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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services.  Applying ASAM guidelines, this patient was at significant risk for relapse and withdrawal without medication-assisted treatment. This patient was at an increased risk given his preference to use fentanyl. The records noted that he continued to receive supportive medications for post-acute withdrawal such as Imodium and Robaxin. The patient has biomedical conditions including obesity, poorly controlled diabetes mellitus, and obstructive sleep apnea (OSA). He was at increased risk of overdose if he resumed opioid use after discontinuation. The patients mental status was sufficient to permit participation and he was unable to control his substance use without 24-hour support. Prior treatment has included at least two treatment admissions with supervised withdrawal and RTC level of care treatment. The patient demonstrated limited insight and awareness into his need for continued care. He remained at high risk for relapse as he was in imminent danger of relapse due to a crisis. The patient endorsed high cravings and multiple psychosocial stressors including the sudden death of his father and his close friend. The patients cravings, prior treatment failures, and acute stressors of losing his father and close friend support that he was in imminent danger of relapse. The patients recovery environment was too chaotic to support the patients treatment goals. The records establish that the patient required structured therapy and 24-hour milieu during the period under review. All told, the RTC services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for advanced lipoprotein testing. There is a lack of clinical studies demonstrating that addressing issues identified by novel lipoprotein testing analysis will further reduce a patients cardiovascular risk beyond standard analysis and treatment planning. Overall, clinical trial data do not support the superiority of treatment strategies incorporating non-statin lipid modifying agents compared with intensive or moderately intense statin therapy. Current guidelines support use of an LDL lowering statin therapy in this patient with an intermediate risk. Additional testing to determine whether the patient was not needed. Accordingly, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ondansetron 4 mg, 90 tablets per month. Ondansetron is U.S. Food and Drug Administration (FDA) approved for the prevention of nausea and vomiting associated with chemotherapy, post-operative nausea and/or vomiting or radiotherapy-associated nausea and vomiting. Current medical literature supports a clinical role for ondansetron for the treatment of nausea and vomiting. Dosing for the treatment of nausea and vomiting due to other medical conditions that are self-limiting is 4 mg as a single dose. In this case, the documentation supports that the use of ondansetron is for nausea and vomiting related to the use of metformin to treat the patients medical condition of diabetes mellitus. The treatment of nausea related to the use of metformin is to decrease the dose of metformin or take a break from the medication. Overall, ondansetron to treat the side effect of nausea related to the use of metformin is not medically necessary. Furthermore, the requested ondansetron 4 mg, 90 tablets per month, exceeds the recommended dose of 4 mg one time for nausea and vomiting in this clinical setting. All told, the requested ondansetron 4 mg, 90 tablets per month, 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral subtalar implant surgery under local anesthesia prior to giving birth. Bernasconi and colleagues stated that the available data on long-term health outcomes and complications on subtalar arthroereisis is limited. Researchers concluded in their 35 patient study that arthroereisis is valid for the treatment of adult flat foot secondary to posterior tibial tendon dysfunction at this stage, and results in a high percentage of excellent results. Studies found that the adjunct use of an arthroereisis implant in patients undergoing flatfoot correction surgery resulted in improved and maintained radiographic and clinical measurements in patients undergoing correction of stage II flatfoot. This patient presents with a history of chronic bilateral foot pain, with a reported flare up of severe pain over the past three months. Functional limitations are noted in weight bearing activities. She has been diagnosed with a flexible flatfoot deformity. She is currently pregnant. She is no longer able to take non-steroidal anti-inflammatory drugs (NSAIDs) due to pregnancy. However, there is a lack of documentation that the patient has exhausted reasonable less invasive treatment options. Moreover, there is a paucity of medical literature supporting the utility of subtalar arthroereisis as a standalone procedure with use of local anesthesia. All told, the requested bilateral subtalar implant surgery under local anesthesia prior to giving birth is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Applying the ASAM guidelines, the patient was not in substantial withdrawal-related distress. The reported CIWA scores represented mild objective withdrawal related distress. The patient did not have any reported biomedical condition that distracts from recovery. The provider reported that the patient has sufficient mental status to permit participation in treatment. According to the records, the patient had no acute symptoms from a substance use disorder, exhibited limited functional impairment, was free of suicidal ideation, and was compliant with his psychiatric medication regimen. The patient has demonstrated limited understanding of his substance use on coping and functioning. He has displayed motivation to change and an interest in continuing outpatient treatment. The provider described the patient as active in all therapy groups. The patient remains at risk for relapse as he is experiencing addiction symptoms including craving and urges to use substances. Given these findings, the patient meets two of the required six criterion for RTC level of care. Therefore, the RTC level of care services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for laparoscopic anti-reflux surgery utilizing the LINX Reflux Management System. Scientific evidence via well-designed controlled studies with adequate follow-up, has not demonstrated the safety and efficacy of the LINX procedure for the treatment of patients with gastroesophageal reflux disease (GERD). Evidence arises largely from case series and cohort studies. The pivotal trial that led to the U.S.  Food and Drug Administration (FDA) approval of therapy was a non-randomized, non-blinded, multi-center trial. Direct comparative studies between surgical interventions are lacking to better assess the long-term safety and efficacy of this intervention in patients. As this patient has GERD with atypical symptoms, further work-up might help ascertain the etiology of his condition. The records do not suggest that the patients symptoms would be substantially improved with the LINX procedure. Moreover, the provider noted that the patients symptoms are improved with PPI use. Given these findings, the requested laparoscopic anti-reflux surgery utilizing the LINX Reflux Management System 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in 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: Overturned Decision of Health Plan

The parent of an enrollee has requested authorization and coverage for general anesthesia.Among their listed indications for general anesthesia for pediatric dental patients, the American Academy of Pediatric Dentistry state that general anesthesia is indicated for patients who cannot cooperate due to a lack of psychological or emotional maturity, the extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent, and patients requiring immediate, comprehensive oral dental care. In this case, the patient has a documented history of previous difficulty with dental procedures and was intolerant of basic dental examinations. The submitted records also document an attempt to provide restorative care to the patient using nitrous oxide which had to be stopped due to the patient not tolerating the procedure. Therefore, standard behavior guidance techniques have failed, attempts to treat the patient under moderate sedation with nitrous oxide have failed, and the required restorative work is extensive and involves four quadrants of the mouth. Under these circumstances, the requested general anesthesia is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for the OncotypeDX Prostate Cancer genetic testing provided by Genomic Health, Inc. This patient underwent genomic and protein biomarker testing with the OncotypeDX to aid in clinical decision-making with regard to his prostate cancer. Current peer-reviewed medical literature supports an indication for molecular and genomic testing for patients with low risk disease to make decisions regarding observation versus treatment. Drawbacks include heterogeneity of prostate cancer and uncertainty of potential clinical benefit. Researchers concluded that further understanding is needed to appreciate the potential benefits and limitations of these novel tests. All told, the OncotypeDX Prostate Cancer genetic testing provided by Genomic Health, Inc. was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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/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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test DecisionDx-UM. Cytogenetic testing of choroidal melanoma is an established method of laboratory evaluation of melanomas. The medical literature supports the routine use of the DecisionDx-UM to adjust a patients surveillance based on the genetic profile of the tumor. In addition, the counseling and eligibility for clinical treatment trials is based heavily on the tumor genetic profile. Given this support, the gene test DecisionDx-UM was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the gene test DecisionDx-UM was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 ophthalmology 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

The parent of the patient has requested authorization and coverage for Dupixent syringe injections. Atopic dermatitis is an itchy inflammatory skin disease characterized by marked epidermal hyperplasia and defective barrier function. Frequent disruption of sleep is common, and emotional stress associated with the illness can have a significant impact on quality of life for patients and families. Dupixent has been demonstrated to reduce the molecular signature and clinical manifestations of moderate to severe atopic dermatitis. Dupixent also importantly significantly reduces the pruritus of moderate to severe atopic dermatitis, thus improving patients quality of life. This patient meets the criteria for treatment with Dupixent as she has tried and failed standard topical and systemic treatments for atopic dermatitis, including triamcinolone and tacrolimus ointments. There is evidence of effectiveness to reduce symptoms and markers of inflammation associated with atopic dermatitis in pediatric populations as young as six months. For these reasons, the requested Dupixent syringe injections are 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 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 for Otezla 30 mg tablets, 60 tablets for 30 days.Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. About 20% of patients suffer from severe psoriasis, necessitating systemic drugs such as acitretin, methotrexate, cyclosporin A or the newer biologic agents. Up to 30 percent of psoriatic patients develop psoriatic arthritis, a type of inflammatory arthritis. The long-term use of traditional systemic therapies is frequently unacceptable due to toxicity and limited efficacy. The use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. However, patients treated with anti-TNF drugs may develop adverse events. Otezla is an oral phosphodiesterase-4 (PDE-4) inhibitor that provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Apremilast (brand name Otezla) has been studied in more than 4,000 patients, and the safety profile is consistent across indications. In this case, the patient has chronic plaque psoriasis that requires systemic treatment. The physical limitations and risks associated with injectable biologics support the use of Otezla for treatment of this patient. Accordingly, the requested medication Otezla 30 mg tablets, 60 tablets for 30 days, is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the 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

An enrollee has requested reimbursement for sub-acute detoxification Residential Treatment Center (RTC) services for a period of seven (7) days, and for substance abuse rehabilitation Residential Treatment Center (RTC) services for twenty (20) days.The submitted documentation supports that sub-acute detoxification Residential Treatment Center (RTC) services were medically necessary for an initial period of four (4) days. During the first four (4) days of sub-acute detoxification Residential Treatment Center (RTC) services, the patients vital signs, CIWA scores and reported symptoms reflect that she had mild to moderate symptoms of alcohol withdrawal. Under these circumstances involving managed detoxification and symptoms of withdrawal, sub-acute detoxification Residential Treatment Center (RTC) services provided during the initial period of four (4) days were medically necessary to treat the patients medical condition.The submitted documentation does not support that sub-acute detoxification Residential Treatment Center (RTC) services were medically necessary during the final three (3) of seven (7) days these services were received, or that substance abuse rehabilitation Residential Treatment Center (RTC) services were medically necessary for twenty (20) days. Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient did not meet Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. Accordingly, sub-acute detoxification Residential Treatment Center (RTC) services provided during the final three (3) of seven (7) days these services were received were not medically necessary to treat the patients medical condition, and substance abuse rehabilitation Residential Treatment Center (RTC) services provided for twenty (20) days were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that a portion of the services at issue were 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 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.