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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for guselkumab (Tremfya). The submitted documentation does not support the medical necessity of the requested medication. This patient has tried and failed therapy with topical steroids, methotrexate, and Humira. However, there is no documentation that the patient has tried and failed, or has a contraindication to the Health Plans formulary alternatives including Enbrel and Remicade. Therefore, guselkumab (Tremfya) 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization for Dynamic Temporal and Tactile Cueing (DTTC) services five times a week for treatment of the enrollees severe childhood apraxia of speech. Findings:  The physician reviewer found that the submitted documentation does support the medical necessity of the requested services. Maas and colleagues have studied current trends in treatment for childhood apraxia of speech (CAS) and found that motor-based interventions can produce gains in speech production abilities in children with CAS. Their study found that, at present, a DTTC-type integral stimulation approach has the strongest evidence base, with replicated evidence of efficacy from several well-controlled single-case experimental design studies from different, independent research groups. The literature supports that the use of Dynamic Temporal and Tactile Cueing (DTTC) is efficacious for patients with apraxia of speech. The submitted documentation shows that the patient continues to use his letter board. Additionally, the records show that the patient scored in the less than 0.1 percentile for articulation/phonology and, as of July 2018, continues to have severe sound production difficulties and mild groping. As the patient has been in standard speech therapy since 2015, two times per week, and continues to have severe sound production difficulties, the use of DTTC is a reasonable approach to try to increase his verbal communication. The frequency of this therapy would be appropriate at five times per week, with a re-assessment of efficacy at six months. Therefore, the requested Dynamic Temporal and Tactile Cueing services five times per week is medically necessary to treat the patients medical condition.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 physical medicine & rehabilitation, with sub-specialty certification in pediatric rehabilitation 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services. The records document an inflamed epidermal cyst on the cheek. The patient sought treatment on two consecutive days. The medical records indicate that the patient had a dime-sized area of redness and inflammation on the cheek.  The submitted documentation indicates that the lesion was not painful. The patient was treated with cephalexin, an oral antibiotic. This patient did not have signs or symptoms which were life threatening, urgent, or emergent in nature. Based on the records, the services at issue were not emergent in nature. The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services.Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Leukocyte Histamine Release test provided on 11/10/17. The Health Plan has denied this request as investigational for evaluation of the enrollees possible allergies. Findings:  There are insufficient medical notes provided to support the reasoning behind the test for leukocyte histamine release and whether it would be more beneficial in the evaluation and treatment of the patient than standard tests. While the release of histamine from leukocytes upon exposure to an allergen is a valid test for detection of specific IgE to the allergen used in the test, this test is not normally used clinically. It has been used traditionally as a research tool. Quality control studies have shown variability in the measurement of histamine results. Evidence based studies and data supporting its role in the clinical setting are lacking. There is not an established alternative for this test, and the quality and quantity of data in the current peer-reviewed scientific medical literature is inadequate to establish the clinical utility or efficacy of this test. Therefore, Leukocyte Histamine Release test was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: All 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 internal medicine with a sub-specialty in allergy and immunology 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 Stelara. Current medical literature supports the use of Stelara in this case. Stelara is U.S. Food and Drug Administration (FDA) approved for Crohns disease. One 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. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. A recent study demonstrated that a majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara. In this patient with primary nonresponse to anti-TNF medication (Humira), a medication with an alternative mechanism of action, such as Stelara, is more appropriate to control disease and to prevent further complications. For these reasons, Stelara is medically necessary for the treatment of this patients Crohns disease.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An male enrollee has requested authorization and coverage for anesthesia during magnetic resonance imaging (MRI) of the brain. The patients records support an ASA preoperative physical status classification score of 2. In this clinical setting, intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in practice and in the research, given the patients low preoperative ASA physical status classification score. The Health Plan has authorized a large bore MRI with sedation, which should be appropriate in this clinical setting. Thus, the requested authorization and coverage for anesthesia during MRI of the brain, is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lorzone 375 mg tablets. Chlorzoxazone (Lorzone) is a muscle relaxant that works primarily in the spinal cord and the subcortical areas of the brain. The mechanism of action is unknown but the effect is thought to be due to general depression of the central nervous system. Advantages over other muscle relaxants include reduced sedation and less evidence for abuse. Muscle relaxants usually cause drowsiness and dizziness but chlorzoxazone is better tolerated. However, chlorzoxazone should be avoided if the patient has a history of liver disease.  Muscle relaxants are prescribed for a variety of indications, however the comparative efficacy of these drugs is not well known. Skeletal muscle relaxants consist of both antispasticity and antispasmodic agents. The efficacy data from comparator trials do not particularly favor one skeletal muscle relaxant over another. Therefore, the choice of a skeletal muscle relaxant should be based on its adverse-effect profile, tolerability, and cost. Chlorzoxazone is particularly well tolerated according to current literature. As such, after unsuccessful use of cyclobenzaprine, the prescription of chlorzoxazone is appropriate, reasonable, and medically necessary. Therefore, Lorzone 375 mg tablets are 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Zoll LifeVest. Findings:  Two of the three physician reviewers found that this patient experienced a ventricular fibrillation arrest that was secondary to an acute myocardial infarction due to complete occlusion of the mid left anterior descending coronary artery. In this circumstance, ventricular fibrillation within the first 24-hours of an acute myocardial infarction is not predictive of subsequent ventricular fibrillation, especially after the treatment rendered in this case and the normal ejection fraction recorded. There is potential for recovery of any regional left ventricular dysfunction after treatment, and there was no documented indication for immediate placement of a defibrillator, such as sustained or inducible post-myocardial infarction ventricular tachycardia. Placement of a prophylactic defibrillator is not recommended until a period of time, greater than 90 days, where continued left ventricular dysfunction is documented to persist despite appropriate treatment. A prophylactic defibrillator before this time has not been demonstrated to improve outcome. A prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. In sum, the Zoll LifeVest was not likely to have been superior over other available treatment options.Final Result: The reviewers determined that the device at issue was 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 sub-specialty certification in cardiovascular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services for substance abuse. The American Society of Addiction Medicine (ASAM) criteria, a set of objective guidelines used by providers to assist with treatment planning, advocates for service intensity provided in the least intensive, but safe treatment setting. The ASAM guidelines advise that length of service should be determined by the patients progress with his or her treatment plan as determined by the treating providers. Per the documentation, this patient has a long history of substance use. In addition, the patients providers noted that she is unable to control her impulses and remains at high risk for relapse. Thus, treatment at the IOP level of care is consistent with the current medical literature, ASAM criteria, and the documented clinical history. Accordingly, the IOP level of care services were and are medically necessary for treatment of this patients behavioral health issues. 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.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for emergency services. After careful review of the enclosed information and the health plan definition for emergent care, this patient did receive emergency care. It is well documented that this patients provider was unable to perform a matrixectomy for this patients paronychia. The patient was placed on oral antibiotics and advised to see a podiatrist for care. The next available appointment was nine days later. Given the patients infection, pain, and history of diabetes, immediate treatment was appropriate to avoid potential complications. It is also noted that the patients blood glucose was elevated, likely due to infection. For these reasons, the partial matrixectomy performed on this patients right hallux was performed emergently and was a necessary procedure. Final Result: The reviewer determined that the services at issue were necessary for treatment of an emergency medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in podiatry 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: The parent of an enrollee has requested reimbursement for fecal analysis. Findings:  Three physician reviewers found that fecal calprotectin testing has been recognized as an accurate method to assess the likelihood of a child having inflammatory bowel disease, without the discomfort and need for sedation which a colonoscopy entails.  It is used both clinically and in research studies as a marker of intestinal inflammation. In a single-center study, calprotectin was found to be far superior to commonly utilized blood parameters such as C-reactive protein and white cell count. There is sufficient support for the services at issue in this patients case. Therefore, fecal analysis was likely to be of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 are board certified in pediatrics with sub-specialty certification in pediatric gastroenterology 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. In the documentation available for review, the recent examination is not consistent with facet arthropathy. In addition, the literature states that a diagnostic medial branch block should be performed prior to radiofrequency ablation. A pain diary should be kept for the day of the medial branch block to help determine when the local anesthetic wore off. Further, only a local anesthetic should be used for the medial branch block. This patient received monitored anesthesia care with a medial branch block. All told, the requested authorization and coverage for radiofrequency ablation is not medically necessary for treatment of this patients back pain and lumbar radiculopathy. 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 anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla. Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Traditional systemic therapies for psoriasis have a well-documented array of toxicities. Otezla is an oral PDE4 inhibitor, which provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Otezla has been widely studied for this indication. The provider documented the patient has been treated with Otezla with good results and no side effects. Given this patients history and presentation, the requested Otezla is medically necessary for treatment of this patients chronic plaque psoriasis.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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization for Cosentyx. The submitted documentation does not support the medical necessity of the requested medication. This patient has tried and failed treatment with topical steroids and ultraviolet light therapy. The Health Plan has denied the request as not medically necessary because the patient has not failed one of the preferred oral agents, including methotrexate, cyclosporine, or acitretin. As there are no documented contraindications to the use of methotrexate or acitretin in the patient, the request for coverage of Cosentyx should be denied as not medically necessary given the availability of alternative, preferred agents that have not been tried.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.