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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydrocodone polistirex/chlorpheniramine polistirex extended-release (ER) oral suspension, for a quantity of 690 mL for 30 days. According to the American College of Chest Physicians (CHEST) guideline, the differential diagnosis for cough is extensive and may include intrinsic lung disease such as asthma, chronic obstructive pulmonary disease (COPD), pleural irritation, or interstitial lung disease. Recommendations for treatment include use of non-narcotic medications such as dextromethorphan, benzonatate, gabapentin or pregabalin. Non-narcotic formulations are preferable to narcotics due to risk of dependency. Further, long-term use of narcotics may lead to tolerance requiring higher doses of the medication. In this case, the patient has chronic cough associated with gastroesophageal reflux disease (GERD) and low grade Barretts esophagus or possibly anxiety-provoking situations. This disorder can cause symptoms of retrosternal discomfort, esophagitis, and occasionally cough. Most patients respond to treatment with PPIs with conservative therapy including anti-reflux measures. This patient underwent surgical fundoplication. However, the patients records do not document that the patient has exhausted optimal medical therapy, either with the use of another PPI, escalating, or splitting the dose. The use of the narcotic cough medication may relieve some of the symptoms of cough. However, with the use of narcotic medication comes the risk of dependency and tolerance. Moreover, the records suggest that this patient has become tolerant to hydrocodone polistirex/chlorpheniramine polistirex ER oral suspension as she reported persistent symptoms despite escalating her dose from 5 mL twice daily, to 8 mL every six hours, up to 690 mL per month. The most appropriate treatment for this patient is to optimize her GERD therapy with a non-narcotic option to treat her cough. Therefore, the requested hydrocodone polistirex/chlorpheniramine polistirex ER oral suspension, for a quantity of 690 mL for 30 days 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 expertise 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gazyva, cycles 7-12.  Findings:  The physician reviewer found that Stage at presentation and certain biomarkers in CLL affect an individual patients clinical course. Imbruvica is a tyrosine kinase inhibitor with some specificity toward the Bruton tyrosine kinase. The Bruton tyrosine kinase-signaling pathway is important for normal B-cell function and B-cell neoplasms. Thus, Bruton tyrosine kinase inhibition is a reasonable treatment choice for patients with diverse B-cell malignancies. Imbruvica has been tested against CLL in phase Ib-II clinical trials (Byrd, et al). The authors found that Imbruvica induced durable remissions in patients with relapsed and refractory CLL with minimal side effects. Six cycles of Imbruvica in combination with anti-CD20 immunotherapy resulted in increased progression free survival compared to chlorambucil and Gazyva in previously untreated CLL patients (Moreno, et al). The U.S. Food and Drug Administration (FDA) approval of Gazyva does not include a provision for additional cycles in the treatment of CLL. This patient has CLL treated with six cycles of Gazyva. Based on the current medical literature, there is a lack of support for extending therapy beyond six cycles in this clinical setting. Therefore, Gazyva, cycles 7-12 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 certifications in medical oncology and hematology 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 patients parent has requested authorization and coverage for residential treatment center (RTC) services. The progress notes indicate the patient has been treated in an intensive outpatient program/partial hospitalization program (IOP/PHP). At the beginning of this program, he appeared to make some progress in treatment. The patient has shown a regression in his symptoms. He is experiencing passive suicidal ideation and has a history of a recent suicide attempt. He is engaging in substance use numerous times per week as well as other oppositional behaviors. He reports motivation to change his behaviors. However, he has made no significant changes behaviorally. He has continued depression that has affected his treatment. The records demonstrate that he has been unable to stay sober from substances at the current level of care. Applying the American Society of Addiction Medicine (ASAM) criteria for level of placement, this patient meets the threshold for RTC services. Although the patient does not meet all of the dimensional requirements, his presentation merits the increased monitoring and supervision provided at the RTC level of care. The patients records meets the requirements for dimensions 3 through 5. For dimension 3, emotional, behavioral or cognitive conditions, the patient continues to endorse passive suicidal ideation as well as depression. For dimension 4, readiness to change, the patient meets this criterion given his lack of motivation for change. For dimension 5, relapse, continued use, the patient has shown a lack of recognition of relapse triggers and continues to engage in substance use multiple times per week. Overall, the patients presentation meets the criteria for RTC level of care. Therefore, the requested RTC services are medically necessary for treatment of this patients behavioral health issues. 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 with subspecialty 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 patient has requested reimbursement and prospective authorization and coverage for Testopel pellets. The Endocrine Society and American Urological Association (AUA) have published guidelines to direct treatment of hypogonadism. According to the current guidelines, patients with signs and symptoms of testosterone deficiency plus a consistently low serum total testosterone and/or free testosterone, less than 300 ng/dl  for patients under 70 years of age. Documentation of low fasting morning serum testosterone on at least two occasions is required. Treatment for hypogonadism addresses adult patients who are hypogonadal as evidenced by suggestive clinical symptoms such as decreased libido, low bone mineral density, and small testes, as well as low morning serum testosterone levels. The American Urological Association (AUA) guidelines for the treatment of hypogonadism describes the different testosterone preparation including gels, transdermal, intranasal, buccal agents, intramuscular injections and subcutaneous pellets. About 70-80% of patients achieved a total testosterone concentration within the physiological range at steady state with all these agents. Overall, the data suggests equivalence among the different forms of testosterone preparations. In this case, the patient has lab results showing a consistently low morning testosterone below 300 ng/dl. The patient has undergone adequate work-up for primary or secondary hypogonadism with measurements of luteinizing hormone (LH) and follicle stimulating hormone (FSH). The records support a diagnosis of hypogonadism per Endocrine Society and AUA guidelines. The patient had also tried and failed testosterone cypionate intramuscular injections. Testosterone implants have improved the patients testosterone level, energy and libido. For these reasons, the Testopel pellets were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the medication 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:  One reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism 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: The patient has requested Aimovig. Findings: The physician reviewer found that the medical evidence does not support the requested medication is medically necessary. Aimovig is one of three medications in a new class for treatment of migraine headaches, calcitonin gene-related peptide (CGRP) antibodies. Aimovig is considered a novel treatment, and there are no conclusions on the efficacy of this medication relative to other established medications for migraine prophylaxis. Multiple questions remain regarding the long-term efficacy and safety of Aimovig (Silberstein). The American Headache Society (AHS) only recommends CGRP-based medications for patients with episodic migraines and when a patient has had an inadequate response to a six-week trial of at least two therapies. For chronic migraines, the guidelines recommend that in addition to a trial of two oral agents, that a patients headaches should be refractory to Botox. The patient has not been evaluated for other conditions that can aggravate migraines, such as medication overuse headaches. The AHS guidelines also recommend a six-month trial and failure of Botox for migraine prophylaxis. There was no documentation the patient had failed therapy with Botox. The medical evidence does not support the requested medication in this clinical setting. Therefore, Aimovig 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for compound thyroid cream with a combination of T3 and T4. Thyroid hormone therapy as an initial full replacement or as partial replacement with gradual increments in the dose titrated upward using serum thyrotropin is the goal of treatment in patients with hypothyroidism. Providers make dose adjustments when there are large changes in body weight, with aging, and with pregnancy, with thyrotropin assessment four to six weeks after any dosage change. A substantial number of studies on patients with TSH levels between 2.5 and 4.5 have reported beneficial response in atherosclerosis risk factors such as atherogenic lipids, impaired endothelial function, and intima media thickness. Although the treatment of choice remains oral levothyroxine, absorption can be affected by many factors, malabsorption syndromes and medications. Two peer-reviewed articles from researchers found promising results of transdermal delivery of levothyroxine. Considering this patients oral malabsorption due to lye injury of the upper gastrointestinal system and failure of standard therapies, the requested T3/T4 compound is a reasonable thyroid delivery option. Moreover, the patient had documented therapeutic response to the requested compounded preparation. The patients flow sheet of TSH levels demonstrate that over time, she has absorbed the transdermal compound, and not the oral preparations. Therefore, the requested compound thyroid cream with a combination of T3 and T4 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 subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The enrollee has requested authorization and coverage for Xolair injections. A review of the records indicates the enrollee has moderate to severe asthma. His environmental triggers include grass, hay, pollen, dust, cats, smoke, perfumes, feathers and cold and damp weather. He had an elevated immunoglobulin E (IgE) level and was using a Symbicort inhaler daily to treat his asthma condition. He started receiving Xolair injections. He also tried antihistamines and nasal sprays to control his symptoms. His physician indicated he has a history of frequent exacerbations, which require urgent care visits and the use of oral steroids for acute exacerbations.  Notes indicate his symptoms had improved significantly while on Xolair and he was using his Symbicort inhaler only once a day. Emergency room visits had decreased and the patient was maintaining his pulmonary function testing results. Xolair injections were administered on 5/3/19 and 5/16/19. According to the enrollee, he has only been to the emergency department once in the past years since being on Xolair injections, and he does not have to use his inhalers as frequently. His physician has recommended continued treatment of his asthma with Xolair injections, Symbicort, and Singulair. According to the medical literature, Xolair is an anti-IgE antibody indicated for moderate to severe persistent asthma for patients six years of age and older. These patients have a positive skin test or in vitro reactivity to a perennial aeroallergen and have symptoms that are not adequately controlled with inhaled corticosteroids. It is not indicated for patients with other allergic conditions, other forms of urticaria, acute bronchospasms or status asthmaticus.  Ledford and colleagues indicate this medication is also recommended for patients with asthma that have failed other first line therapies.  In a randomized controlled study, long-term use of this medication in established patients has provided positive outcomes in symptom management. The records indicate the enrollee has been utilizing the requested Xolair injections for many years and have dramatically decreased his symptoms to where he does not utilize other medications, such as inhalers often.  He has remained stable with the addition of Xolair injections.  The enrollee also had a pulmonary function test which showed significant bronchodilator response. It would not be medically prudent to discontinue Xolair injections at this time because the enrollee has been utilizing the requested medication for an extended time and has benefitted from this treatment.Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician reviewer is board certified in Pulmonary 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested coverage for psychotherapy two to three times per month with a therapist that specializes in treating children with chronic illness and pain. A review of the pediatricians records indicates enrollee complaints of abdominal pain and vomiting, which he has had intermittently over the past year. His mother reports daily emesis with these episodes. He was diagnosed with eosinophilic esophagitis (EoE) that was initially treated with viscous budesonide, was doing well but he started having abdominal pain again. In an assessment note, the pediatric gastroenterologist indicates the vomiting may have a volitional/psych component. Recommendations on this date included anxiety evaluation and management. History notes seven weeks of daily vomiting, with emesis to 20+ times a day. Pain is several times a day and at bedtime. Enrollee is missing school.  Many stressors are noted, some fear of dying with family losses and generalized anxiety. Enrollee is hungry, eats, but vomits and is losing weight. Social history indicates anxiety, deaths in family and fear of dying. Etiology unclear; consider anxiety disorder; appears to have a volitional component. Another note indicates possibility ongoing vomiting is psychosomatic especially since biopsies are essentially normal. Parents report enrollee was depressed and in pain even though vomiting started to subside. Recommendations from the enrollees providers for treatment include anxiety evaluation and management.  There is sufficient documentation in the record of functional impairment and distress related to the enrollees severe medical illness, which impacts his life significantly on a daily basis. The medical literature indicates the treatment of anxiety disorders in children and adolescents usually involves a multimodal approach. Comprehensive treatment includes consideration of education of the parents and the child about the specific anxiety disorder, consultation with school personnel and primary care physicians, behavioral interventions, psychodynamic psychotherapy, family therapy, and pharmacotherapy.  Children with anxiety disorders manifest a spectrum of symptomatology ranging from mild worry and distress to overwhelming, incapacitating anxiety that greatly interferes with functioning. In practice, child and adolescent psychiatrists usually use a combination or integration of several approaches in treating a child or adolescent with an anxiety disorder.Final Result: The reviewer determined that the requested service is medically necessary for thetreatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Psychiatry and 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 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 Serostim. Findings:  The physician reviewer found that wasting, or cachexia, is a debilitating complication of human immunodeficiency virus (HIV). Cachexia is associated with reduced strength and functional ability, as well as a decreased ability to withstand opportunistic infections. The U.S. Food and Drug Administration (FDA) has approved Serostim, a recombinant human growth hormone for treatment of HIV-related cachexia. In addition, clinical studies support a role for Serostim in this clinical setting. The provider in this case noted that an alternative form of hormonal replacement with testosterone is not optimal for this patient, whose testosterone level is currently therapeutic. Therefore, the use of Serostim for the treatment of HIV-related cachexia 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 allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.