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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for immunoassay, spectrophotometry and column chromatography/mass spectrometry. The enrollee has a history of viral versus autoimmune meningoencephalitis, seizure disorder and anxiety. The enrollee continues to demonstrate severe anxiety and symptoms of an overstimulated nervous system, despite high doses of anti-epileptic medications. He complains of blurry vision and episodes of vertigo. He underwent a NutrEval, which showed a need for thiamine (vitamin B1) and magnesium. It also showed borderline whole blood mercury, antioxidants within range, and positive dysbiosis markers. The enrollees provider recommended benfotiamine daily, magnesium threonate, twice daily and biocidin for treatment of fungal dysbiosis. Labs were re-checked, which showed normal C3/C4 protein levels and elevated serum CH50 levels. Past blood and immunology tests have been inconclusive. The laboratory tests were ordered to find the cause of why a healthy, active man went into a coma within 48 hours after admission to the hospital, with continual seizures. The goal is to prevent possible flare-ups or setbacks. This enrollee was assessed with a comprehensive digestive stool analysis 2.0 (CDSA 2.0) and a nutritional evaluation (NutrEval). Researchers claim these tests offer insight into the individuals functional status with regard to several of the proposed core pathways comprising functional medicine. The clinical trials will need to demonstrate efficacy of the functional medicine approach before its incorporation into clinical practice. The manufacturer describes the NutrEval profile as a laboratory panel designed to give physicians a better understanding of individuals' nutritional deficiencies. There is minimal available peer-reviewed literature regarding the NutrEval test panel. There is no documentation to support why the enrollee needed chromatography/mass spectrometry.  Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in neurology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested authorization and coverage for Xifaxan (rifaximin) 550 mg. SIBO is a recognized cause of gastrointestinal distress and a contributing factor of irritable bowel syndrome (IBS). Although SIBO is typically treated with antibiotics, there are not any U.S. Food and Drug Administration (FDA) antibiotics specifically approved for this indication. Rifaximin, which has been FDA approved for treatment of inflammatory bowel syndrome, has been found to be most effective in treatment of SIBO in adults. The data are more limited in children. However, non-controlled prospective data does support the effectiveness of Xifaxan in the treatment of SIBO in children and adolescents. Medical literature concluded that, these results indicate that antibiotics are an effective means of treating SIBO in children and, although non-rifaximin antibiotics appear to produce greater resolution, the data is weaker for such medications and rifaximin has demonstrated safety in a greater number of participants and studies. All told, the requested Xifaxan (rifaximin) 550 mg is medically necessary for 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 with subspecialty certification in pediatric 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Stelara 90 mg every four weeks. Current medical literature supports the requested dose escalation of Stelara in this case. The patient has active disease symptoms. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed. The mechanism of Stelara is different from anti-TNF medications. One study showed Stelara dosing at 90 mg every four weeks can address inadequate disease control, and a large proportion of patients have been able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. The American Gastroenterological Association (AGA) guidelines for the management of Crohns disease state that when response to a biologic medication is lost in the setting of a low drug level and lack of anti-drug antibodies, the drug dosage should be increased. In this case, the patient has failed multiple conventional and biologic alternatives, as well as Stelara every eight weeks. She responds to Stelara, but routinely loses response at four weeks after injection in the setting of a low Stelara level. Continuation of the current dose may result in complications. For these reasons, Stelara 90 mg every four weeks is medically necessary for 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 subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement and prospective authorization and coverage for Sipuleucel-T (Provenge). Based on the available medical documentation, this patient has castrate resistant prostate cancer with lymph node metastasis. The records report a rising prostate specific antigen (PSA) with a testosterone of less than 20 ng/dL. As such, use of Provenge is clinically appropriate and generally accepted standard of care for management of this patients medical condition. In addition, the patient meets the recommendations from the National Comprehensive Cancer Network (NCCN) guidelines on prostate cancer. All told, the requested sipuleucel-T (Provenge) was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested sipuleucel-T (Provenge) was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the medication at issue was and 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 reviewers 1, 2, and 3 are board certified in urology 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

The patient has requested authorization and coverage for cyclobenzaprine and methocarbamol. According to the American College of Physicians, most patients with acute or subacute musculoskeletal pain will improve over time regardless of treatment. Patients with chronic pain are recommended to participate in rehabilitation, exercise and other non-pharmacologic modalities. If pharmacologic therapy is indicated, then treatment with NSAIDs are a first-line therapy, or tramadol or duloxetine as a second-line therapy for chronic pain. The evidence suggests that NSAIDs have been more effective than SMR medications, including cyclobenzaprine. Current data supports use of SMR medications at the lowest dose possible for the shortest amount of time. Overall, there is a lack of evidence that the use of SMR medications provide significant improvement in a patients function. The documentation indicates that cyclobenzaprine was prescribed for 60 tablets with three refills, which would be an approximately three-month supply. The records do not include documentation that the patient has exhausted non-pharmacologic therapy as well as standard first-line therapies for management of his condition. Further, there is a lack of an indication for ongoing treatment with either medication. In the absence of an indication for ongoing treatment with an SMR, the requested cyclobenzaprine and methocarbamol are not medically necessary for treatment of this patient.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 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

The patient has requested authorization and coverage for eight weeks of behavioral health intensive outpatient program (IOP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets level 2.1 criteria for IOP level of care services. The patient meets the criteria for dimensions 3 through 6. For dimension 3, the patient has comorbid depression, anxiety and ADHD. Dimension 4 is met given the patients lack of readiness to change, need for support, and inability to remain sober without structured treatment. The patient is at high risk of relapse. The provider noted that the patient requires support and structure to prevent relapse. The patients living environment provides poor local support and limited coping skills in the setting of isolation. Given that the patient has a high risk of relapse history, legal problems in the setting of his substance dependence, poor functioning, and little local social support, the patient meets the criteria for IOP level of care based on the ASAM level 2.1 criteria. Therefore, the requested eight weeks of IOP services are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in addiction 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has been diagnosed with chronic low back pain and right carpal tunnel syndrome. The patient was noted to have a history of a cerebrovascular accident without residual deficits. The patient reported back pain and occasional burning right leg pain. Right hand and right knee pain were also reported. He reported difficulty using his walker due to right hand pain. He also receives 16 hours per week of home care assistance. Physical examination findings included slow ambulation without focal neurological deficits. Tenderness was noted over the spine at multiple regions. Lumbar spine range of motion was reduced. In a letter, it was noted the patient was able to ambulate independently in his home with or without a walker. The patients fall risk was noted to be low. A heavy duty wheeled walker was recommended for aiding his mobility. The patient has requested authorization and coverage for a power wheelchair. The Health Plan denied the request and reported the requested device is not medically necessary for the treatment of this patient. At issue in this case is whether a power wheelchair is medically necessary for the treatment of the patients medical condition. In this case, this patient was noted to ambulate slowly but independently. He was able to ambulate up to 100 feet with the assistance of a walker. There is no indication that the patient would be bed or chair confined without a power mobility device. The patient does not have cardiac, pulmonary, neurological, musculoskeletal or other pertinent organ system impairments that would preclude ambulation with a walker. Furthermore, the patient has multiple health conditions that would be better addressed through higher levels of physical activity, rather than the lower levels of physical activity that a power mobility device would encourage. Hagen and colleagues reported that the use of wheelchairs in place of physical exercise impairs bone and muscle health. The medical evidence does not support the requested device in this clinical setting. Therefore, a power wheelchair is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 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

The enrollee is requesting authorization and coverage for an esophagogastroduodenoscopy (EGD). The enrollee has hypertension and hypercholesterolemia with complaint of abdominal pain. She stopped taking levothyroxine due to fear that it was causing her pain.  The gastroenterology record indicates a rounded abdomen.  The treatment plan included referral to a rheumatologist, laboratory work, a computed tomography (CT) scan of the abdomen with contrast dye, and an esophagogastroduodenoscopy (EGD) without biopsy.  The enrollee reports abdominal pain.  However, the record does not indicate the pain is upper abdominal.  The enrollee does not have alarm symptoms, such as anemia, weight loss, GERD that is unresponsive to therapy, or a lesion on the CT scan.  The enrollee does not meet guidelines for the performance of this test.  Since there is insufficient evidence in the record of persistent upper abdominal pain, the requested EGD is not medically necessary.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for Eye Movement Desensitization and Reprocessing (EMDR) therapy, provided once a week. The enrollee has post-traumatic stress disorder (PTSD), anxiety, depression and grief. The enrollee has intense symptoms of restlessness, sleep deprivation, social isolation, and grief over losing their significant other several months ago. Eye Movement Desensitization and Reprocessing (EMDR) therapy has been prescribed. The diagnosis and treatment plan indicates EMDR will be utilized to reduce the enrollees emotional reactivity to the traumatic events she has experienced and PTSD symptoms. Eye movement desensitization and reprocessing (EMDR) is prescribed to reduce emotional distress related to traumatic thoughts, feelings, and images.  The medical literature indicates trauma-focused psychotherapies that include exposure have been supported by multiple clinical trials in adults with PTSD and include exposure therapy, such as prolonged exposure, a combination of exposure and a cognitive therapy, also known as trauma-focused cognitive behavioral therapy, and eye movement desensitization and reprocessing. EMDR is one of the most studied treatments for PTSD and has the strongest recommendation for being an effective treatment in most clinical practice guidelines for the treatment of PTSD.  Over the years, there have been a multitude of clinical reports and research data confirming its success in other clinical areas including the diagnostic clusters related to anxiety, as well as complicated grief, disturbing memories, panic attacks, and stress reduction. This enrollees profile, throughout the record, indicates symptom corroboration in sync with the uses of this technique to address PTSD, grief/bereavement, anxiety, panic attacks, stress reduction, and anxiety. Standard prolonged exposure (PE) and eye movement desensitization and reprocessing (EMDR) protocols are effective, safe, and feasible in enrollees with PTSD and severe psychotic disorders, including current symptoms. Given the supportive literature, the requested Eye-Movement Desensitization and Reprocessing (EMDR) therapy, provided once a week, is medically necessary to treat the enrollees medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. For dimension 1, the records document that the patient is experiencing moderate to severe withdrawal symptoms as evidenced by his CIWA scores. The patient does not meet the criterion for dimension 2, given the lack of biomedical conditions. For dimension 3, the patient has comorbid depression, PTSD and ADHD, which are all associated with more severe substance disease. The patient meets the criteria for dimension 4, as he is in the early stage of dealing with trauma. He is currently in a stage of unpreparedness without having developed the necessary recovery skills. For dimension 5, the patient continues to work to identify triggers and causes as well as strategies to change to be able to live a sober life outside of the structure of RTC. The patient continues to report cravings. The patient meets dimension 6, as he is still learning triggers and coping skills. Given the patients current level of function, he requires a structured supportive treatment environment. The patient requires a safe and stable living environment in order to develop his recovery skills. He meets the criteria for ASAM Level III treatment, which is similar to the services provided at the current RTC. Given these findings, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 with expertise in addiction 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. For dimension 1, the patients CIWA score of mild to moderate withdrawal symptoms meets this criterion. The patients meets dimension 2 given the presence of significant hypertension worsening with withdrawal. For dimension 3, the patient has a comorbid diagnosis of depressive disorder. The records support evidence to meet dimension 4, as the patient is noted to be engaging in self-sabotaging behaviors. The provider noted that the patients insight is partially improved, but he still needs to learn alternative coping skills to deal with emotional distress. For dimension 5, the patients avoidance and isolation with partial insight present risks for relapse. At this stage of recovery, the patient is unaware of his relapse triggers. The patient also meets the criterion for dimension 6, as he hosts social events serving alcohol, as he owns a vineyard. The patient requires a safe and stable living environment in order to develop his recovery skills. The patient meets the ASAM Level III treatment level of care, which is similar to the services provided at the current RTC facility. Given the severity of the patients illness, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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.