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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation services. Findings:  Three physician reviewers found the American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder. However, the recommendation does not yet extend to bipolar disorder or personality disorder. At the time of the disputed service, the patient had not exhausted standard available therapies, such as mood stabilizing medicines that work well for bipolar depression, like lithium, quetiapine and olanzapine-fluoxetine combination, or electroconvulsive therapy, which remains the most reliable, expeditious and efficacious neuromodulating intervention available today. The safety and appropriateness of transcranial magnetic stimulation in this setting remains unclear. All told, the superior efficacy of transcranial magnetic stimulation services has not been established.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 psychiatry 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 reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) level of care services. The records provided for review do not support the IOP level of care services provided. The documentation reported that the patient was progressing with controlling her symptoms. The patients mood was euthymic and she was interactive with others. The patient was able to stop a binge eating episode. The patient was compliant with her Lamictal and Wellbutrin. The records indicate the patient has been able to function and attend to her activities of daily living. The patient was engaged in treatment and motivated for recovery. Therefore, the patient was a candidate for treatment in a less restrictive environment in a routine outpatient setting. Accordingly, the IOP services provided were not and are not medically necessary. 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 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 a patient has requested authorization and coverage for methylphenidate (5 mg/5 mL, which equals 20 mg, four times daily). The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients attention-deficit/hyperactivity disorder (ADHD). The submitted documentation does not support the medical necessity of the requested medication regimen. The medication dosage requested exceeds the U.S. Food and Drug Administration maximum allowed for adolescents. The progress notes indicated that the patient has tried and failed several medications with some resulting in side effects. There are multiple treatment options available for adolescents with attention-deficit/hyperactivity disorder. The records do not indicate whether the patient has been adherent to past medication regimens. It is not clear whether the patient has undergone psychotherapy to help decrease some of the patients symptoms or help with organizational skills. The exact length of previous medication trials was not indicated in the records. There is a lack of support for the requested medication regimen in this clinical setting. In summary, methylphenidate (5 mg/5 mL, which equals 20 mg, 4 times daily) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for allergy testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of food allergies.Findings:  There is support for the services at issue in this clinical setting. The use of food specific IgG is utilized in the setting of oral immunotherapy (OIT) administration to monitor tolerance. According to current management guidelines for chronic urticaria, chronic autoimmune urticaria can be differentiated from idiopathic urticaria by the presence of auto-antibodies to IgE receptors. Patients with a chronic urticaria and who have a positive functional test result for autoantibody to the immunoglobulin E (IgE) receptor, will likely have an autoimmune basis for the diagnosis. The records indicate that this patient has a history of chronic urticaria despite treatment with antihistamines and allergy evaluation for food and environmental triggers. As such, the evaluation, for an autoimmune process, was necessary to identify non-allergic triggers for the patient's symptoms. The implication of such distinction has a direct effect on the choices of treatment, as to include OIT or suppressor agents in addition to the conventional antihistamines for the treatment of chronic urticaria.  In addition, the portion of the testing which correlates to IgG subclasses, this test was utilized to determine the presence of immunodeficiency. This particular test is considered standard of care for the evaluation of this patient. In sum, the allergy testing was likely to have been of greater benefit than the available standard therapies for the evaluation of this patients medical condition. Final Result: Two of the three reviewers have determined 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:  One reviewer is board certified in allergy and immunology with expertise in pediatrics and is actively practicing. One reviewer is board certified in allergy and immunology and pediatrics and is actively practicing. One reviewer is board certified in pediatrics and is actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transportation services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. Air ambulance is considered medically necessary under certain circumstances. The patients condition must be such that any other form of transportation would be medically contraindicated and the patients condition is such that transportation by land poses a threat to survival. The use of air ambulance to transport a patient from one hospital to another is medically necessary if certain criteria are met, and the sending institution does not have the required services to treat the patient. The transport usually involves the sending hospital and the closest facility capable of treating the patient. The records indicate at the time of the transport, the patient was medically stable. The records did not show that this patient required acute medical intervention during transport. She was not transported emergently. The patients vital signs remained stable. The submitted records did not indicate the patient received any other medications or interventions while en route. For these reasons, the medical necessity for the transportation services was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 emergency 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: A patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines issued by two associations, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Mavyret for eight weeks. These guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret for eight weeks is medically necessary for this patient.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has a history of persistent asthma.Findings:  The medical evidence supports that this patient may benefit with bronchial thermoplasty. The U.S. Food and Drug Administration (FDA) has approved bronchial thermoplasty for patients with refractory asthma. Multiple studies have indicated that bronchial thermoplasty can decrease symptoms and the use of medications for asthma, decreases the number of exacerbations, and improve quality of life. It is also safe and effective when compared to monoclonal antibody therapy. This patient with refractory severe persistent bronchial asthma is still symptomatic despite maximal medical therapy. Given the medical records, this patient meets the criteria for bronchial thermoplasty. As such, bronchial thermoplasty is likely to be superior over the other standard treatment options available for treating this patients medical condition. Final Result: All three reviewers have determined 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the wearable cardioverter defibrillator. Findings:  Two of the three physician reviewers found the use of wearable cardioverter defibrillators is reasonable when there is a clear indication for an implanted/permanent device accompanied by a transient contraindication to implantable cardioverter defibrillator (ICD), as in this patients case. This patient with recurrent syncope and easily inducible ventricular tachycardia/ventricular fibrillation meets criteria for an ICD. A definitive diagnosis of possible structural heart disease required an MRI, for which the presence of an implanted ICD would have been suboptimal. There is sufficient support for the device at issue in this clinical setting. Thus, wearable cardioverter defibrillator provided was and is likely to be more efficacious than other treatment options. Final Result: The reviewers determined that the device at issue was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Solesta directed submucosal injection with anoscopy. Solesta is a U.S. Food and Drug Administration (FDA) approved treatment for fecal incontinence. In the peer-reviewed medical literature, study found that one large controlled trial demonstrated that this form of treatment using dextranomer in stabilised hyaluronic acid (NASHA Dx) improves continence for a little over half of patients in the short term. Study noted that the development of sacral nerve stimulation and other forms of neuromodulation and the injection of biologically compatible substances into the anal sphincter complex have brought renewed enthusiasm for using these novel treatments in this underserved population. This patient historically has benefited from Solesta and likely will again experience a positive outcome with future Solesta applications. Accordingly, the requested Solesta directed submucosal injection with anoscopy are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested Solesta directed submucosal injection with anoscopy are 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 Solesta directed submucosal injection with anoscopy are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 17-year-old male enrollee has requested authorization and coverage for non-surgical scoliosis services activities of daily living (activities of daily living (ADL), posture, gait, and neuromuscular retraining - 97110, 97112, 97530, 97116; administration and prescribed home use of custom mechanical traction equipment - 97012, E1399; custom scoliosis brace - L1300, L1210, L1220, L1240, L1250, L1260, L1270, L1290, L0999). The use of non-surgical scoliosis services including ADL, posture, gait, and neuromuscular retraining, administration and prescribed home use of custom mechanical traction equipment is not supported as medically necessary for this patient with idiopathic scoliosis. There is currently a lack of peer-reviewed medical literature supporting the use of these items in this patient population. Moreover, these services are not supported by the Scoliosis Research Society. All told, the requested non-surgical scoliosis services (ADL, posture, gait, and neuromuscular retraining - 97110, 97112, 97530, 97116; administration and prescribed home use of custom mechanical traction equipment - 97012, E1399; custom scoliosis brace - L1300, L1210, L1220, L1240, L1250, L1260, L1270, L1290, L0999) are not medically necessary for treatment of this patients medical condition. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing. Findings:  Three physician reviewers found in this patients case, the records document melanoma which was known to be at high risk for recurrence based on the pathology. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical trial. Despite the patient having high-risk results, treatment and surveillance recommendations were not likely to have been altered from those dictated by the pathology. Therefore, DecisionDx-Melanoma testing was not likely to have been of greater benefit than other methods of evaluating this patient. 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 sub-specialty certification in medical oncology 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 Otezla for treatment of the enrollees psoriatic arthritis.  Findings:  The physician reviewer found that Otezla is an orally administered phosphodiesterase-4 inhibitor available for the treatment of PsA but it is not currently known to be disease modifying at this time. As such, it is not a preferred agent for the treatment of PsA.  Additionally, the American College of Rheumatology does not have recommendations for the treatment of PsA.  Moreover, anti-tumor necrosis factor (TNF) agents have been proven to be effective for PsA, prevent progression of disease, and are thus the preferred agent for PsA. The current literature supports the use of conventional and anti-TNF agents over the use of targeted synthetic biologics such as Otezla for the treatment of PsA. In the medical literature, Haber and colleagues stated that, apremilast should be reserved for patients unable to take disease-modifying antirheumatic drugs. The records fail to demonstrate failure of FDA approved contraindication to bDMARDs. In this case, the patient has a history of PsA, palpitations and hypertension. The most recent evaluation fails to demonstrate active PsA or active psoriasis. While the patient reported muscle pain and bilateral lower extremity edema, there is no active synovitis on examination in either the large or small joints. She does have increased liver function testing, but the chronicity is unknown and it is unclear if the etiology has been further evaluated. The patient is noted to have a history of hypertension and palpitations but the submitted records fail to demonstrate a history of coronary artery disease, heart failure or arrhythmia. Hypertension and palpitations are not a contraindication to TNFi use. Moreover, the patient has no personal history of malignancy and the records provided do not establish that she is at an increased risk for malignancy. The current international guidelines recommend their use prior to Otezla due to their safety, efficacy and disease modifying affects. As such, the request for Otezla has not been demonstrated as medically necessary for treatment of this patients PsA. 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 rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through