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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for nerve stimulation services for treatment of the enrollees urinary frequency and urgency.  Findings:  Three physician reviewers found that this patient is quite symptomatic with urgency and frequency. She failed multimodal therapy. Percutaneous tibial nerve stimulation is considered to be an appropriate salvage therapy for patients with intractable lower urinary tract symptoms according to the current guidelines. The duration of the treatment and the frequency is not established. It is generally agreed upon that the patient should at least have six treatments to decide whether this is effective form of treatment. Final Result: two of three reviewers determined that the services at issue were 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 urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: 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 inflammatory polyarthropathy. Findings:  The physician reviewer found that per the peer-reviewed evidence based medical guidelines, Otezla is indicated for the treatment of psoriatic arthritis or plaque psoriasis. In the records provided for review, there is no documentation of objective findings that this patient has either of these diagnoses. Currently, there is a lack of scientific data supporting a clinical role for Otezla in patients with inflammatory polyarthropathy. On the basis of this lack of documentation and peer-reviewed evidenced based guidelines, the requested Otezla is not medically necessary for treatment of this patients medical 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 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 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: A 56-year-old female enrollee has requested authorization and coverage for occipital nerve block injection for treatment of the enrollees chronic intractable migraine without aura.  Findings:  The physician reviewer found that the records do not indicate the presence of occipital neuralgia as documented by physical examination findings. Occipital nerve blocks are not supported for the treatment of migraine or other type headaches. Dilli and colleagues noted that greater occipital nerve blocks do not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. Thus, the requested occipital nerve block injection is not likely to be superior over other treatment options. Final Result: Two of three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: An enrollee has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1b patients should be treated with regimens including Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The records do not show post-acute withdrawal symptoms. The patient was not a danger to self or others and she showed no self-harming urges or behaviors.  There were no emotional, behavioral, or cognitive issues at play to warrant further residential care. Her activities for daily living were intact.  She was not manic and had no hallucinations or delusions in any modality.  Her medical condition was stable and did not require residential level of care for management. The records did not show that significant medication changes were made to her regimen. She was psychiatrically stable. She had not been placed on any psychotropic medications. She was medication compliant.  The patient was aware of triggers and able to identify coping mechanisms and utilize skills to improve impulse control, which provided her a better chance of lowering her risk of relapse.  She lived with her mother.  She had improved and no longer required the structure of the residential setting.  She received a Vivitrol injection, which she could have received as an outpatient. She could have been stepped down to an ambulatory level of care such as intensive outpatient services. For the reasons stated above, the residential treatment center services were not medically necessary for 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 psychiatry with sub-specialty certification in addiction 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test for evaluation of the enrollees invasive ductal carcinoma.  Findings:  Two physician reviewers found that Tamoxifen has to be metabolized to endoxifen, an active compound in the body. This process involves cytochrome P-450 CYP2D6 enzyme. In patients with a genetic variant that causes poor function of CYP2D6, there is concern that the patient will not receive the full benefit of the tamoxifen. There have been several attempts to evaluate this possible relationship between enzymatic activity and the effectiveness of tamoxifen. A e study of 500 women treated with adjuvant tamoxifen, and concluded that CYP2D6 assay was unlikely to be useful in clinical practice. A study reviewed six studies of this relationship and concluded that there was no clinically important association between CYP2D6 genotype and breast cancer survival in tamoxifen treated patients. One physician reviewer found that [atients with hormone receptor positive breast cancer usually receive some pharmacologic therapy to inhibit the estrogen induced growth of the cancer. Tamoxifen is the preferred agent in premenopausal patients whereas aromatase inhibitors are preferred in postmenopausal patients. This patients provider states that genotyping CYPD26 was indicated to determine tamoxifen efficacy and risk of relapse. There is some data in support of CYP2D6 testing in this clinical setting. Thus, based on the current medical literature, CYP2D6 genotyping is supported especially in premenopausal patients. Final Result: Two of three physician reviewers determined that the testing at issue was 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: All three physician reviewers 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision Dx Melanoma testing for evaluation of the enrollees melanoma. Findings:  The 3 physician reviewers found that the patient underwent Decision Dx Melanoma testing to assess the metastatic risk of his melanoma of 1.0 mm Breslow depth on the chest. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the Decision Dx Melanoma assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered the standard of care in the treatment of the patients melanoma. Thus its usage is not expected to impact the treatment or outcome of the patients melanoma. Therefore, the Decision Dx Melanoma testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was 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 reviewer number one is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for private duty nursing for treatment of the enrollees seizure disorder. Findings:  The physician reviewer found that in the medical literature, colleagues found that approximately one in five patients born before 26 weeks gestation will develop major neurodevelopmental disorders. The overarching goal of home health care is to optimize each patients health and function while minimizing recurrent or prolonged hospitalizations through the provision of comprehensive, family-centered health care rendered in a nurturing home environment. According to this patients home nursing health plan, home nursing is indicated to monitor vital signs, perform nursing assessment, provide gastrostomy tube care, implement seizure precautions, monitor lungs sounds, perform oral suctioning, assists with range of motion and monitor for skin breakdown. While the family may be able to meet the ongoing needs of the patient in the short-term, this is not a sustainable long-term treatment plan. Common indications for private duty nursing include the administration of medications, monitoring oxygen saturations, and enteral feeding, which are required in this case. Given the ongoing seizure concerns, oxygen needs, gastrostomy tube cares, oral suctioning and global developmental delays, the request for private duty nursing is medically necessary for treatment of this patients medical condition. 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 pediatrics with sub-specialty certification in neurodevelopmental behavioral pediatrics 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 male enrollee has requested reimbursement for Urolift procedure performed for treatment of the enrollees benign prostatic hyperplasia. Findings:  The 3 physician reviewers found that the Urolift procedure has been approved as an effective treatment of appropriately selected patients 50 years of age and older with benign prostatic hyperplasia. It has been shown to be successful and relatively safe in the short-term. There is good quality evidence to establish the efficiency of the Urolift procedure in treating symptomatic benign prostatic hyperplasia without adversely affecting quality of life. Based on the current literature, the Urolift procedure can be considered as an option for those symptomatic benign prostatic hyperplasia patients with small or medium size prostates (less than 80 ml) without median lobe enlargement, who failed medical therapy or are intolerant to it and wish to preserve their sexual function. However, this patient only had a cystoscopy in the record to evaluate his lower urinary tract symptoms. Furthermore, his urinary tract symptoms were not scored. Thus, the records do not demonstrate that Urolift procedure performed was likely to have been of greater benefit than other available treatment options.  Final Result: The 3 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 reviewer number one is board certified in urology 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.Physician reviewer number two is board certified in urology 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.Physician reviewer number three is board certified in urology 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 reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the Level of Care Utilization System (LOCUS) criteria, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is two (2), mild risk of harm. The patient did not have any suicidal ideation or homicidal ideation. The patient has no history of any suicide attempts. The patients functional status score is two (2), mild impairment. The patient has a successful job that he has been able to keep. He reported that he did not drink on the job. He reports that he is not concerned about any family issues. He has good relationships with Alcoholics Anonymous (AA) friends and work friends. The patient broke up with his significant other after relapsing on alcohol. The patient has no legal problems. The patients medical, addictive, psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of alcohol use disorder, depression, and anxiety. He has no medical problems which require 24-hour monitoring. The patients recovery environment score is two (2), mildly stressful environment. The patient is single. He recently broke up with his significant other due to his drinking. The patients level of support score is two (2), supportive environment. The patient has supportive contacts including AA friends. The patients treatment history score is two (2), significant response to treatment and recovery. The patient has had prior sobriety. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient is motivated for recovery and is compliant with treatment recommendations. Based on these criteria, the patient has a total score of 15 and would meet criteria for outpatient treatment along with AA treatment.  Final Result: The reviewer determined that the residential treatment 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 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: A male enrollee has requested authorization and coverage for 20.5 hours per week of one-on-one applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the requested 20.5 hours per week of one-on-one ABA services are medically necessary for this patient. Children and adolescents with autism spectrum disorder have a high rate of irritability and aggressive symptoms. Matson and colleagues note that because of the increased physical size of older children and longer history of these problems, treating these behaviors effectively is important. Psychological methods, particularly ABA therapy, and pharmacotherapy have been the most frequently addressed treatments for challenging behaviors associated with autism spectrum disorder in the peer-reviewed literature. Severe problem behaviors such as aggression, self-injury, and property destruction can result in injury, and that behavioral interventions can significantly reduce such behaviors. In this case, the patient displays behaviors that put him at risk, including pica and elopement. In addition, his physical aggression towards others and inappropriate behaviors in public put him at risk. As such, the request for 20.5 hours per week of one-on-one ABA services have been established as medically necessary for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.