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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mobile cardiac outpatient telemetry (MCOT) device for 30 days for treatment of the enrollees chest pain. Findings:  The physician reviewer found that based on the records provided the patient presents with palpitations that are not further characterized in the records provided. In this circumstance, if additional evaluation for a dysrhythmia is indicated then prolonged serial 48-hour Holter monitoring or off-line self-activated or auto-triggered cardiac event monitoring is sufficient in recording cardiac rhythm during symptoms. There is no documentation to indicate that these devices have been tried and failed for evaluation of the patients current symptoms.  Current expert consensus guidelines endorsed by national organizations also consider Holter monitoring and/or patient-activated or auto-triggered event recorders appropriate initial tests and standard of care for evaluation of dysrhythmias. Continuous real-time monitoring by telemetry services is not medically necessary in this case, since off-line analysis of a patient-activated or auto-triggered event recorder is sufficient in the identification of dysrhythmias during symptoms without jeopardizing patient safety. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services is not medically necessary and has not been shown to improve health outcome compared to standard monitoring techniques. For the reasons provided, the request for MCOT device for 30 days has not been established as medically necessary for the treatment of the patients medical condition.  Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 11 hours per week of direct applied behavioral analysis (ABA) services and 10 hours per month of enhanced supervision services for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that based on the clinical documentation provided for review, the request for 11 hours per week of direct ABA services and 10 hours per month of enhanced supervision services has been established as medically necessary for treatment of the patients medical condition. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. A study found that children receiving more than 27 hours per week of ABA and starting earlier were more likely to have optimal outcome. There was a decrease over time in the intensity, but a notable difference above 27 hours per week. Another study found that longer duration and higher intensity ABA led to more goals being met and more skills mastered. In addition, researchers found that pivotal response treatment (PRT), which is similar to ABA therapy is effective in reducing aggression in school age children. In this case, the patient has made progress with goals and has learned many skills, but the patient still continues to have aggression and non-compliance which support ongoing ABA therapy at the proposed frequency. 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.
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 intravenous (IV) Remicade infusions. Findings:  The physician reviewer found that the request for IV Remicade infusions has been established as medically necessary for treatment of the patients juvenile spondyloarthritis. The patient has been treated with NSAIDs, methotrexate, and Humira. The patient did respond to Humira initially but then lost response. The provider recommends Remicade infusions to treat the patients inflammatory arthritis. Remicade is indicated for children with Crohns disease, thus supporting its safety in the pediatric population. There are additional studies indicating that Remicade is safe in juvenile arthritis. Remicade is also indicated for adult ankylosing spondylitis, which is the same category of arthritis as this patients disease. The efficacy and safety of Remicade in ankylosing spondylitis is well established. For juvenile spondyloarthritis, Remicade has demonstrated a significant improvement in arthritis, enthesitis, inflammatory markers, pain, and physical function. In this case, the patients inflammatory disease will likely respond to Remicade, and is medically necessary for prevention of long-term damage that may result from untreated inflammatory arthritis. For the reasons provided, the requested services are 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 pediatric 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: The patient has requested reimbursement for the advanced lipoprotein testing for evaluation of the enrollees risk for heart disease. Findings:  Three physician reviewers found that this patient presents with baseline elevation of low density lipoprotein (LDL) cholesterol and non-high density lipoprotein (HDL) cholesterol but with negative risk factor of high HDL cholesterol. Advanced lipoprotein markers had been evaluated previously approximately six months prior. Reported clinical risk factor of family history of cardiovascular disease, but no report of diabetes, smoking, hypertension, or history of prior established cardiovascular disease. In some clinical circumstances, a single advanced lipoprotein analysis can sometimes be reasonable for assessment in intermediate risk individuals prior to any decisions regarding pharmacological therapy for cholesterol reduction, but this was performed six months prior. However, there is no evidence for repeated advanced lipoprotein analysis after the initial advanced risk assessment, and further lifestyle and/or pharmacologic therapy should be guided by both ongoing, unmodified, clinical risk factors and standard lipid profile monitoring of LDL and non-HDL cholesterol levels. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pulsed radiofrequency treatments for treatment of the enrollee's complex regional pain syndrome. Findings:  Three physician reviewers found that the medical records fail to demonstrate the superior effectiveness of the requested services. In this patients case, not all standard treatment options for complex regional pain syndrome have been tried or discussed. While research does exist for pulsed radiofrequency treatments for complex regional pain syndrome, it is of overall poor design, as thus far it is mostly case studies and retrospective analysis. Additional research is needed at this time, as clear and convincing evidence is not found in the peer-reviewed scientific journals. Based on the medical evidence, the requested pulsed radiofrequency treatments are not likely to be of greater benefit than other available treatment options. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewer 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 speech therapy performed by a speech therapist who is certified in orofacial myology for treatment of the enrollees apraxia of speech. Findings:  The physician reviewer found that there is a lack of peer-reviewed literature showing that orofacial myofunctional therapy is effective for children with childhood apraxia of speech. Orofacial myofunctional therapy improves speech intelligibility in adults with persistent speech impairments. Typical speech therapy is not necessarily effective for childhood apraxia of speech. In this case, the patient has minimally understandable speech. Intensive speech therapy by a speech therapist with experience with childhood apraxia of speech is clinically indicated. A speech therapist certified in orofacial myology is not medically necessary as there is a lack of research supporting its treatment in children with childhood apraxia of speech. As such, the request for a speech therapist who is certified in orofacial myology is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental and 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tecfidera Capsule DR 240 mg for treatment of the enrollees multiple sclerosis (MS). Findings:  The physician reviewer found that there are 14 available U.S. Food and Drug Administration (FDA) approved therapies for the treatment of relapsing MS. There are similarities, but also major differences as far as mechanism of action, route and frequency of administration, tolerability, safety, and efficacy. Making a decision on MS therapy is a joint decision-making process in order to find the best medication for each patient based on many factors including age, stage of disease, risk tolerance, and co-morbidities. Tecfidera has been approved by the FDA as a first-line MS therapy. While there are a lack of quality head to head studies, Tecfidera is generally recognized to be more effective than the platform agents such as Extavia and Copaxone, and less effective than the highly active agents such as Tysabri, Ocrevus, and Lemtrada. In this case, the provider indicates that because the patient does not want to use injections an oral agent has been recommended. Given that Tecfidera capsule DR 240 mg has been approved as a first-line MS therapy, it is a reasonable treatment for relapsing MS and as such is medically necessary for treatment of this patients relapsing MS. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for physical and occupational therapy services provided at a skilled nursing facility. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the services at issue in this clinical setting. The patient is being treated with diagnoses including metastatic breast cancer as described above. She received physical and occupational therapy as part of the patients SNF level care for two weeks after previously receiving custodial level care. The patient has skilled nursing needs. The patient has pain interfering with function, which needs to be assessed and treated. The patient requires oversight of her medical conditions and medication management. The patient is at risk for secondary complications of immobility such as pressure ulcers and contractures. However, there was no new injury or impairing condition. The patient is receiving care that can be provided by the patients non-skilled caregivers with periodic skilled oversight and modification of the care plan if needed. The patients care can be appropriately provided at a custodial level. Based on the documentation provided, ongoing SNF level skilled therapy services are not medically necessary. Therefore, physical and occupational therapy services provided at a skilled nursing facility 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 physical medicine and rehabilitation 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 authorization and coverage for spine surgery for treatment of the enrollees low back pain. Findings:  The physician reviewer found that Evidence based medical guidelines and peer reviewed criteria have not been met in this patients case. Current evidence based medical guideline criteria for lumbar decompression include symptoms/findings that confirm the presence of radiculopathy and correlate with clinical examination and imaging findings. Guidelines do not recommend lumbar fusion for patients with degenerative disc disease, disc herniation, spinal stenosis without degenerative spondylolisthesis or instability, or non-specific low back pain. Fusion may be supported for segmental instability (objectively demonstrable) including excessive motion, as in isthmic or degenerative spondylolisthesis, surgically induced segmental instability and mechanical intervertebral collapse of the motion segment and advanced degenerative changes after surgical discectomy. Preoperative clinical surgical indications require completion of all physical therapy and manual therapy interventions, x-rays demonstrating spinal instability and/or imaging demonstrating nerve root impingement correlated with symptoms and examination findings, spine fusion to be performed at one or two levels, psychosocial screening with confounding issues addressed, and smoking cessation for at least six weeks prior to surgery and during the period of fusion healing.  This patient presents with persistent severe low back pain radiating into the right lower extremity in a reported L3/L5 distribution. The patient reported significant functional difficulty in her daily activities. Detailed evidence of at least six months of reasonable and/or comprehensive nonoperative treatment protocol trial and failure have been submitted. However, there are no clinical findings of nerve root compromise correlated with imaging evidence of degenerative disc disease at L3/4 and L4/5. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no discussion or imaging evidence supporting the need for wide decompression that would result in temporary intraoperative instability that would necessitate fusion. Potential psychological issues are documented with no evidence of a psychosocial screen. For these reasons, the requested spinal surgery is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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 orthopedic surgery with expertise in spine surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha for treatment of the enrollees elevated low density lipoprotein (LDL) cholesterol. Findings:  The physician reviewer found that the requested use of Repatha in this patients case is in concert with the U.S. Food and Drug Administration (FDA) recommendations for use of the PCSK9 inhibitors for treatment of lipids. Repatha, the second drug approved in a new class of drugs known as PCSK9 inhibitors, has been approved for use in addition to diet and maximally-tolerated statin therapy in adult patients with heterozygous familial hypercholesterolemia (HeFH), homozygous familial hypercholesterolemia (HoFH), or clinical atherosclerotic cardiovascular disease, such as heart attacks or strokes, who require additional lowering of LDL cholesterol. Given these findings, the requested Repatha is supported as medically necessary for treatment of this patients medical condition. 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 enrollee has requested authorization and coverage for Otezla 30 mg for treatment of the enrollees moderate psoriasis. Findings:  The physician reviewer found that the patient presents with chronic plaque psoriasis. She has tried and failed therapy with topical steroids. She has been treated with Otezla with good effect. However, there is no documentation of the patient having tried and failed any of the first-line systemic treatments, including methotrexate, cyclosporine, Humira or Enbrel. In addition, there is no documented contraindication to the use of these agents which have been used successfully and safely for years. As there are other preferred medical therapies available, the requested Otezla 30 mg is not medically necessary for treatment of this patients plaque psoriasis. 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 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.