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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of chronic headaches.Findings:  Botox, a brand name for botulinum toxin, has been U.S. Food and Drug Administration approved for the treatment of migraine headache in adults. However, the medical literature indicates that Botox has been used off label for a number of years for treatment of those who are diagnosed with chronic migraine headaches and is consistent with the standard of care for those who manage such patients. The medical evidence has shown Botox as a safe and effective treatment option in patients for whom standard therapies have failed. The provider noted that this patient has failed treatment with parenteral Depakote, parenteral ergotamine, parenteral Toradol, Phenergan, Zofran, oral triptans, topiramate, and amitriptyline. This patient, with intractable chronic migraine and tension like headache, now rendered non-functional due to headache pain, has tried and failed a majority of standard as well as some non-standard treatment modalities. Accordingly, in this patients case, Botox has been demonstrated as medically necessary for treatment of this patients medical condition.Final Result: The reviewer has determined that 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 with expertise 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a minor has requested authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy, or in the alternative, 30 hours per week of direct ABA therapy. Findings:  The physician reviewer found that that ABA therapy is effective for children with autism. ABA therapy is designed to treat the medical problems related to autism spectrum disorder. Studies have found that school age children benefit from ABA therapy when targeting maladaptive behaviors such as non-compliance. Other studies reported a significant correlation between treatment intensity and goals mastered. This patient was progressing and mastering targets slowly, but consistently. He had a considerable decrease in maladaptive behaviors. However, with the decrease in intensity of the ABA services, he demonstrated an increase in maladaptive behaviors. This indicates that he cannot tolerate the change in the hours of ABA services provided. Thus, 30 hours of direct ABA per week is medically necessary to treat this patients autism spectrum disorder and trisomy 21.  Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics 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 laser refractive surgery. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee who was diagnosed with bilateral myopia and astigmatism.Findings:  There is a lack of support for the services at issue in this clinical setting.  Photorefractive keratectomy/laser refractive vision correction is an elective procedure that reshapes the cornea to eliminate or reduce the need for glasses or contact lenses.  The submitted documentation noted that the patient wore glasses and contact lenses to correct his vision prior to the surgery.  He reported that he experienced dryness while wearing contact lenses; however, the services at issue were elective and not medically necessary. The standard treatment for myopia and astigmatism is correction by glasses or contact lenses. The documentation provided did not demonstrate the patient was not able to correct his vision with glasses or contact lenses. Accordingly, the laser refractive surgery was not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer has 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines issued by two associations, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Mavyret for eight weeks. These guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret for eight weeks is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for esophageal sphincter augmentation device (LINX procedure). Overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication. Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. For these reasons, the requested esophageal sphincter augmentation device (LINX procedure) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested esophageal sphincter augmentation device (LINX procedure) is 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 requested procedure is 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 reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for an echocardiogram. The overall yield of positive findings on echocardiogram are low in patients with undifferentiated syncope. However, studies suggest it may be beneficial in this clinical setting. Transthoracic echocardiogram can be useful in selected patients presenting with syncope if structural heart disease is suspected. Cardiac imaging is often used to identify a structural cardiac abnormality, and imaging with transthoracic echocardiogram is widely used for this purpose because it is noninvasive and low risk. Transthoracic echocardiogram can be useful when providers are concerned about the presence of valvular disease. Although an echocardiogram may not be able to establish the immediate cause of syncope, it provides information for a potential disease substrate related to prognosis. Thus, the guideline supports the use of the echocardiogram for evaluation of the cause of syncope. For these reasons, the requested echocardiogram is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the requested echocardiogram is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: A 70-year-old male enrollee has requested authorization and coverage for continued transcranial magnetic stimulation (TMS) for up to 26 treatment sessions. The Clinical TMS Society recommends considering continuation or maintenance TMS therapy when other established methods of maintenance antidepressant therapy fail to provide a satisfactory sustained pattern of clinical benefit or a patient has a history of frequent relapse. The initial records did not include clinical documentation to support an indication for maintenance TMS. However, the additional documentation documents the longitudinal illness burden and extent of impairment, psychosocial stressors, and medical comorbidities. Further, the records document improvement in the patients illness burden with prior TMS treatment. Thus, the additional documentation supports the medical necessity of the requested TMS services for up to 26 treatment sessions. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy 25 mg tablet, daily for treatment of the enrollees hepatitis B.  Findings:  The physician reviewer found that There is sufficient support for the requested medication in this clinical setting. The goal of treatment is long-term viral suppression. The American Association for the Study of Liver Diseases guidelines recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient was previously taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. Therefore, Vemlidy 25 mg tablet, daily 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 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 Keytruda. The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee who has been diagnosed with cancer.Findings:  Ipilimumab, nivolumab, and Keytruda (pembrolizumab) are new monoclonal antibodies that bind with tumor antigens responsible for blocking immune attack from circulating lymphocytes. The latter two antibodies bind to programmed cell death protein 1 (PD-1) and the ipilimumab binds to CTLA-4. The Keynote-028 trial enrolled 24 patients with advanced endometrial cancer and pembrolizumab was found to be well tolerated in this heavily treated group of patients and showed some efficacy. Moreover, the U.S. Food and Drug Administration has approved pembrolizumab for metastatic solid tumors that have been identified as MSI-H, such as in this patients case. According to the current medical literature, Keytruda is likely to be of greater benefit for the treatment of this patients medical condition than the available standard therapies.  Final Result: Two of the three reviewers have determined 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:  All three reviewers are board certified in in internal medicine with sub-specialty certification in medical oncology 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 parent of a patient has requested authorization and coverage for Nutropin AQ Nuspin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patient, who has a history of short stature. The submitted documentation does not support the medical necessity of the requested medication. The patients pre-treatment height was not more than two standard deviations below the mean for age and gender. The patients growth velocity was normal, and pre-treatment insulin-like growth factor 1 level was normal. The patients pre-treatment bone age is not known, and laboratory testing results ruling out other causes of growth failure are not available. Thus, the patient does not meet standard criteria for growth hormone deficiency. The fact that the patient failed provocative stimulation testing does not prove that he is growth hormone deficient. Therefore, Nutropin Nuspin is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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

An enrollee has requested authorization and coverage for bilateral whole breast ultrasound (twice per year), in conjunction with the annual mammogram, or bilateral whole breast ultrasound (once a year), in conjunction with the annual mammogram. For this patient, the recommendation for an MRI breast examination every six months or every year will result in a considerable long-term dose of gadolinium. While MRI is preferable to breast sonography, the risks of gadolinium should not be ignored.  Previously, the main risk associated with the use of gadolinium was felt to be nephrogenic systemic fibrosis in patients with impaired renal function.  More recently, however, there has been increasing attention to the retained deposition of gadolinium in the brain. In this case, it is reasonable to augment her mammograms with regular whole breast ultrasound studies. There is support for whole breast ultrasound in this clinical setting. It is important to note that there are limitations for any type of sonography in evaluating breasts. Specifically, automated whole breast ultrasound cannot diagnose microcalcifications, and is marginal in evaluating the deeper portions of the breast. In this patients case, the medical evidence supports the requested bilateral whole breast ultrasound at a frequency of once per year.  For screening tests, the clue that there may be an abnormality is the change from one study to the next. Obtaining ultrasound studies every six months will likely not be any more accurate than obtaining these studies at yearly intervals. All told, the requested bilateral whole breast ultrasound (once a year) in conjunction with the annual mammogram is medically necessary for the evaluation of this patient. However, bilateral whole breast ultrasound (twice per year) in conjunction with the annual mammogram is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 12-year-old male enrollee has requested authorization and coverage for Nutropin AQ Nuspin pen injector. Based on the available documentation, GH therapy is not medically necessary for this patient. The patient has a normal height, normal growth velocity, normal IGF-1 level, and normal results on provocative GH testing. Based on the bone age and height measurement at age 12 years two months of age, the patients estimated final adult height prediction is normal for a U.S. adult male and not short enough to consider GH therapy for idiopathic short stature. Thus, the requested Nutropin AQ Nuspin pen injector is not medically necessary for treatment of the patients medical condition.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 pediatrics with sub-specialty certification in pediatric endocrinology 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.