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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Lupin levonorgestrel and ethinyl estradiol tablets USP 0.1mg for birth control due to a diagnosis of Polycystic Ovarian Syndrome. There is a place for deference to branded birth control pills and the American College of Obstetrics and Gynecology has addressed this issue. The medical issue for why the patient is on the pill, management of her polycystic ovarian syndrome (PCOS), does not specifically command a particular formation of birth control pill. However, generic oral birth control pills (OCPs) approved by the FDA have been shown to be bioequivalent and pharmaceutically equivalent to the branded product and are interchangeable. There is no evidence-based data to challenge this conclusion. In this case, the patients provider has offered the patient several different alternative formulations to Lupin (not just generic equivalents of the same formulation), but the patient has declined these. There was no medical documentation provided to support a failure of alternative medications. The request for the branded OCP is not medically necessary as alternative, equally efficacious generic OCPs are available which contain the same active ingredients. Therefore, the requested Lupin levonorgestrel and ethinyl estradiol tablets USP .1mg is not medically necessary.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 obstetrics and gynecology 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 coverage for skilled nursing facility services. Chronic leg wounds in the setting of venous stasis can be difficult to heal, with many wounds persisting beyond 6 months. The cornerstones of care include compression and keeping wound beds moist to promote autolytic debridement, angiogenesis and formation of granulation tissue. The records in this case indicate that the patient had chronic edema, venous stasis, and a traumatic right knee area wound which was very slow to heal. As of late October, she was receiving a wound treatment regimen which consisted of a wound VAC dressing being changed on an intermittent basis. The records do not indicate that the patient required any treatments that could not have been provided in the community setting. Her functional status otherwise remained essentially dependent for mobility and lower body self-care, in part due to her ongoing non-weightbearing restrictions for the right lower limb. Ongoing skilled nursing facility level care on the dates of service at issue would not have been expected to marginally improve her clinical course or outcomes over community-based care. The records do not otherwise document services that the patient needed in an inpatient setting that could not otherwise have been delivered in the community with custodial level assistance and home nursing and therapy services.Final Result: The reviewer determined that the skilled nursing facility 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization for 10 additional sessions of transcranial magnetic stimulation (TMS) therapy. Transcranial Magnetic Stimulation (TMS) is a non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population. A typical treatment course of TMS consists of 30 to 40 sessions spanning 4 to 6 weeks. According to the summary of TMS treatment recommendations in recent literature, the standard parameter setprovided clinical benefit in treatment courses up to 6 weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established.  At this time, there are no adequately powered, controlled studies showing the benefit of longer courses of TMS therapy. Thus, the medical literature does not support a reasonable expectation that additional TMS therapy at this time would improve the patients condition or prevent a more serious episode of illness. Further, the medical record does not include a longitudinal inventory of relevant clinical factors related to the TMS therapy or report of current status. Thus, it would be speculative to assert the necessity of additional treatment at this time. Therefore, the requested 10 sessions of transcranial magnetic stimulation (TMS) are not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is 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 parent of a female enrollee has requested authorization and coverage for Aptiom (eslicarbazepine acetate) 800 mg.  The patient has refractory localization-related epilepsy that has come under control with Aptiom 800mg and Keppra. Although other anticonvulsants are available on the Health Plan formulary, it is unknown whether any other monotherapy or combination antiepileptic drug regimen would control the patient's seizures. In 30-year review of 1795 patients with newly diagnosed epilepsy, colleagues stated that Most patients who attain control do so with the first or second antiepileptic drug. The probability of achieving seizure freedom diminishes substantially with each subsequent antiepileptic drug regimen tried. More than one-third of patients experience epilepsy that remains uncontrolled. Colleagues noted that epilepsy associated with tumors is generally poorly controlled by antiepileptic drugs. Colleagues explained that Aptiom (eslicarbazepine acetate) is effective in the treatment of refractory partial seizures in children, and that it is well tolerated from a neurocognitive and behavioral standpoint. Therefore, Aptiom 800 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 pediatrics and neurology, with special qualification in pediatric 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Otezla 30 mg, 60 tablets for 30 days. This patient has a history of chronic plaque psoriasis, and the records document that he has tried and failed therapy with topical steroids and calcipotriene. The Health Plan requires that the patient first try the preferred formulary agents, including acitretin, cyclosporine, or methotrexate, and two preferred biologic agents, which include Enbrel, Humira, Remicade and Stelara, prior to covering Otezla. The medical records fail to indicate a treatment trial or any contraindications to the use of any of the preferred agents. The formulary agents are medically appropriate and are likely to be as effective as the requested medication. Therefore, Otezla 30 mg, 60 tablets for 30 days is not medically necessary for the 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: An enrollee has requested reimbursement and prospective authorization and coverage for inpatient behavioral health treatment level of care. Findings:  The physician reviewer found that the  submitted documentation fails to demonstrate the medical necessity of the services at issue. The most appropriate setting for this patient is a long-term residential treatment facility. Per the records, the patient was unable to safely manage herself independently.  She was impulsive and was using drugs. She was non-adherent to treatment efforts in the outpatient setting. The inpatient team determined that the client was gravely disabled.  The patient was not motivated to participate in treatment or actively engage the therapeutic process, and at times expressed desire to resume using drugs. However, despite her skewed perspectives, the patient was not suffering from an acute psychiatric syndrome. She was not psychotic, suicidal, delusional, paranoid or homicidal. She was tolerating her psychotropic medication. Although isolative and guarded, she was neither disruptive nor disrespectful on the unit. This patient needed the structure of a 24-hour treatment facility, although this could be provided in a long-term residential treatment facility. Therefore, inpatient behavioral health treatment level of care was not and is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne test. Findings:  Three physician reviewers found that although tumor based molecular assays are recommended by the National Comprehensive Cancer Network (NCCN) guidelines for men with clinically localized disease, generalized molecular testing, such as with FoundationOne, is not supported by the NCCN Guidelines for prostate cancer. The use of molecular profiling for prostate cancer and other solid tumors is the subject of an ongoing clinical trial. There is also some data suggesting that intratumoral heterogeneity limits the use of gene expression analysis as a potential prognostic or predictive biomarker in patients treated with androgen deprivation therapy. Therefore, FoundationOne test was not likely to have been more effective than other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene assay testing.  Findings:  Three physician reviewers found that the National Comprehensive Cancer Network (NCCN) Guidelines state that while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine (baseline) prognostic genetic testing of primary cutaneous melanomas (before or following sentinel lymph node biopsy) is not recommended outside of a clinical study (trial). Should a patient have high risk results, treatment and surveillance recommendations would unlikely be altered. Therefore, the services in issue were not likely to have been more beneficial than any available standard treatment for the patients medical condition.Final Result: The reviewers determined that the services in issue were 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 internal medicine, with subspecialty certification in medical oncology, and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma injections. The Health Plan has denied this request as investigational for treatment of the enrollees condition. Findings:  Current evidence based medical literature suggests that platelet rich plasma is promising for rotator cuff and distal biceps tendinopathy. However, there is an absence of large well-designed clinical studies to support the safety and efficacy of platelet rich plasma in this patients clinical setting. Recent literature concluded that further studies are necessary to guide clinicians on the value of this therapy for each clinical diagnosis. One study conducted a randomized controlled trial with one-year follow-up and concluded that platelet rich plasma injection was no more effective in improving quality of life, pain, disability, and shoulder range of motion than placebo in patients with chronic rotator cuff tear who were treated with an exercise program. Another study conducted a systematic review and concluded that there is no solid scientific and/or clinical evidence supporting the use of PRP in the treatment of rotator cuff pathology in routine clinical practice.Final Result: Two of the three reviewers determined that the services at issue were 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/QualificationsAll three reviewers are board certified in orthopedic surgery 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: An enrollee has requested authorization and coverage for Glumetza. Recent literature explains that metformin is a widely used medication which is often the first line of therapy for the treatment of type 2 diabetes. While metformin is an effective medication, it may be associated with gastrointestinal side effects, such as diarrhea. Studies indicate that extended release metformin has better gastrointestinal tolerability and fewer side effects as compared to immediate release metformin, with similar efficacy regarding anti-hyperglycemic effects. Therefore, the requested Glumetza is medically necessary for treatment of this patients condition. Final Result: The physician reviewer determined that the requested medication is medically necessary for treatment of the enrollees condition.Credentials/Qualifications: The physician reviewer is board certified in endocrinology 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: The parent an enrollee has requested coverage for 30 hours per week of direct intervention applied behavioral analysis (ABA) therapy. On review of the available records, 30 hours per week of direct intervention ABA therapy, to be administered in home and community settings, is supported as medically necessary for this patient based on current available medical literature and National Autism Center guidelines. To determine the medical necessity of ABA, researchers provide guidelines. According to the researchers, the definition entails healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Further, the Behavior Analysis Certification Board (BACB) indicates that treatment for autism can be focused with 25 hours or less per week, or comprehensive with 30-40 hours per week. The BACB notes that behavior that threatens the health or safety of the client or that constitutes a barrier to quality of life should result in more intensive ABA services. In this case, the patient presents with pica, which poses a threat to his safety. He continues to require continuous monitoring and intervention. While comprehensive ABA therapy is appropriate, the setting of implementation must be considered. The patients provider reports document minimal parental involvement with the patients treatment. Moreover, the majority of ABA hours have been provided within the school setting. Thus, provision of ABA services within the home and community settings would foster parental involvement and maximize treatment outcomes across settings. Accordingly, 30 hours per week of direct intervention ABA therapy, to be administered in home and community settings, is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that of 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 psychology and am a board certified behavioral analyst 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: A 64-year-old male enrollee has requested authorization and coverage for Orthovisc injections. Hyaluronic acid injection for osteoarthritic knee pain is generally considered a second-line treatment option after independent exercise, weight loss and medications such as non-steroidal anti-inflammatory medications and/or acetaminophen. The provider noted the patient presented with mild left knee pain. However, there is no documentation of left knee osteoarthritis and no mention of any prior treatment for symptoms attributed to left knee osteoarthritis. Given the lack of documentation supporting an indication for the requested hyaluronan injections, the requested Orthovisc injections are not medically necessary for treatment of this patients mild knee pain. 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dexcom continuous glucose monitoring system (CGMS). As noted in the medical literature, CGMS 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. CGMS can help identify fluctuations, maintain glycemic control, and prevent hyperglycemia and hypoglycemia. In addition, CGMS 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. Moreover, CGMS has been shown to improve hemoglobin A1C levels in diabetic patients. With the requested CGMS, this patient will be able to improve his glycemic control and thereby decrease the likelihood of developing diabetic complications. Consistent with these findings, a Dexcom CGMS is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device 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.