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

The parent of an enrollee has requested reimbursement for Xifaxan 200 mg tablet, three (3) times a day (42 tablets for a 14-day supply). Small intestinal bacterial overgrowth (SIBO) is a recognized cause of gastrointestinal distress and is also thought to be one of the contributing factors to irritable bowel syndrome (IBS). Although SIBO is typically treated with antibiotics, there are not any antibiotics which are specifically approved for this indication by the U.S. Food and Drug Administration (FDA). Xifaxan (rifaximin), which has been FDA approved for treatment of IBS-D, is one of the antibiotics which has been found to be most effective in treatment of SIBO in adults. The low-FODMAP diet is another treatment for SIBO which is often recommended but which also does not have double-blind randomized controlled trial evidence to support its use. In this case, given the absence of safer alternatives and of other medications with stronger evidence of efficacy, Xifaxan (rifaximin) was the most appropriate treatment for the patients small intestinal bacterial overgrowth (SIBO). Therefore, the medication Xifaxan 200 mg tablet, three (3) times a day (42 tablets for a 14-day supply), was medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the medication at issue was medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics, with subspecialty certification in pediatric 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

The patient has requested authorization and coverage for Vascepa one gram (120 capsules for 30-day supply). The U.S. Food and Drug Administration (FDA) noted that Vascepa (icosapent ethyl) was approved as an adjunctive (secondary) therapy to reduce the risk of cardiovascular events among adults with elevated triglyceride levels (a type of fat in the blood) of 150 milligrams per deciliter or higher. Patients must also have either established cardiovascular disease or diabetes and two or more additional risk factors for cardiovascular disease. In this case, the patient has established severe coronary artery disease and multiple high-risk conditions, including diabetes, hypertension, and hyperlipidemia. Laboratory results showed that the patients triglyceride levels are not well controlled, despite the improved control of his diabetes and hemoglobin A1c levels by lifestyle and medications. The medical evidence supports the requested medication in this clinical setting. Therefore, Vascepa one gram (120 capsules for 30-day supply) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco. The Centers for Disease Control and Prevention (CDC) guidelines state that, clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The Federation of State Medical Boards guidelines report that, continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. The records provided for review document that this patient sustained a non-displaced left tibial fracture. The provider advised that the patient does not need to be evaluated for acute or subacute pain. The provider also reported that the patient is not a good candidate for opioid therapy since the benefits of treatment do not outweigh the potential risks. The records reviewed do not include a current Controlled Substance Utilization Review and Evaluation and System (CURES) report demonstrating continued compliance with her opioid regimen. The CDC guidelines recommend providers to discontinue opioid therapy in patients where the risks outweigh the benefits. Accordingly, the requested Norco 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 subspecialty certification in pain management 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 patient has requested authorization and coverage for Ajovy. According to the American Headache Society (AHS), four injectable preventive therapies are available for the treatment of chronic migraine including Botox and three monoclonal antibody targeting calcitonin gene-related peptide (CGRP) or the CGRP receptor. Ajovy is a monoclonal antibody that targets CGRP that is U.S. Food and Drug Administration (FDA) approved for episodic and chronic migraine. The lack of need for slow dose escalation, the rapid onset of therapeutic benefits, and the favorable tolerability profiles are advantages that injectable therapies have in common. CGRP monoclonal antibodies are biologic agents that have demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3, randomized, placebo-controlled trials. Robbins and colleagues found that more patients reported constipation with Emgality than Ajovy. In this case, the patient has a history of chronic migraines that did not respond to multiple oral preventative medications. She meets the AHS criteria for continuation of CGRP monoclonal antibody therapy. The use of Ajovy has been effective in decreasing the frequency and severity of the patients migraines for the past 15 months. Given this support, the requested Ajovy is 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 neurology 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 reimbursement for occipital nerve block injections and prospective authorization and coverage for occipital nerve block injections every three months. According to the International Headache Society (AHS) classification, occipital neuralgia is defined as paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distribution(s) of the greater, lesser and/or third occipital nerves. An observation report found that the use of greater occipital nerve blocks markedly decreased migraine attack frequency, severity and duration, and analgesics use compared with baseline symptoms in patients with chronic refractory migraines. The authors reported that the results suggest that greater occipital nerve blocks resulted in reduction in pain severity and frequency, and use of analgesics for up to three months after the third injection. In this case, the patients symptoms and physical examination findings are consistent with occipital neuralgia. Treatment with occipital nerve blocks have helped in decreasing the frequency of the patients migraine headaches. All told, the occipital nerve block injections provided, and occipital nerve block injections administered every three months, were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the occipital nerve block injections provided, and occipital nerve block injections administered every three months, were and 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 services at issue were and are 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 neurology 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 patient has requested authorization and coverage for eight hours of neuropsychological testing. Formal neuropsychological testing entails the use of assessments with normative values that can account for gender and a wide range of ages and educational backgrounds, and can distinguish between the causes of cognitive impairment. Neuropsychological testing can last up to several hours, oftentimes divided across multiple visits. By determining the etiology of a patients cognitive problems, this testing can help guide treatment as well as medical management. If her cognitive complaints are due to depression or anxiety, medication changes can alleviate these symptoms. However, if her symptoms are due to chronic drug exposure and learning disabilities, her provider may avoid medication changes. In this limited clinical instance, complete neuropsychological testing is indicated to help determine the patients diagnosis and appropriate medical management. All told, the requested eight hours of neuropsychological testing is medically necessary for this patient. 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 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

The patient has requested authorization and coverage for Spinraza. Spinraza is a U.S. Food and Drug Administration (FDA) approved medication for the treatment of SMA, which is an autosomal recessive neuromuscular disorder characterized by degeneration of spinal motor neurons and poses significant adverse outcome in affected population. Survival motor neuron 1 (SMN1) and protein encoded by SMN1 is critical for survival and functioning of motor neurons. An almost identical gene SMN2 produces a truncated protein (SMN2). The number of copies of SMN2 genes determines the severity of disease, with a greater number of copies associated with less severe disease. Spinraza was demonstrated to be safe and effective in the treatment of patients with SMA in a sham controlled phase 3 clinical study. The authors reported that the study was stopped early based on significantly favorable results in interim analysis and all the patients were transitioned to receive Spinraza in an ongoing open-label, phase 3 study. Given this support, the requested Spinraza is 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 neurology 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

The patients parent has requested authorization and coverage for additional 28 hours/week of direct applied behavioral analysis services (for a total of 40 hours/week) for school holiday. This patients records support a diagnosis of autism and an indication for ABA services. However, the current authorization request includes 11 goals and low levels of problem behavior. Based on so few goals, minimal challenging behaviors, and the provider requesting 12 hours per week, the additional hours are not necessary for the patient to make appropriate progress. Additionally, the requested hours during holidays and when school is out of session appears to be out of convenience for the patient. The records do not document specific rationale to support the requested additional hours of ABA services in this clinical setting. All told, the additional 28 hours/week of direct applied behavioral analysis services (for a total of 40 hours/week) for school holiday are 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 a licensed B.C.B.A, board certified in psychology, 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 Lunesta (eszopiclone) 2 mg. Chronic insomnia can be a symptom of an underlying problem such as poor sleep behavior, mood disorder, or obstructive sleep apnea. The first-line of treatment for patients with chronic insomnia is cognitive behavioral therapy and brief behavioral therapy conducted by a sleep specialist. In addition, the patient should undergo a comprehensive clinical evaluation to evaluate and treat other underlying problems. The records reviewed do not include evidence that the patient has undergone an appropriate evaluation by a sleep specialist to support treatment with Lunesta. In patients over age 65, Lunesta can be associated with increased fall risk, sleep walking, and exacerbation of sleep apnea. All told, the requested Lunesta 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 with subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with dyslipidemia, coronary artery disease, cardiomyopathy, and paroxysmal atrial fibrillation. Laboratory results revealed a cholesterol level of 225 mg/dL, a low-density lipoprotein (LDL) level of 122 mg/dL, and a high-density lipoprotein (HDL) level of 87 md/dL.  The provider noted the patient previously had tried atorvastatin and ezetimibe, which were both not tolerated due to muscle aches and cramping. A cardiac catheterization report revealed an ejection fraction of 30 to 35%, severe coronary disease of the left anterior descending artery and moderate disease of the ostial left main coronary artery. A stent was placed. The patient denied angina, dyspnea, syncope, and edema. The patient has requested authorization and coverage for a Repatha Sureclick 140 mg/ml pen injector. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether a Repatha Sureclick 140 mg/ml pen injector is medically necessary for the treatment of the patients medical condition. Grundy and colleagues reported, At a median follow-up of 2.2 years, evolocumab significantly reduced composite atherosclerotic cardiovascular disease (ASCVD) without neurocognitive side effects. In this case, the patient has established coronary artery disease and ischemic cardiomyopathy. The patient is status post left anterior descending coronary artery stenting. He has tried and failed statin therapy in the past with atorvastatin and ezetimibe, both of which were not tolerated due to joint and muscle aches. The patients LDL level in December 2019 was 122 mg/dL. The medical evidence supports the requested medication in this clinical setting. Therefore, a Repatha Sureclick 140 mg/ml pen injector is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Nuedexta capsules (dextromethorphan HBr-quinidine sulfate 20-10 mg). The patient has been diagnosed with pseudobulbar affect (PBA). Researchers reported that PBA is characterized by uncontrolled crying or laughing which may be disproportionate or inappropriate to the social context. There is a disparity between the patients emotional expression and his or her emotional experience. The authors also reported, that the goal of treatment of PBA is to diminish the severity and frequency of episodes. The targets of treatment are primarily norepinephrine, serotonin, or glutamate, using tricyclic antidepressants (TCAs), selective serotonin reductase inhibitors (SSRIs), and, most recently, the cough suppressant dextromethorphan. Medical literature states that dextromethorphan/quinidine is indicated for the treatment of PBA and has shown efficacy in patients with underlying ALS and MS. There is insufficient evidence for the use of Nuedexta in the treatment of PBA associated with TBI. In this case, the patient has been diagnosed with PBA secondary to TBI. The record does not clearly document the patient has had benefit with Nuedexta. The medical evidence does not support the requested medication in this clinical setting. Therefore, Nuedexta capsules (dextromethorphan HBr-quinidine sulfate 20-10 mg) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology 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

The patient has requested authorization and coverage for revision of previous bariatric surgery (gastric bypass) excluding lap band. Researchers reported the evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. The authors also reported that purse-string transoral outlet reduction (TORe) to treat weight regain after RYGB is technically feasible and safe. Additionally, it is associated with improvement in weight and comorbidity profiles up to 12-months post-procedure. In this case, the patient has experienced weight regain after a RYGB procedure with co-morbidities including type 2 diabetes mellitus, hyperlipidemia, and gastroesophageal reflux disease. The provider also noted an upper gastrointestinal imaging revealed that the patients stoma was greater than two centimeters, indicating dilation. The medical evidence supports the requested service in this clinical setting. Therefore, revision of previous bariatric surgery (gastric bypass) excluding lap band is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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.