home to help sustain reasonable blood glucose control and avoid associated short- and long-term diabetic complications (Zheng, et al.). The introduction of continuous glucose monitors (CGMs) has improved the ability of patients to monitor their glycemic control without the need for finger sticks (Olczuk and Priefer). The FreeStyle Libre CGM is a wireless device using a sensor for monitoring interstitial fluid glucose that was introduced to help patients with type 1 and 2 diabetes mellitus achieve better glucose control. The FreeStyle Libre CGM, unlike other devices, does not require finger stick calibration. Recent data suggests that the FreeStyle Libre CGM is accurate, and patients report excellent satisfaction with use of the device (Olafsdottir, et al.). Given this support, the requested glucose monitor is medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the jaw and Botox injections to the jaw.The current, well accepted, universally performed test to identify the presence or absence of TMD is a comprehensive evaluation of the patients history and clinical examination and when indicated, select imaging, such as MRI. Additionally, Khawaja and colleagues state, There are conflicting reports in the literature regarding the efficacy, safety, and predictors of therapeutic response to botulinum toxin type A therapy for management of refractory masticatory muscle pain. Given this patients clinical findings, an MRI is medically appropriate to evaluate her TMJ. An MRI in open and closed mouth positions is medically appropriate when evaluating for internal derangement. It provides the most information regarding the soft tissue structures and disk position. However, there is insufficient documentation to support the use of Botox for the treatment of her TMD symptoms. Therefore, the MRI of the jaw is medically necessary for the evaluation of the patients medical condition. However, the Botox injections to the jaw are not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the some 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 board certified in oral and maxillofacial 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Clocortolone pivalate cream 0.1%. Both lichen simplex chronicus and lichen sclerosus of the genital skin are chronic diseases that are difficult to control. The use of topical class 1 corticosteroids is considered the mainstay of therapy for these conditions. The current medical literature and guidelines support the safety and efficacy of clobetasol for the treatment of lichen sclerosus. Researchers noted that for male patients, clobetasol propionate 0.05% ointment must be used once daily for one to three months with an emollient soap substitute and barrier preparation. There is a lack of randomized controlled clinical trials for male lichen sclerosus management. However, a large retrospective series demonstrated that 50% of male patients with lichen sclerosus responded to clobetasol propionate. This patients records do not document an adequate trial of treatment with clobetasol. For these reasons, the requested Clocortolone pivalate cream 0.1% 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Verzenio 150 mg tablets, twice a day. The U.S. Food and Drug Administration (FDA) has not approved Verzenio for the adjuvant treatment of patients with breast cancer after neoadjuvant chemotherapy. There is a lack of support for treatment with Verzenio in the major drug compendia and the medical literature. Findings reported by Johnston and colleagues suggest that Verzenio may have a role in the treatment of patients with hormone receptor (HR) positive, HER2 negative breast cancer, following treatment with radiation, neoadjuvant chemotherapy, and/or adjuvant chemotherapy. However, the findings in the monarchE study are preliminary and additional data are needed to determine whether Verzenio is safe and effective for use in this patients clinical setting (Johnston, et al.). Additional data are needed to understand the long-term impact from the adjuvant use of CDK4/6 inhibitors in this setting. Although the monarchE study assessed early recurrence, this may have a different biology from last recurrences. Moreover, the findings of the PALLAS trial note that two year of adjuvant treatment with a CDK4/6 inhibitor and endocrine therapy did not improve invasive disease-free survival compared with adjuvant chemotherapy alone. The authors concluded that, this regimen cannot be recommended in the adjuvant setting. Given these findings, the requested Verzenio 150 mg tablets, twice a day are 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 certifications in medical oncology and hematology 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 budesonide.According to the American College of Gastroenterology (ACG) guidelines for the treatment of Crohns disease, Controlled ileal release budesonide at a dose of 9 mg once daily is effective and should be used for induction of symptomatic remission for patients with mild-to-moderate ileocecal Crohns disease. Additionally, American Gastroenterological Association (AGA) guidelines for the treatment of Crohns disease state, The adverse effects in both the short and long-term with systematic corticosteroids are substantialbudesonide, however, due to a first-pass metabolism in the liver is better tolerated with fewer adverse effects and no significant alterations on serum cortisol level. Finally, Rezaie and colleagues state that budesonide is effective for the treatment of Crohns disease with less adverse effects than systemic alternatives. In this case, the patient has uncontrolled Crohns disease. According to the medical literature, budesonide is an appropriate treatment for patients with mild-to-moderate ileocecal Crohns disease. Therefore, budesonide is medically necessary for the treatment of the 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lidocaine adhesive patch 5%. The U.S. Food and Drug Administration (FDA) has approved the lidocaine patch for the treatment of patients with post-herpetic neuralgia. A review by researchers reported that there is a lack of evidence to support the use of lidocaine patches for the treatment of musculoskeletal pain. A systematic review completed by researchers evaluated the medical evidence supporting the use of lidocaine patches for chronic low back pain. The authors analyzed seven studies and concluded that there is a paucity of randomized controlled trials with substantial evidence to support the use of 5% Lidocaine patch in chronic low back pain. In this case, the patient has chronic low back pain due to high grade spinal stenosis. Her records do not report any history of symptoms suggestive of post-herpetic neuralgia. Moreover, the providers notes document that the lidocaine patch was not effective for relief of this patients chronic back pain, which is consistent with the current evidence-based medical literature. All told, the requested lidocaine adhesive patch 5% 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for readmission to custodial level of care.The records indicate that the patient has had spinal issues and a left elbow fracture in late 2020 that was surgically repaired. She has been at an independent living facility since March 2021. There is no documentation of impairments or ongoing medical issues that establish the need for a higher level of care than an independent living facility. The facility has been working with the patient and her family to return to the community, but there are no indications in the records that the objections to returning to the community are based on any medical issues. The medical necessity of a return to a facility level of care is not established. Therefore, readmission to custodial level of care is not medically necessary for the treatment of the 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for exome sequencing testing (CPT 81415). The provider caring for this patient has recommended whole exome sequencing (WES) for diagnostic purposes given the constellation of symptoms including enamel hypoplasia, eczema, vitiligo, xerosis, and skin hypopigmentation. In contrast to current sequencing tests that analyze one gene or small groups of related genes, WES will analyze the exons or coding regions of over 20,000 genes. Therefore, sequencing the exome is an effective method of analyzing the patients DNA to discover the genetic cause of diseases or disabilities. Researchers found that of 100 families with 119 children affected by neurodevelopmental disorders, WES led to a diagnoses leading to a change in the clinical care or impression of the pathophysiology in 49% of newly diagnosed families. Similar findings have been reported by another study, which noted that WES yielded a presumptive diagnostic rate of 41% in patients with neurodevelopmental disabilities and unrevealing work-up. Moreover, the American College of Medical Genetics and Genomics supports the use of WES in this patients clinical setting. As noted, the patient has undergone a robust genetic evaluation of all know genes associated with ectodermal hypoplasia, which failed to identify a unifying diagnosis. All told, the requested exome sequencing testing (CPT 81415) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested exome sequencing testing (CPT 81415) is likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 2 is board certified in genetics and is actively practicing. Physician reviewer  is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics and is 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.