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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for autonomic testing for evaluation of her autonomic impairment. Findings:  Two physician reviewers found that in this case, the patient had a non-specific collection of symptoms that were potentially suggestive of an autonomic disorder (dizziness and nocturnal hypotension and constant sensation of being cold).  These symptoms raised suspicion for the possibility of an autonomic disorder. As noted by researchers, the goals of autonomic testing is to help the clinician diagnose the presence of dysautonomia, its distribution and severity, and since they are quantitative, whether it is getting better or worse. Goal number one is to evaluate the severity and distribution of sudomotor, cardiovagal, and adrenergic function using non-invasive quantitative tests. The techniques used in this patients case (tilt-table testing, heart rate variability and Valsalva maneuver evolution), are noted by researchers, to confirm that a specific autonomic function is affected and when other systems are intact. In this patients case, the performance of such testing provided the clinician an evaluation and autonomic etiology for the patients symptoms. Moreover, the testing modalities used in this patients case have also been validated within technology reviews performed by the American Academy of Neurology and are otherwise supported for use within general clinical practice. Final Result: The reviewers determined that the requested services are 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: Reviewers 1, 2, and 3 are board certified in radiation oncology and is 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 for residential treatment at Hoag Memorial Hospital from the date of service in question, forward. Findings:  The physician reviewer found that the request for residential treatment center services provided from the date of service in question, forward were and are medically necessary for treatment of the patients medical condition. In general, the American Psychiatric Association provides the following guidance regarding the level of care decision process Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case, the patients alcoholism was central to his daily routine and contributed to his significant impairment across multiple domains of functionality. The patient has demonstrated minimal motivation for recovery. The patient was struggling with the concept of committing to long-term recovery, and the day before he was noted to be depressed and minimally social with a flat affect. As such, the patient has not yet consolidated the treatment gains necessary to succeed in an outpatient based treatment program. The services and setting were and are safe, appropriate and consistent with good practice, while the proposed duration of treatment aligns with community standards. Additionally, the services provided were and are reasonably expected to improve his condition and prevent a more serious episode of illness. In sum, considering the clinical presentation and peer-reviewed literature, the services at issue were and are medically necessary for treatment of the patients behavioral health condition. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fentanyl patch Td72 (12 mcg/hour). Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this patients case.  The records document metastatic breast cancer.  This patient has tried and failed hydrocodone/acetaminophen.  She also reported that she has taken morphine.  She reports continued pain with activities of daily living.  The medical evidence supports the requested medication in this clinical setting.  There is evidence suggesting the superiority of fentanyl over oral agents due to less constipation.  Therefore, the requested fentanyl patch Td12 (12 mcg/hour) is medically indicated 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic or laparoscopic assisted hysterectomy. Findings:  The physician reviewer found that, although hysterectomy may be the ultimate management, there is increased morbidity associated with this procedure and it is not a default or first-line management for patients frustrated with irregular menses. Hysterectomy is reserved for patients who have undergone an appropriate work-up and have an indication for the procedure. As noted by the American College of Obstetricians and Gynecologists (ACOG), the work-up for this patient would typically include pelvic exam, current Pap smear, evaluation of the uterus-cavity either by pelvic ultrasound, hysteroscopy or sonohysterogram, and evaluation of the endometrial lining either by endometrial biopsy or dilation and curettage. Overall, there is a lack of documentation of this patients work-up to support an indication for hysterectomy. There is no current Pap smear noted or record of the evaluation of the uterus and endometrium available. The patients pelvic exam describes an abnormal bimanual exam, suggesting a bulky non-specifically enlarged uterus. There is discussion of an endometrial biopsy in the past, but no documentation is provided for review. Further, the records do not indicate whether endometrial ablative procedures have been considered, or that the patient is a poor candidate or has other contraindications to the procedure. The notes indicate that the patient in the past had been treated with over the counter pills and progesterone to control cycles, which are no longer effective. However, two other options within the hormonal management realm include longer term progestins such as Depo-Provera or a progestin containing intrauterine device (IUD). All told, this patients records do not support the medical necessity of the requested laparoscopic or laparoscopic assisted hysterectomy. Final Result: The reviewer determined that the requested surgery 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 obstetrics and gynecology 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 continued Klonopin (clonazepam) and eye movement desensitization and reprocessing (EMDR). Findings:  The physician reviewer found that, according to the patients CURES report, she is being prescribed Klonopin in a limited manner and appears to be using the medication in an appropriate manner. Klonopin should not be abruptly discontinued due to risk of seizures. In this clinical setting, Klonopin is medically necessary to prevent seizures. However, the request for EMDR is not clinically indicated for this patient. EMDR is a treatment modality used for individuals with post traumatic stress disorder (PTSD). In this case, the documentation submitted for review does not support a diagnosis of PTSD or the nature of traumatic events. The records also do not describe any precipitating event or subjective symptomatology. Thus, a portion of the requested services are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center level of care provided from the date of service in question, forward. Findings:  The physician reviewer found that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Outpatient treatment and least restrictive options are considered first lines of care. Studies have shown that treatment outside of a residential setting are effective and appropriate and are as beneficial as residential programs. In this case, the patient presented to residential treatment with a history of aggression. At the beginning of the patients residential stay he was struggling with noncompliance behavior with staff and peers. Over the course of several weeks the patient had a dramatic change in his behavior. He became more polite and cooperative with treatment staff and his peer relationships improved. Although the patient requires continued treatment to further improve his social functioning and impulsive behaviors, he no longer needs the restrictiveness of a residential treatment facility as he has stabilized enough to transition to a less restrictive setting. In sum, the services at issue were not and are not medically necessary, and the patient could have been treated in a less restrictive setting safely and effectively as of the date of service in question. 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 sub-specialty certification in child and adolescent 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for tobramycin. Findings:  The physician reviewer found that the patient had a positive sputum culture for Pseudomonas stutzeri, but the bronchoalveolar lavage results were not positive for this organism. The notes by the pulmonologist comment on the appearance of bronchiectasis on computed tomography, but the official radiology reports spanning a five month period did not state there was the presence of bronchiectasis.  The information provided documents only a single sputum Pseudomonas isolate (not found on bronchoalveolar lavage), and the patient does not have a documented history of recurrent infections to warrant treatment with inhaled tobramycin. 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 pulmonary disease 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 intraoperative radiation therapy for treatment of her breast cancer. Findings:  Two physician reviewer found that there are many ways to deliver partial breast radiation, either as a sole modality or as a boost.  These radiation approaches of partial breast radiation include linear accelerator (LINAC) based, interstitial brachytherapy catheters, MammoSite balloon, intraoperative radiation therapy with a portable LINAC, and electronic brachytherapy.  Intraoperative radiotherapy with electron therapy was investigated in a study.  A total of 1,305 women were randomized to receive a single intraoperative radiotherapy fraction versus conventional whole breast radiation of 50 Gy in 25 fractions followed by a boost of 2 Gy in five fractions.  Intraoperative radiation therapy was associated with a nine-fold increase in ipsilateral breast recurrence, although five-year overall survival was similar.  A recent systematic review of intraoperative radiation therapy versus whole breast radiation also demonstrated a higher risk of ipsilateral breast tumor recurrence with intraoperative radiation therapy. The authors emphasized the need for prudent patient selection.  The medical evidence has not demonstrated that intraoperative radiation therapy is superior to standard approaches of delivering breast radiotherapy. 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: Reviewers 1, 2, and 3 are board certified in radiation oncology and is 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 Actiq, fentanyl citrate 1600 mcg.Findings:  The physician reviewer found that the medical records have shown the patient to have chronic non-malignant pain. There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic pain. The current standard of care for chronic pain is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. Based on a study, there are Well-established guidelines, for routine back pain, stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy There are a variety of anti-convulsants and anti-depressants considered adjunctive to pain management therapy. If there is poor response to conservative therapy, then surgery should be considered. High dose opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. The studies have shown that short-acting opiates are more   likely to cause adverse outcomes. In this patients case, he has been on Actiq: fentanyl citrate 1600 mcg for over seven years. The requested medication is excessive in light of the patients medical condition and in addition to his medication regimen. Final Result: The reviewer determined that 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Benicar for treatment of his hypertension. Findings:  The physician reviewer found that the American Heart Association, American College of Cardiology, and American Society of Hypertension 2015 scientific statement for the treatment of hypertension in patients with coronary artery disease recommends the use of an angiotensin II receptor blocker or angiotensin converting enzyme inhibitor as part of a regimen in patients with hypertension and chronic stable angina if there is prior myocardial infarction, left ventricular systolic dysfunction, diabetes mellitus, or chronic kidney disease.  In this case, the documentation suggests that the patient has had a distant myocardial infarction and current hypertension.  Recently, a cardiac stress echocardiogram was normal.  The patients blood pressure is well-controlled.  The documentation submitted for review does not support that the patient has tried and failed treatment with one of the Health Plans formulary drugs.  According to the documentation, the patient has not had adverse drug reaction to other antihypertensive medications tried or suggested by the Health Plan. 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: An enrollee has requested authorization and coverage for Soma. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  In the documentation available for review, not all other muscle relaxants have been noted as tried and failed. There is also insufficient data to recommend the use of Soma over other muscle relaxants. Moreover, Soma is a controlled substance and the guidelines recommend use of this medication only for a short time. However, this patient has used this medication for over three years. Finally, multiple minimal requirements for controlled substance prescribing have not been performed in this patients case. As such, the use of Soma as the primary medication treatment strategy for pain has not been established. For all these reasons, Soma 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xolair 150 mg tablets for treatment of her allergic bronchopulmonary aspergillosis. Findings:  The physician reviewer found that there are two main indications for Xolair, severe allergic asthma and urticaria.  There are a few literature reports regarding the use of Xolair for allergic bronchopulmonary aspergillosis, but this is off-label. This patient has a diagnosis of allergic bronchopulmonary aspergillosis, and there is a lack of support for the requested medication in this case.  In this clinical setting, steroids are the primary treatment.  The records indicate that the patient was on a low dose of prednisone, although the records also described a steroid burst.  However, the standard treatment for allergic bronchopulmonary aspergillosis is high-dose prednisone.  More studies are needed to clarify the role of Xolair for the patients 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 pulmonary disease 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.