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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for air ambulance transport. The records provided for review document that this patient had significant and rapid gastrointestinal bleeding requiring a large-volume blood transfusion of six units. The patient was found to have variceal bleeding, which is considered a medical emergency (Kim; Maruic, et al.). According to American Association for the Study of Liver Disease (AASLD) guidelines for the management of variceal bleeding, acute variceal hemorrhage is a medical emergency requiring intensive care, and endoscopy is done as soon as possible and not more than 12 hours after presentation. If a variceal source is confirmed, endoscopic variceal ligation should be performed. Based on these guidelines, the patient warranted both intensive care unit (ICU) services and immediate specialized endoscopic intervention, neither of which were available at the original facility. Therefore, an emergent transfer was warranted. Due to the high risk in variceal bleeding, the AASLD guidelines would support air transport in this patients case. A ground ambulance transfer would have taken too long, and an emergency could not have been adequately managed during transport. For these reasons, the air ambulance transport was medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested reimbursement for fecal calprotectin test. The enrollee has a history of poor linear growth velocity despite adequate weight gain.  Documentation from an office visit indicates the enrollees growth had been tracking around the 50th percentile until age two, decelerated to the 25th percentile at age three, and dropped to the 10th percentile by age five. Patients body mass index (BMI) had been tracking along the 50th percentile in this time frame.  The enrollee has had no abdominal pain, fatigue, headaches, changes in bowel habits, loose stools or constipation. Bone age results were normal. Due to the enrollees family history of Crohns disease and unexplained growth failure, the provider ordered a fecal calprotectin lab test to evaluate for possible inflammatory bowel disease.  These results were normal. Literature shows fecal calprotectin (FC) can accurately test for bowel inflammation, but it is not site-specific. The test can potentially be used to differentiate between irritable bowel syndrome (IBS) and other inflammatory diseases, but to rule out Crohns disease definitively, imaging diagnostics, such as computerized tomography (CT) scanning or magnetic resonance enterography (MRE) and endoscopy are used. Research is ongoing to determine the feasibility and reliability of using FC to diagnosis IBS in children. Studies showed 12-36% of patients with IBS also have elevated FC. However, the testing is more appropriate for those with a higher chance of having the disease. Studies do not demonstrate FC testing affects overall management, treatment or outcome for children with poor linear growth.  In this case, the enrollee has poor linear growth with no intestinal symptoms, anemia or bloody stools. Additionally, there is no robust data supporting use of calprotectin among asymptomatic children with short stature or that this assay improves outcomes for an asymptomatic pediatric population.Final Result: Three of the three reviewers determined that the requested service was not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in pediatric gastroenterology 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Home Health Transitional Care Management (TCM), including weekly home nurse visits. The enrollee has a history of type II diabetes, recurrent seizures, and migraines. Enrollee was hospitalized for abdominal pain and was treated with intravenous (IV) antibiotics for methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. At the time of hospital discharge, the enrollee completed five days of intravenous antibiotics, and did not require peripherally inserted central catheter (PICC) line-placement for continuous outpatient intravenous antibiotics. On an outpatient follow-up visit, notes indicate the enrollee was feeling great and denied symptoms of infection since hospital discharge. Despite her stable condition and ability to follow-up as an outpatient, authorization for Transitional Care Management was requested due to the enrollees hospital admission for bacteremia. Literature support for Transitional Care Management is focused on enrollees who are at high-risk for re-hospitalization, which include enrollees with multiple comorbidities; polypharmacy (use of multiple drugs); depression; functional impairment; low self-health rating; history of non-adherence; an inadequate support system; or are greater than 65 years old. Although this enrollee has poorly controlled diabetes, there is no medical indication of the enrollees non-adherence or non-compliance to medication or outpatient care. Rather, the medical records show outpatient follow up for her diabetes management, and the hemoglobin (Hg) A1c is an improvement (reduction) from previously elevated HgA1c. The request for Transitional Care Management for bacteremia is not supported by the literature or the enrollees clinical presentation. The enrollee completed course of intravenous antibiotics while in the hospital, and is asymptomatic and able to follow-up with outpatient provider without difficulty.  While she reports seizures and needing assistance getting out of bed sometimes, this is unrelated to enrollees recent admission for bacteremia, and thus, does not support the request for Transitional Care Management. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal medicine and infectious diseases 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for theta burst transcranial magnetic stimulation (TMS). Based on a review of the records provided, this patient has undergone a trial of two different agent classes at or above the minimum effective dose. Further, the duration of these trials included at least two evidence-based augmentation therapies or inability to tolerate pharmacologic agents. Specifically, the patient experienced severe insomnia and constipation with Nardil, a seizure with Wellbutrin, and nausea with vomiting with Brintellix. The patient has responded well to treatment with theta burst TMS without untoward side effects. The patients condition has improved with electroconvulsive therapy (ECT) and TMS. TMS treatment is a U.S. Food and Drug Administration (FDA) approved for treatment of major depressive disorder in a safe and effective manner. Based on the information provided, this patient does meet the clinical criteria for the use of TMS therapy. However, the current data do not support theta blast TMS in lieu of standard TMS. The patients Health Plan has providers available to render standard TMS services. Overall, theta burst TMS lacks adequate research to support its use in lieu of standard TMS. As this patient meets the criteria for treatment with TMS, the patient should obtain the standard of care TMS services from a provider within their Health Plans network. Therefore, the theta burst TMS services were not and are not medically necessary for treatment of this patient.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for onabotulinumtoxinA (Botox) in conjunction with Aimovig. The enrollee has chronic migraines, intractable to multiple medications.  The enrollee reported partial response to the anti-calcitonin gene-related peptide (CGRP), Aimovig.  Enrollee began Aimovig at a dosage of 70mg, for a total of seven injections. The dosage was then increased to 140mg, which reduced headache frequency to two per week from an average of four per week. The enrollee has failed traditional migraine preventative options, including amitriptyline, Depakote, propranolol, venlafaxine, topiramate, gabapentin, and verapamil.  Headache frequency is currently at about five per month. The neurologist recommended the inclusion of Botox as an adjunctive therapy to Aimovig in order to provide a more aggressive treatment. The record indicates, while on Aimovig, the enrollees headache frequency decreased by half, which is generally considered an effective therapy in treating chronic migraines. Both Botox and Aimovig are FDA approved for use in the prophylaxis of chronic migraine headaches.  However, there is no published evidence in current medical literature to support the use of Botox with Aimovig, which has only been studied for use as monotherapy for the prophylaxis of migraine headaches.  Clinical trials of Aimovig have excluded participants from the phase II trial in chronic migraine if they had received Botox injections four months prior to the start of Aimovig therapy.  The provider indicated the enrollee will be receiving Botox while on Aimovig, as she had previously.  There are no completed studies with published results demonstrating the efficacy and safety of the Botox/Aimovig combination, or that the combination is more effective than the use of either agent alone or combined with an oral prophylactic agent. Therefore, the proposed treatment regimen cannot be expected to be more effective than any other treatment regimen for the prophylaxis of migraine.Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz 5 mg, quantity of 60 per month. The American Academy of Dermatology (AAD) guidelines for management of patients with alopecia areata or alopecia universalis includes intralesional or systemic corticosteroids, topical corticosteroids with Minoxidil, immunotherapy such as diphenylcyclopropenone (DPCP), and phototherapies (Alkhalifah, et al.). Cyclosporine, methotrexate, and sulfasalazine are other potential treatment options. For adults with more than 50% scalp involvement, DPCP is the treatment of choice. In this case, the patients history of alopecia universalis has lasted for approximately eight years. The patients provider has recommended treatment with Xeljanz. However, Xeljanz is not U.S. Food and Drug Administration (FDA) approved for the treatment of alopecia universalis. Xeljanz is FDA approved for rheumatoid arthritis, psoriatic arthritis, and ulcerative colitis. Although the patients provider noted concern for use of some medications due to the patients atopic dermatitis, there is a lack of data to support use of Xeljanz in this clinical setting over the AAD recommended treatment options. All told, Xeljanz 5 mg, quantity of 60 per month is not 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 requested medication is 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:  One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in dermatology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device LINX Reflux Management System. The enrollee has medically refractory gastroesophageal reflux disease (GERD).  The enrollee has developed tachyphylaxis to previous medical therapy and has been advised to abstain from proton pump inhibitors (PPI) because of complications. Enrollee has daily reflux symptoms including heartburn, regurgitation, cough, sore throat, and inadequate throat clearance.  The enrollee manages with Tums and diet modification. However, symptoms occur daily and are severe.   An esophagram showed a normal esophagus, normal motility and no hiatal hernia. Probable pH testing revealed a DeMeester score of 132. A value above 14.72 is considered abnormal. Enrollee is a candidate for both laparoscopic fundoplication and magnetic sphincter augmentation. The enrollee prefers magnetic sphincter augmentation with LINX device because of the added benefit of preserving the ability to produce eructation and emesis. The medical literature supports LINX device safety. Efficacy was demonstrated in a normalization of pH, a reduction in proton pump inhibitor (PPI) use, and an improvement in quality of life. The enrollee is a good candidate for this procedure due to high DeMeester score and failure at PPI therapy. The device provides a minimally-invasive solution to alleviating Gastroesophageal Reflux Disease (GERD) symptoms and studies demonstrate its success over the long term. Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gastroenterology 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for FreeStyle Libre blood glucose 14-day reader device and FreeStyle Libre sensors. According to the medical literature, FreeStyle Libre flash glucose monitor obtained approval to function as an alternative for self-monitoring, such as finger-stick  glucose monitoring. The factory-calibrated disk-like sensor is worn on the upper arm for 14 days and promotes the ease of taking multiple glucose readings per day. An enrollee may do so by passing a reader device over the sensor and obtain real-time glucose levels and trends. Although literature supports that FreeStyle Libre flash glucose monitoring is equivalent to self-monitored glucose monitoring in terms of glucose reading accuracy and reliability, this finding cannot be generalized to this enrollee, who has end stage renal disease (ESRD) on renal dialysis. Current literature does not support FreeStyle Libre flash glucose monitoring for enrollees with ESRD in their sample population. Thus, the unclear efficacy of FreeStyle Libre flash glucose monitoring in an enrollee with ESRD does not make this device safe or comparatively beneficial to self-monitoring, such as finger-stick glucose monitoring. Additionally, finger-sticks are required for treatment decisions when the enrollee sees the check blood glucose symbol, when symptoms do not match system readings, when the enrollee suspects readings may be inaccurate, or when the enrollee experiences symptoms that may be due to high or low blood glucose. The device may inaccurately indicate hypoglycemia. The results of the clinical study conducted for this device showed that 40% of the time when the device indicated that user sensor glucose values were at or below 60 mg/dL, user glucose values were actually in the range of 81-160 mg/dL. It should also be added this is not a pump device and thus insulin injection by the enrollee is still required. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology, diabetes 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for diagnostic mammogram and SAVI placement of left breast. The enrollee who underwent routine mammography that showed new calcifications in the left breast. These were confirmed by magnification views and biopsied. Pathology showed low grade ductal carcinoma in situ (DCIS) of the left breast. The patient underwent SAVI placement followed by left breast lumpectomy and left axillary sentinel lymph node biopsy. The physician believed the procedure was the most appropriate and effective treatment for the patients cancer. Multiple studies have shown and confirmed evidence on the safety and effectiveness of SAVI SCOUT localization (SSL) surgical guidance system when compared to traditional methods, of wire localization (WL) to localized non-palpable breast lesions. SAVI SCOUT surgical guidance is a non-radioactive infrared (IR)-activated electromagnetic wave reflector that is implanted into the breast under ultrasound or mammographic (imaging) guidance. In addition to its safe and feasible use, literature supports SSL due to its comparable effectiveness, in terms of accuracy and reliability to localize and excise breast lesions with acceptable margin positivity to that of traditional methods including wire localization and radioactive seeds. SSL has the added advantages of not needing to use a wire or radioactive materials. Surgical outcomes with SSL were no different from that with wire localization. However, SSL is considered more beneficial than wire localization in terms of technical feasibility and avoiding the complications associated with wire localization. Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: One reviewer is board certified in diagnostic radiology and vascular and interventional radiology; another reviewer is board certified in general surgical oncology and; the third reviewer is board certified in medical oncology. All three reviewers are actively practicing and 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

Age: 28Gender: MNature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for next generation sequencing. Mutations in genes involved in three major pathways of energy metabolism, including glycogenolysis, fatty acid oxidation, and mitochondrial oxidative phosphorylation are the main causes of metabolic myopathies. The predominant clinical symptoms associated with metabolic myopathy include chronic muscle weakness, myoglobinuria, and/or acute and recurrent episodes of irreversible muscle dysfunction related to exercise intolerance. Diagnosis of patients with metabolic myopathy may be possible based on clinical features, abnormal metabolites, and enzymatic deficiency. However, for a definitive diagnosis, the identification of deleterious mutations in the causative gene is required. This patients clinical features are concerning for an underlying metabolic myopathy. Given the molecular basis for metabolic myopathies, next generation sequencing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found that next generation sequencing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patient's medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 3 is board certified in genetics and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.