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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for eculizumab therapy for treatment of the enrollees C3 glomerulonephritis. Findings:  The 3 physician reviewers found that Eculizumab has not been U.S. Food and Drug Administration (FDA) approved for use in the treatment of C3 glomerulonephritis. This monoclonal antibody has been FDA approved for paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. However, there are clinical trials that are ongoing currently determining the efficacy of eculizumab in C3 glomerulonephritis. Both atypical hemolytic uremic syndrome and C3 glomerulonephritis are disorders of alternate complement pathway resulting in abnormal production of membrane attack complex (MAC), leading to damage to various organs including kidneys. The goal of this therapy is to block the production of membrane attack complex, thus preventing the cascade of events leading to endothelial injury in various organs. The medical evidence supports the requested medication in this clinical setting, as eculizumab has been used with success in patients with C3 glomerulonephritis, preventing further renal injury.  In this patients case, off-label usage of eculizumab is warranted to see if her renal function reverses. Steroids, plasma exchange and other immunosuppressive agents have not been found to be useful as definitive agents for this condition. Dialysis is only a supportive treatment for renal failure. Based on the current evidence, eculizumab therapy is likely to be of greater benefit than other treatment options in this patients case. Final Result: The 3 reviewers determined that the 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: Physician reviewer number one is board certified in pediatrics with sub-specialty certification in pediatric 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.Physician reviewer number two is board certified in pediatrics with sub-specialty certification in pediatric 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.Physician reviewer number three is board certified in pediatrics with sub-specialty certification in pediatric 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: An enrollee has requested authorization and coverage for the Dexcom G5 Mobile Continuous Glucose Monitor for treatment of the enrollees type 1 diabetes. Findings:  The physician reviewer found that a continuous glucose monitoring system is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed. Continuous glucose monitors can help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia. Continuous glucose monitoring can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, and evaluate how diet and exercise affect blood sugars. It can be used as a precautionary device in order to prevent potentially dangerous consequences of uncontrolled diabetes. Continuous glucose monitors have been shown to improve hemoglobin A1c levels of diabetic patients.  The current medical evidence supports the requested equipment in this clinical setting. Therefore, the Dexcom G5 Mobile Continuous Glucose Monitor is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A emale enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival.  For these reasons, Epclusa for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health conditions.Findings:  The physician reviewer found that to objectively determine if the patient meets criteria for length of stay, the Level of Care Utilization System (LOCUS) criteria will be utilized. This is an accepted, national standard for determining the appropriate level of care for adults. The records supported a score of 2 with regards to risk of harm. No documentation could be found of a history of suicide attempts. In terms of functional status, the records support a score of 3.  Her schizoaffective disorder appears to have significant impairment on the patients life. Recent gains in functionality have been achieved while participating in structured and protected settings. In terms of medical/addictive/psychiatric comorbidity, the records support a score of 3. The patient has a significant comorbidity of schizoaffective disorder, bipolar type and anxiety. However, she was medically stable and did not require 24-hour monitoring for any medical conditions. With regards to recovery environment, the records support a score of 3. The patients mental health condition has led to a moderate stressful environment. In terms of level of support, the records support a score of 3. It appears that the patient has a few supportive resources which may be capable of providing some help if needed.  With regards to treatment history, the records support a score of 3. The patient has had a moderate response to treatment and recovery. The patient had a calm affect, and she was compliant with medications. She was eating well. She did not have any suicidal or homicidal ideation. She did not have any auditory or visual hallucinations. She did not have any paranoia or mania. She continued to have anxiety.  In terms of engagement and recovery status, the records support a score of 2. The patient had a positive attitude toward recovery. She had positive relationships with staff. She was compliant with treatment recommendations. Thus, the records support a total score of 19. Based on these criteria, the patient would meet criteria for an intensive outpatient program. The patients medication management could have been accomplished in an outpatient setting. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that in order to objectively determine if the patient meets criteria for length of stay, the Level of Care Utilization System (LOCUS) criteria will be applied. This is an accepted, national standard for determining the appropriate level of care for adults. With regards to risk of harm, the records support a score of 2.  There was no documentation of prior suicide attempts, and the patient did not have suicidal ideation.  In terms of functional status, the records support a score of 3.  The patient had moderate impairment and had significant deterioration in his ability to fulfill his responsibilities. With regards to medical/addictive/psychiatric comorbidity, the records support a score of 3. The patient has alcohol use disorder and marijuana use disorder. The patient has also been diagnosed with reactive attachment disorder.  His recent substance use has had detrimental effects to the patient. With regards to recovery environment, the records support a score of 3.  The patient reported interpersonal conflicts with his mother. In terms of level of support, the records support a score of 2.  The patients father was supportive of the patient and would be likely be willing to participate in treatment if asked to do so. With regards to response to treatment and recovery, the records support a score of 3. The patient had partial recovery for moderate periods of time with strong professional help. In terms of engagement and recovery status, the records support a score of 3.  The patient had limited engagement and recovery.  He is ambivalent about changing. He was passively engaging in treatment. Thus, the records support a total score of 19. Based on these criteria, the patient would meet criteria for an intensive outpatient program. Therefore, residential treatment center services provided were not medically necessary for the 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vision restoration therapy for treatment of the enrollees vision changes status post cerebrovascular accident (CVA). Findings:  The physician reviewer found that currently, there is a lack of consensus on the usefulness and effectiveness of such vision therapy after stroke. Strength of this evidence is not yet sufficient to warrant clinical recommendations. Results with vision therapy has not been demonstrated to have a role in the standard of care. Given the paucity of data supporting improved patient outcomes, the requested vision restoration therapy is not medically necessary for treatment of this patients vision changes. 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 ophthalmology 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 of either Aromasin (exemestane) tablet or Arimidex (anastrozole) tablet for treatment of his history of low testosterone levels.  Findings: The physician reviewer found that Aromasin and Arimidex are aromatase inhibitors. They are commonly used in women with breast cancer as it reduces breast cancer recurrence and breast cancer mortality in postmenopausal women with non-metastatic hormone receptor-positive breast cancer. Aromatase inhibitors suppress plasma estrogen levels by inactivating aromatase, the enzyme responsible for the peripheral conversion of androgens to estrogens. This patient is on testosterone replacement therapy for a diagnosis of hypogonadotropic hypogonadism and was started on Arimidex therapy in March 2017 for elevated estrogen levels. However, because estrogen is also an important player in many physiologic functions in men including bone metabolism and cardiovascular health, caution must be exercised, as there is a lack of long-term data on adverse effects on bone and cardiovascular system during treatment with aromatase inhibitors in hypogonadal men. During testosterone replacement, estrogens may rise and occasionally reach elevated levels. As such, there is a lack of evidence that treatment of elevated estrogen levels during testosterone replacement has benefit in this clinical setting. Therefore, both Aromasin and Arimidex are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the 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 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 reimbursement for partial hospitalization services and prospective authorization and coverage for partial hospitalization services for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that the Level of Care Utilization System (LOCUS) criteria is an accepted, national standard for determining the appropriate level of care for adults. According to the LOCUS criteria, her risk of harm is scored a 3, moderate risk. The record does not indicate that the patient has attempted suicide. The patient does have intermittent suicidal ideation, but she did not have any current suicidal ideation. She has a history of superficially scratching herself. Her functional status is also a 3, moderate impairment. The patients eating disorder has caused impairment in her eating habits. It does not appear that the patient is employed and able to maintain a job. The patients medical/addictive/psychiatric comorbidity is scored a 3, which correlates to significant comorbidity. The patient has a significant comorbidity of anorexia nervosa restricting type, major depressive disorder, and social phobia. She has been medically stable and has no medical conditions that require frequent monitoring. Her eating disorder at times can be debilitating. Her recovery environment is scored a 2, mildly stressful environment. The patient recently came out as lesbian which the patient reports triggered body image issues. Under the LOCUS criteria, her level of support is a 2, supportive environment. The patient has supportive parents. Her treatment history is scored a 2 which correlates to significant response to treatment and recovery. The patient has had a good response to treatment. She is at 100% of her ideal body weight and has been compliant with treatment. Her engagement and recovery status is a 3, limited engagement and recovery. The patient is compliant with treatment, but will still restrict food when home alone. She still has some hesitation in accepting her illness. She has a limited confidence to change despite intensions to do so. Based on the LOCUS criteria, her total score is 18, which meets criteria for a less restrictive environment at an intensive outpatient program and not PHP.   Final Result: The reviewer determined that the services at issue were and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 magnetic resonance imaging (MRI) of the thoracic spine and discography for evaluation of the enrollees neck and back pain with radiculopathy.Findings:  The physician reviewer found that the records do not include any evidence of concerning findings to provide an indication of immediate MRI scan of the thoracic spine. Moreover, there is no documentation of a plain x-ray report of a thoracic spine series or evidence of fracture on prior imaging. Neurological examination shows no absent reflexes or other red flags. The patient has been referred for a 12 week program of aqua therapy and stretching, which has not reportedly begun. Thus, the requested MRI of the thoracic spine is not medically necessary. In addition, discography is reserved as a problem solving tool in rare instances when no explanation can be found for a patients symptoms despite standard imaging such as MRI and its use as a diagnostic test in this clinical setting is not considered to be within the standard of care. Final Result: The reviewer determined that the requested services are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Forteo 20 mcg for treatment of the enrollees osteoporosis.Findings:  The physician reviewer found that antiosteoporosis agents consists of mainly of two types, antiresorptive agents and anabolic agents. Antiresorptive agents include bisphosphonates and denosumab, which the Health Plan indicates should be used prior to considering Forteo. According to Xue and colleagues treating patients with bisphosphonates during bone healing is controversial because osteoclasts are important for remodeling callus into cortical bone. Moreover, the available data suggests that bisphosphonates do not cause a clinically detectable delay to indirect bone healing regardless of the timing of bisphosphonate delivery in relation to the fracture.In this case, the patient had a recent fragility fracture that appears to not be healing properly, and a very low bone density in the spine. The patients degree of osteoporosis in the spine with a T-score -3.9 is concerning. This degree of osteoporosis at age 51 places the patient at great risk for compression fractures and their associated morbidity. If left untreated, the patients condition will likely worsen. In this clinical setting, the sequence of therapy is important. Based on the medical literature, the patients level of osteoporosis must be treated with Forteo first. It has been shown from early studies that the effect of Forteo is superior in increasing bone mass due to its anabolic effect of bone formation, and decreases spinal fractures by 65% versus a 50% decrease risk of fracture with bisphosphonates. Forteo therapy must be followed by an antiresorptive agent. Studies have shown that bisphosphonates given prior to Forteo, will decrease the efficacy of Forteo. There are also reports in the medical literature that Forteo showed to have positive effect on fracture healing, which is an issue in this case.  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.