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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for functional electrical stimulation (FES) for treatment of the enrollees spinal cord injury.  Fulfills Findings:  The physician reviewer found that there is a lack of sufficient peer-reviewed literature supporting definitive physiological responses of a spinal cord injured individual to FES devices. Moreover, there is a lack of literature support demonstrate that FES provides a clinically meaningful benefit beyond that of standard exercise recommendations for an individual with T6 paraplegia, including aquatic exercise, upper body ergometry, and passive stretching. For the reasons provided, the request for FES is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested equipment is 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 and coverage for Vyvanse 60 mg twice daily for treatment of the enrollees attention deficit-hyperactivity disorder (ADHD). Findings:  The physician reviewer found that according to the U.S. Food and Drug Administration (FDA), the maximum daily dosage approval for Vyvanse is 70 mg per day for the treatment of ADHD. The medical literature does not show that doses of Vyvanse above 70 mg are more effective and safer than lower doses of Vyvanse. There are also cardiovascular concerns with using higher than recommended doses above 70 mg. There is also concern for potential abuse with doses higher than recommended as tolerance, psychological dependence, and severe social disability. Therefore, Vyvanse 60 mg twice daily has not been established as medically necessary for treatment of the patients ADHD. 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 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 an enrollee has requested authorization and coverage for speech therapy, at a frequency of one time per week for 45 minutes. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees mixed receptive-expressive language disorder. Findings:  The physician reviewer found that rReview of the submitted documentation demonstrates the medical necessity of the request for speech therapy at the frequency of one time per week for 45 minutes. The study by Ohare and Bremner found that treating speech and language disorders early leads to better outcomes. In this case, the patient has made progress, but the patient continues to have a few areas that are not age appropriate. In addition, the Health Plan indicates that an assessment and/or re-evaluation should be done. This recommendation is medically reasonable, however speech therapy should not be stopped pending the results of testing. Based on the clinical documentation submitted for review, the request for speech therapy at the frequency of one time per week for 45 minutes has been established as medically necessary for treatment of 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 pediatrics with sub-specialty certification in developmental and behavioral 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zydelig for treatment of the enrollees relapsed B-cell prolymphocytic leukemia/mantle cell lymphoma. Findings:  The physician reviewer found that this patient has advanced mantle cell lymphoma. There are very limited treatment options for patients  diagnosed with this disease, although some patients have long durable responses to chemotherapy. Like many difficult to treat cancers, it usually responds to initial chemotherapy but invariably relapses. In this patients clinical course where she has a good performance status, off label medications are available for use. There is data supporting Zydelig for the treatment of mantle cell lymphoma with good responses. Thus, Zydelig is medically necessary for the treatment of this patients medical condition. 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 medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 30 pills in 30 days of azithromycin 250 mg for treatment of the enrollees pustular rosacea. Findings:  The physician reviewer found that There is support in the medical literature for the requested medication quantity in this clinical setting. The tetracycline family of oral antibiotics is typically used for the treatment of inflammatory rosacea, even for extended courses.  However, the patient had a severe reaction when previously prescribed minocycline.  Consequently, further use of the tetracycline should be avoided. This patient has previously tried azithromycin with good effect. Given the circumstances, coverage for 30 pills in 30 days of azithromycin 250 mg is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication quantity is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa tablet 400/100 mg at a quantity of one tablet daily for twelve weeks or treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. In this patients case, there is imaging evidence of cirrhosis. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment is needed at this time, and the requested treatment with Epclusa tablet 400/100 mg at a quantity of one tablet for twelve weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Zepatier 50-100 mg tablets for a duration of 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated (except those with limited life expectancy due to non-liver-related conditions). This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including or Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50-100 mg tablets for a duration of 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT) for treatment of the enrollee who has been diagnosed with invasive adenocarcinoma of the prostate. Findings:  The physician reviewer found that There is support in the medical literature for the medical necessity of the requested services in this clinical setting. The guidelines acknowledge that the clinical decision to initiate treatment will be dependent on multiple factors including patient and provider interaction rather than a specific prostate specific antigen threshold value. In this patients case, it is reasonable to begin salvage radiotherapy based on this patients presented clinical factors. Morgan and colleagues evaluated 14 different definitions of post prostatectomy failure, but the study also took into account pathologic factors. For this patient with a Gleason score of 9 and pathologic T2c disease, a PSA failure threshold of 0.03 ng/mL is predicted to have a 77% chance of PSA progression at five years. Using a threshold of 0.1 ng/mL, there is an 88% chance of progression at five years. These numbers should then be taken into consideration along with age, life expectancy, quality of life, and patient preference. But, for any patient with a life expectancy more than two years, an 88% chance of PSA progression almost certainly warrants treatment, but especially so in a patient who is only 55. Waiting for this patients PSA to rise would not be beneficial to this patient. Therefore, in light of the medical evidence as well as this patients clinical factors, IMRT is medically necessary for treatment of this 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of mometasone furoate 50 mcg spray pump for treatment of the enrollee who has history of allergic rhinitis.Findings:  The physician reviewer found that according to the progress notes and the prior authorization form from the provider, the patient has symptoms consistent with chronic sinusitis and allergic rhinitis.   On the other hand, the patient has tried the requested medication mometasone furoate (Nasonex) and achieved good symptom control with minimal adverse reaction. Therefore, mometasone furoate 50 mcg spray pump is medically necessary for treatment of this patients medical condition. 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 allergy and immunology 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 magnetic resonance imaging for treatment of the enrollees knee pain.Findings:  The physician reviewer found that the American College of Radiology (ACR) has established appropriateness criteria for the evaluation of various clinical presentations. Under their category of chronic atraumatic knee pain, the first recommended study is a plain x-ray, which this patient has already had.  In patients with demonstrated degenerative changes, in consideration for surgery, the ACR considers MRI appropriate.  As stated by the ACR, MRI is more sensitive than radiography and provides more specific information compared with radionuclide bone scan.  MRI of non-traumatic knee pain may document a joint effusion, communicating popliteal cysts, proliferative changes of the synovial membrane (such as, but not limited to lipoma arborescens, synovial chondromatosis, or synovitis associated with arthritis), osteophytes, subchondral cysts, articular cartilage loss, meniscal and/or ligamentous tears and/or degeneration, extensor mechanism disorders, bone marrow edema (bearing in mind that actual edema is not a major constituent of this abnormal edema-like signal in the setting of osteoarthritis), fractures, and osteonecrosis. In this particular patient, there is evidence of degenerative disease.  As noted by the patients primary care provider, there are multiple treatment options.  While one should never rush into surgery for the knee, as acute symptoms will often resolve, an MRI can be used to evaluate this patient prior to making treatment decisions. The Health Plan has suggested that the patient should first see an orthopedist. However, in this patient, with radiographic signs, a standard practice by most orthopedist will request an MRI often before seeing the patient. In conclusion, MRI of the knee is medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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:The patient has requested authorization and coverage for an attended overnight polysomnography sleep study on continuous positive airway pressure (CPAP) or bi-level positive airway pressure (Bi-PAP) for evaluation of the enrollees obstructive sleep apnea (OSA). Findings:  The physician reviewer found that the use of CPAP is considered first-line treatment for patients with OSA and its use is supported across multiple practice guidelines. However, current practice guidelines do not indicate which CPAP should initially be provided via an attended titration study versus an auto-titrating device. Current literature has shown that home based attended positive airway pressure (AutoPAP) is as effective as automatic in-laboratory titrations when used as initial treatment for OSA. There is also no proven difference in comfort or compliance rates between the two approaches to treatment. In this case, the patient is not reported to have any comorbid medical conditions which would necessitate an attended titration due to respiratory problems such as congestive heart failure, chronic obstructive pulmonary disease, or neuromuscular disease. The patient should be able to undergo a home trial of AutoPAP and the performance of an attended study would therefore exceed the patients clinical needs. All told, the requested attended overnight polysomnography sleep study on CPAP or Bi-PAP is not supported as medically necessary for evaluation of this patients OSA. Final Result: The reviewer determined that the requested diagnostic procedure is 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 neurology with sub-specialty certification in sleep 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Linzess 145 mcg capsules for treatment of the enrollees slow transit constipation. The documentation indicates that the use of an osmotic laxative (MiraLAX) has not been successful in this patient. The American Gastroenterological Association (AGA) medical position statement on constipation states that the first line of therapy should be an osmotic agent. If that first line fails then another type of laxative such as a stimulant laxative should be tried before attempting treatment with newer agents, such as Linzess or Amitiza. Additionally, the AGA position statement notes that these newer agents have more adverse effects. In this patients case, a stimulant laxative has not been documented.  Moreover, the studies have shown that both Amitiza and Linzess are effective, and a reason to use Linzess over Amitiza in this case has not been provided.  For these reasons, Linzess is not supported as medically necessary for the 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 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.