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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for omeprazole sodium bicarbonate 40 mg-1.1 gram for treatment of the patients gastroesophageal reflux disease (GERD) with esophagitis.Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.  The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD) with esophagitis. The submitted documentation supports the medical necessity of the requested medication. The American College of Gastroenterology guidelines recommend proton pump inhibitor therapy for enrollees with GERD and esophagitis. This enrollee has failed prior treatment with multiple formulary proton pump inhibitors. It is unlikely that re-trial of these medications would be effective. Continued proton pump inhibitor therapy is supported by the current guidelines. The records indicate that this enrollee had improvement with omeprazole sodium bicarbonate. Therefore, omeprazole sodium bicarbonate is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the enrollees 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty.Findings:  Three physician reviewers found the scientific evidence and peer-reviewed literature support improvement in health outcomes with the use of bronchial thermoplasty. Bronchial thermoplasty has been recommended for the treatment of severe persistent asthma. The literature supports the safety and efficacy of this modality. This patient has limited options, and he continues to utilize his rescue inhaler three to four times per day and utilizes steroids with exacerbations. Therefore, the requested bronchial thermoplasty is likely to be more efficacious than other available treatment options. 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 internal medicine with sub-specialty certification in pulmonary disease 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation of the lower extremities. This patients documentation does not support the medical necessity of radiofrequency ablation. The areas of reflux do not match the providers assessment based on the patients symptoms. It is noted the patient is not having symptoms in the area of his varicose veins. Additionally, the assessment of arterial perfusion is insufficient to rule out the presence of significant peripheral artery disease in the presence of the patients medical condition. All told, the requested radiofrequency ablation of the lower extremities is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for Botox injections and prospective authorization and coverage for Botox injections. The US Food and Drug Administration (FDA) approved Botox for headache prophylaxis in patients with adult chronic migraine with headaches on 15 or more days per month, each lasting more than four hours. To treat chronic migraine, Botox is given approximately every 12 weeks as multiple injections around the head and neck to try to dull future headache symptoms. Botox has not been shown to work for the treatment of episodic migraine headaches that occur 14 days or fewer per month, or for other forms of headache. The available medical records provided for review document failure of at least two medications for prophylaxis of migraine. The records also report the patient is having chronic headaches, migraine type, and does specifically delineate and quantify the frequency of the headaches in terms of days per month on an ongoing basis demonstrating at least headaches lasting four or more hours on 15 days or more per month for at least three months. Moreover, there is documentation that Botox has been effective in reducing the patients headache frequency and severity with positive functional benefit. For these reasons, Botox injections were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that Botox injections were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were and 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:  One reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS).Findings:  Two of the three physician reviewers found the records documented bipolar I disorder. Following the Health Plans denial, the diagnosis was changed to major depressive disorder. On 2/05/18, the records noted that the patient was currently taking lamotrigine, quetiapine, and duloxetine for the treatment of his depression. Both lamotrigine and quetiapine are U.S. Food and Drug Administration (FDA) approved for the treatment of bipolar disorder. Lamotrigine and quetiapine are not FDA approved for the treatment of unipolar major depressive disorder. Thus, the records indicate that the patient is psychopharmacologically being treated for bipolar disorder, and documentation states that the patient was previously hospitalized in a psychiatric unit due to manic episodes. The patients manic episode which led to his hospitalization was questioned due to co-occurring substance use at the time of the hospitalization. TMS treatment is not FDA approved for the treatment of bipolar disorder. At this time, there is lack of evidence to support the use of TMS for the treatment of bipolar depression. Therefore, TMS is not likely to be of greater benefit than other available treatment options. 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 psychiatry 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP). The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Findings: There is support for a portion of the services at issue in this clinical setting. The patient made gains in her weight since admission to the program increasing her weight from 95.2 pounds to 105 pounds or an IBW of 81% to 89%. The patient reports that she continues to struggle with body checking and feels that she will relapse if she does not have enough support from the IOP. The patient reported that she continues to follow the meal plan at home and at school. The patients weight was 110.2 pounds with an IBW of 93.7%. The patient continued to have high emotional lability, anxiety, and fear of gaining weight. The patient reports that she has strong urges to restrict food intake, but has been completing 100% of her meals/snacks during the program. The patient fears that she will be rejected by her peers once she has restored her body weight. It appears that the patient has been able to remain compliant with her eating plan and functionality at the IOP at three days a week. Due to the patients strong urges to restrict and strong emotional lability, it is highly possible that the patient could relapse and end up in a more restrictive environment. Based on the documentation provided, the patient requires IOP services at three days a week but not at five days per week for treatment of her anorexia nervosa. Therefore, IOP services for three times per week were and are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the services at issue was and is 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 psychiatry with expertise in eating disorders 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 F-18 fluciclovine positron emission tomography/computed tomography scan (PET/CT scan with Axumin). The Health Plan has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollee who has a history of prostate cancer.Findings:  Upon review of available data, the use of F-18 fluciclovine PET/CT scan with Axumin is likely to be more accurate in the re-staging of the above patient as compared to standard re-staging consisting of bone scan and CT. 18F-fluciclovine was U.S. Food and Drug Administration approved in 2016 for the this patients specific clinical scenario of suspected recurrent prostate cancer in patients with elevated PSA after prior therapy. The recent National Comprehensive Cancer Network (NCCN) guidelines support its use in staging of suspected recurrent disease, specifically stating that F-18 fluciclovine PET/CT may be used to detect small volume disease in soft tissue. The studies have shown that fluciclovine PET is more sensitive to detecting residual prostate cancer than bone scan or conventional computed tomography (CT). Researchers specifically evaluated the use of fluciclovine PET/CT and its influence on postoperative radiotherapy treatment fields in patients with recurrent prostate cancer. They found that the results of a fluciclovine PET changed the radiation fields in 40.5% of the evaluated patients. Additionally, 4.8% of patients had radiotherapy withheld after the discovery of extra pelvic disease. The medical literature indicates that F-18 fluciclovine PET/CT is useful in restaging for suspected recurrent disease. The patient has already undergone previous pelvic radiation, thus further radiotherapy options with definitive intent are likely limited. Based on the above, F-18 fluciclovine PET/CT scan with Axumin is likely to be more effective when compared to conventional CT and/or bone scan for evaluating this patients medical condition.Final Result: All three reviewers determined the requested diagnostic procedure is 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:  One of the three reviewers is board certified in diagnostic radiology and is actively practicing. Two of the three reviewers are board certified in radiation 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance services on the basis that the services at issue were emergent. At the time of her admission to the hospital, the patient had no history of seizures. There is no indication in the records that the patients treating physician at the facility recommended emergent transfer. Nor do the clinical records document that air transfer was recommended. Although the patient reports she was advised against traveling by personal car or ground ambulance transport because of the threat of seizure, in this case based on the patients clinical presentation at the time she was at a low risk of experiencing a seizure and was not experiencing a medical emergency. Further, it is not apparent that transport by air would have provided her any more protection than by ground. In view of that, and the fact that the patient was neurologically stable at the time of transfer, the transfer did not qualify as necessary for treatment of an emergency medical condition.  Final Result: The reviewer determined that the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical 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 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 laser treatment. Findings:  The physician reviewer found that Multiple small randomized controlled studies do not show a benefit of laser over oral antifungal medications in the treatment of onychomycosis. Studies show some clearance with laser but not significantly better than the U.S. Food and Drug Administration approved oral antifungals, terbinafine and itraconazole. Additionally, long term follow up cure rates are low.  As such, the use of laser therapy to treat onychomycosis is not likely to be more efficacious than standard oral antifungal medication treatments.Final Result: All three reviewers determined 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:  All three reviewers are board certified in dermatology 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: An enrollee has requested authorization and coverage for incontinence supplies. The Health Plan has denied this request indicating that the requested supplies are not medically necessary for treatment of the enrollees incontinence. Findings: The documentation provided does not support the medical necessity of the requested supplies in this clinical setting. There is no documentation to support fecal or functional incontinence. Functional incontinence is when a patient does not have an anatomical or neurological problem with the bladder but is unable to toilet themselves in a timely fashion due to an underlying medical illness; conditions like dementia, mental illness, or decreased mobility.  In this case, the provider notations did not provide support for a diagnosis of functional incontinence. Instead, the records appear to support the diagnosis of urinary stress incontinence, which is usually caused by weak pelvic floor. The requested supplies are generally prescribed for a diagnosis of functional incontinence. Initial treatment for urinary incontinence includes lifestyle changes including weight loss, dietary changes, treatment of constipation or smoking cessation.  There is a lack of documentation to support that this patient has failed treatment with more conservative measures. The medical literature support pelvic floor exercises as an effective treatment modality for urinary stress incontinence. Although many women use pads and protective garments these supplies do not address the underlying cause of urinary leakage. As such, the requested incontinence supplies are not supported as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested supplies 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 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: An enrollee has requested reimbursement for laboratory testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees autism spectrum disorder.Findings:  Autism is a complex neurological disorder characterized by restricted repetitive patterns of behavior, as well as variable deficits in speech/language and social interaction. Deficits in fine/gross motor skills and processing of sensory and motor information are also common. There are many potential etiologies, as well as many suspected risk factors and associations, with clinical symptoms being the final common denominator. Many approaches have been used to facilitate development of adequate communication and interpersonal skills in these children. Typically, children on the autistic spectrum require interventions in multiple areas, including speech therapy, occupational therapy, and behavioral therapy.While there is some evidence to support genetic testing of children with autism, the constellation of tests recommended for this patient is not currently considered clinically useful as a screening tool for metabolic and/or immunologic abnormalities. Should he exhibit the clinical profile of a child with immunodeficiency, immune lab testing would be indicated. Should he have a clinical presentation suspicious for encephalitis, laboratory evaluation including lumbar puncture and imaging would be indicated. Until this type of laboratory interrogation has been demonstrated to be useful in patients with autism and/or developmental regression, the laboratory testing was not likely to have been superior over the standard evaluations available for this patient.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One of the three reviewers is board certified in pediatrics with expertise in child neurology and is actively practicing. Two of the three reviewers is board certified in neurology with special qualifications in child neurology. 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: A patient has requested authorization and coverage for Otezla 30 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients psoriasis vulgaris. The submitted documentation supports the medical necessity of the requested medication. The patient has a history of chronic plaque psoriasis. Per the records, the patient has been stable on Otezla for the past three years. The patient has tried and failed treatment with acitretin and topical steroids. It is unreasonable to require that the patient take two immunosuppressive medications prior to approving the current effective therapy, which is U.S. Food and Drug Administration approved for the patients condition. The medical evidence supports the requested medication in this clinical setting. Therefore, Otezla 30 mg is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.