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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested authorization and coverage for the injectable medication, Aimovig, for treatment of chronic migraine headaches.According to the medical record, the enrollee has chronic migraine headaches, status migrainosus, and tectal glioma (a benign lesion in his brain). He underwent endoscopic third ventriculostomy (ETV) surgery for hydrocephalus. He is followed by a neurologist for symptoms of daily headaches with pain spikes. He also gets nausea, lightheadedness, light sensitivity, movement sensitivity, and noise sensitivity associated with the migraines. He has missed a lot of time at school.  For his symptoms, he has tried treatment with Propranolol, amitriptyline, Venlafaxine, riboflavin, Melatonin, Sumatriptan, Rizatriptan, Vicodin, Norco, Diclofenac, Compazine, Zofran, Naproxen, and vaping THC. He also had right occipital trigger point injection and admission for intravenous dihydroergotamine (DHE), but neither had any benefit. He also tried Cognitive Behavioral Therapy (CBT), but after 4 sessions there was no benefit. Amitriptyline was started with some benefit. His neurologist states that his PedMIDAS score is 38, which is indicative of severe disability from headaches. He was hospitalized for 3 days for a Depacon infusion. He continued to have daily headaches and his neurologist increased his dose of amitriptyline and recommended re-trialing CBT. He was 4 weeks into a long stretch of high intensity migraine and his neurologist has determined he needs more aggressive therapy. She recommended an admission for intravenous Thorazine followed by initiation of treatment with monthly subcutaneous injections of Aimovig. The medical literature notes that Aimovig is a calcitonin gene-related peptide receptor antagonist indicated for the preventive treatment of migraine in adults. The safety and effectiveness in pediatric patients has not been established. Future studies are needed to provide additional evidence for both safety and efficacy of migraine-specific agents already in use for treating adults. There is a current clinical trial to evaluate the efficacy and safety of erenumab (Aimovig) in migraine prevention in children (6 to <12 years) and adolescents (12 to <18 years) with episodic migraine.Final Result: Two of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Pediatric Neurology. All are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with coronary artery disease, hypertension, and palpitations. Findings:  The physician reviewer found that the records noted that the patient was status post myocardial infarction with right coronary stent placement. The patient endorsed palpitations and chest pain/tightness. The patient was noted to have normal left ventricular function with an ejection fraction of 55%. Within the medical records it was noted the patient had undergone a diagnostic electrophysiology study, showing no inducible or sustained tachyarrhythmias. Cardiac event monitoring showed one event of 20 beats of paroxysmal supraventricular tachycardia (SVT). The patient reported she had no dizziness or syncope. There is no history of a transient ischemic attack or cerebrovascular accident. She underwent implantation of a loop recorder. The patient had requested reimbursement for an implantable loop recorder that was provided. The Health Plan denied the request and reported the device at issue was not medically necessary for the evaluation of this patient. At issue is whether an implantable loop recorder that was provided was medically necessary for the evaluation of the patients medical condition. Current medical evidence does not support the device at issue in this clinical setting. Of note, there is a lack of evidence that the use of implantable loop recorders changes outcomes. In this case, the patient reported palpitations and chest pain/tightness. The patient had external event monitoring which showed non-sustained SVT and sinus rhythm during symptoms. Additional monitoring is not indicated, as an external monitor is adequate to diagnose her symptoms and guide treatment. The medical evidence does not support the requested device at issue in this clinical setting. Therefore, the implantable loop recorder that was provided was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested device was 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with dysphagia. The patient has a past medical history of hypertension, asthma and prostate cancer. An emergency department report noted the patient had complaints of nausea, vomiting with hematemesis, dizziness, bloody stool, and diffuse abdominal pain. The patient declined esophagogastroduodenoscopy (EGD) and colonoscopy studies. An authorization request noted that the patient endorsed difficulty swallowing in the past. Per the records, the patient has been receiving Ensure. A review of the record indicates that the patient has been diagnosed with dysphagia but there is no detailed description or investigation of dysphagia. There is no active plan documented in any report addressing dysphagia as an active ongoing problem. The patient has requested coverage for Ensure. The Health Plan denied the request and reported that Ensure is not medically necessary for the treatment of this patient. At issue in this case is whether Ensure is medically necessary for the treatment of the patients medical condition. Enteral nutrition is necessary when a patient is unable to swallow regular food but is still able to absorb nutrients enterally. Examples of indications for enteral nutrition, such as Ensure, include severe dysphagia or critical illness, intubation, when regular food cannot be consumed, or when a highly catabolic state is present. The medical records include a diagnosis of dysphagia but do not document any active swallowing difficulty. There is no documentation of weight loss or a highly catabolic state. Additionally, the records do not document prior treatment with Ensure or any response to treatment. Medical evidence does not support Ensure  in this clinical setting. Therefore, Ensure is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 family practice and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Genetic Tests for Common Hereditary Cancers Panel, Renal/ Urinary Tract Cancers Panel, and Add-On Panel. The scientific literature indicates risks for identifying variants of uncertain significance, possibility to receive unexpected results and potential results that do not have medical management guidelines. The literature does not endorse multiplex testing outside of a research setting For these reasons, Genetic Tests for Common Hereditary Cancers Panel, Renal/ Urinary Tract Cancers Panel, and Add-On Panel are not likely to be more beneficial than any available standard therapy.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.Credentials/Qualifications: Two reviewers are board certified in Oncology and Hematology and are actively practicing. One reviewer is board certified in Oncology and is actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 54-year-old male who was diagnosed with erectile dysfunction and Peyronie's disease. The patient had an episode of ischemic priapism, which was likely secondary to medication management of his bipolar disorder. The patient was treated with an operative shunt. Since the time of shunt placement, intracavernosal injections and vacuum erection devices have failed to provide adequate penile tumescence for penetration. The patient has requested coverage for a penile prosthesis. The Health Plan denied the request and reported that the requested device is not medically necessary for the treatment of this patient. At issue in this case is whether a penile prosthesis is medically necessary for the treatment of the patients medical condition. Studies show that a penile implant is a reliable and safe solution for the management of erectile dysfunction, resulting in high couple satisfaction ratings. Patients diagnosed with concomitant Peyronies disease and erectile dysfunction can safely and effectively have an inflatable penile prosthesis placed with similar outcomes as patients without Peyronies disease. In this case, the patient has failed pharmacologic and mechanical treatment to provide functional erections. End-stage erectile dysfunction after ischemic priapism often leads to a penile prosthesis being the final treatment option for achieving adequate erections to maintain sexual activity. The medical evidence supports the requested device in this clinical setting. Therefore, the requested penile prosthesis 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

 Nature of Statutory Criteria/Case Summary:  The enrollee has requested and Parkinsons disease.  The medical literature suggests that it should be used for patients for whom the diagnosis is unclear after serial clinical evaluations and for cases where the clinical exam, history and medication trials have failed to distinguish between essential tremor and Parkinsonian syndrome. Parkinsons disease remains a clinical diagnosis and this test can only distinguish between essential tremor and Parkinsons. The current literature does not show a difference in patient outcomes with the DaT-SPECT scan.                                                       Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.Credentials/Qualifications: Three reviewers are board certified in Neurology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Applying the American Society of Addiction Medicine (ASAM) criteria, the RTC services were not medically necessary for treatment of this patient. The ASAM criteria for level of placement can be applied to a patients presentation to help determine the appropriate level of care. According to the ASAM criteria, documentation should satisfy both dimension 1 to establish acute intoxication and/or withdrawal potential; and dimension 2: biomedical condition and complications. These criteria were not met, according to the patients presentation. The progress notes indicate that the patient was admitted with a history of polysubstance use as well as mood issues. The patient was not exhibiting any withdrawal symptoms during the disputed timeframe. The patient did not report any significant medical issues that were affecting treatment. Her vital signs were within normal range. The patient did not have any plan or intent of self-harm and did not engage in any self-harm behaviors during admission. The patient did not describe any suicidal thoughts or psychosis. The patient expressed motivation for treatment numerous occasions and had identified a sober living facility early in her treatment. The patient expressed a need for continued treatment and expressed an understanding of struggles with substance use and was insightful in therapy sessions. The progress notes do not reflect any aberrant behaviors of any type. The records indicate that the patients overall functioning was good. There was no indication of the problems with activities of daily living. The patient was not experiencing behavioral issues, aggression, or oppositional behaviors. Given these findings, the RTC services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 Pylera capsules 1 box x 10 days. The patient has H. pylori infection found on endoscopy without a subsequent complete treatment. According to the American College of Gastroenterology (ACG) guidelines for the treatment of H. pylori, therapy is recommended in all positive patients, and Pylera is the first-line regimen for penicillin-allergic patients. Pylera has been demonstrated to be effective after failure of clarithromycin-containing triple therapy, and in patients who failed three prior triple therapies, including patients who are resistant to fluoroquinolones and metronidazole. The timing of drug administration is simpler than use of the generic bismuth quadruple therapy, resulting in a compliance rate above 95%. For these reasons, Pylera has been U.S. Food and Drug Administration (FDA) approved for the treatment of H. pylori, while generic alternatives have not been FDA approved. Therefore, the request for Pylera capsules 1 box x 10 days for the treatment of this patients H. pylori infection is supported as medically necessary.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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rituximab. In the medical literature, the use of rituximab is considered a standard of care in the treatment of autoimmune hemolytic anemia (AIHA) when patients are unable to be weaned below 15 mg per day of prednisone. This patient endorses fatigue and dyspnea on exertion that started in 2018, and has not improved. This patients provider recommended treatment with rituximab and pre-splenectomy vaccinations. A clinic note states the patients hemoglobin is improving while on prednisone. However, she has required at least 15 mg of prednisone daily or more to maintain her hemoglobin. She has evidence of only mild hemolysis as her hemoglobin, MCV, and bilirubin have all improved. Her hemoglobin has only dropped slightly in four weeks from 12.7 to 12. For these reasons, rituximab is likely to be more beneficial than any available standard therapy for treatment of this patient than any available standard therapy. Final Result: Two of the three reviewers determined that the requested medication 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:  One reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing.  One Reviewer is board certified in oncology with subspecialty certification in hematology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested authorization and coverage for Botox. Botulinum toxin (Botox) is a potent muscle relaxant which has been found to have analgesic effects in patients with a variety of pain syndromes. Overall, clinical trials have confirmed the efficacy, safety, and tolerability of Botox in the prophylactic treatment of chronic migraine. Moreover, Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of migraine. In addition, there have been several studies that have reported that Botox injections are also effective for chronic daily headache and migraine in children and adolescents. This patient has failed treatment with numerous therapies including a tricyclic antidepressant medication, cyproheptadine, and an anticonvulsant, physical therapy, occipital nerve blocks with lidocaine, and massage. Acute abortive medications have included: ibuprofen; acetaminophen; almotriptan; rizatriptan; and sumatriptan, all of which were ineffective. DHE was given for three days without benefit. Given the support in the medical literature, the requested Botox is medically necessary for treatment of this patients migraine. Botox is a potent muscle relaxant which has been found to have analgesic effects in patients with a variety of pain syndromes. Overall, clinical trials have confirmed the efficacy, safety, and tolerability of Botox in the prophylactic treatment of chronic migraine. Moreover, Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of migraine. In addition, there have been several studies that have reported that Botox injections are also effective for chronic daily headache and migraine in children and adolescents. This patient has failed treatment with numerous therapies including a tricyclic antidepressant medication, cyproheptadine, and an anticonvulsant, physical therapy, occipital nerve blocks with lidocaine, and massage. Acute abortive medications have included: ibuprofen; acetaminophen; almotriptan; rizatriptan; and sumatriptan, all of which were ineffective. Dihydroergotamine (DHE) was given for three days without benefit. Given the support in the medical literature, the requested Botox is medically necessary for treatment of this patients migraine.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology with special qualification in child 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.