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

The patient has requested authorization and coverage for in-home intravenous immunoglobulin (IVIG) infusions given the concerns regarding the Covid-19 pandemic. The American Academy of Neurology (AAN) guidelines support the use of IVIG for refractory dermatomyositis noting that IVIG has been demonstrated to be effective and may be considered for treating nonresponsive dermatomyositis in adults. The records indicate that this patient with dermatomyositis has failed several standard medications. Treatment with IVIG has reportedly improved the patients symptoms. She has expressed concern over possible exposure to Covid-19 with a five-day infusion schedule at the treatment facility. The American College of Rheumatology (ACR) addressed the treatment of active rheumatic diseases, in the absence of infection or Covid-19 exposure. The ACR support continuation of IVIG at the infusion center in this patients clinical scenario. The records fail to demonstrate the presence of life-threatening organ disease or other serious condition that prevents treatment with IVIG in the clinic setting, given the concern for Covid-19. She is receiving IVIG at an immunomodulatory dose and not for a primary immunodeficiency. Her infusion clinic is open and receiving patients with appropriate Covid-19 screening. The records do not demonstrate that she would be at increased risk for infections due to her indication for treatment at home versus an infusion center. All told, the requested in-home IVIG infusions given the concerns regarding the Covid-19 pandemic are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in allergy and immunology and 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested reimbursement and prospective authorization and coverage for applied behavior analysis (ABA) services including 31 hours of 1:1 therapy per week, 12 hours per month of supervision, two hours per month of parent training, and 12 hours total of reassessment. Medical literature states that medically necessary ABA services are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. This patients provider lists 20 goals on the treatment plan and outline. Based on current guidelines, 14 of these goals are required to meet the essential health needs of the patient and directly address behavioral issues related to the patients autism. The other six goals are not medically necessary because there is no specific link between the goal and specific behavioral issues related to the patients diagnosis of autism. Based on this information, 70% of the goals meet medical necessity criteria. Therefore, ABA services including 22 hours of 1:1 therapy per week, 8.5 hours per month of supervision, two hours per month of parent training, and 12 hours total of reassessment, were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is a licensed B.C.B.A, board certified in psychology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for a Zoll LifeVest (wearable cardioverter defibrillator). The enrollee has a complex medical history, including multiple gastrointestinal issues, hyperthyroidism, chronic pain, long Q-T syndrome and bradycardia. The enrollee was admitted to an inenrollee unit due to a syncopal episode. She was started on nadolol and was provided a Lifevest. This enrollee does have a history of confirmed long QT interval type 1, which has been asymptomatic. She has a complicated past medical and past surgical history and has been taking some medications with syncope listed as a side effect. Literature does not support the use of the Zoll LifeVest in this setting.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 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for laparoscopic surgical ablation with imaging guidance. For this patient, radiofrequency ablation allowed the provider to directly visualize and target the one large fibroid. This method is minimally invasive to decrease risks and allows for a quick recovery. Although there is limited long-term data demonstrating superior health outcomes with radiofrequency ablation, data from recent studies have reported excellent results. Researchers found that 94% of the patients in their study reported satisfaction at 12 months. The authors concluded that the procedure is well tolerated and provides symptom relief and short recovery time. Given these findings, the laparoscopic surgical ablation with imaging guidance was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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

An enrollee has requested authorization and coverage for cardiac computed tomography (CT) without contrast with quantitative evaluation of coronary calcium. Based on the documentation provided for review, this patient has increased coronary risk but no evidence of coronary artery disease. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary CT scanning and calcium scoring. Treatment changes or addition based on the results of screening with coronary CT scanning have not been shown to improve cardiac outcome incremental to that achievable with treatment based on a combination of standard risk factor profiling and basic lipid analysis. Thus, the requested cardiac CT without contrast with quantitative evaluation of coronary calcium is not 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 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Ibrance. This patient has metastatic salivary gland cancer. Based on the molecular features of her cancer, there is National Comprehensive Cancer Network (NCCN) guideline support for use of bicalutamide, as the patient has androgen receptor positive results. However, there is a lack of data to support the use of cyclin pathway inhibitors such as Ibrance, including the context of her molecular in the cyclin pathways. Researchers found limited evidence of antitumor activity in one patient who had deletion of CDKN2A, but the patient was also estrogen receptor positive and concurrently treated with Letrozole, which is documented to have antitumor activity in hormone receptor positive metastatic breast cancer. Given the lack of support in the current clinical guidelines and medical literature, the requested Ibrance is not 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 upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in medical oncology 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

An enrollee has requested reimbursement and prospective authorization and coverage for platelet-rich plasma injections. This patient presents with complaints of persistent left shoulder pain. Clinical examination findings have been consistent with imaging evidence of subacromial bursitis and improvement. The patient is reportedly attempting to avoid or delay surgery. She has previously completed physical therapy and corticosteroid injections without sustained improvement. She underwent platelet-rich plasma injections into the subacromial space and medial scapular border. Current evidence-based medical literature does not support the use of platelet-rich plasma injections in the shoulder as safe and effective for rotator cuff pathology or shoulder pain and function. There is a lack of large volume, long-term outcome studies to support the use of these procedures for this patient. Therefore, the platelet-rich plasma injections to the left shoulder were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that services at issue were not and 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery 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

The patient has requested authorization and coverage for Entresto 24 mg- 26 mg twice daily. The patient has been diagnosed with chronic systolic congestive heart failure, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, and hyperlipidemia. Researchers reported sacubitrilvalsartan is an angiotensin receptorneprilysin inhibitor that is indicated for the treatment of patients with symptomatic heart failure with reduced ejection fraction. Entresto could be considered medically necessary in the presence of ongoing New York Heart Association (NYHA) class II-IV heart failure despite standard heart failure medication (diuretics and spironolactone), which this patient is not documented to be taking. In this case, the patient has a history of a reduced left ventricular ejection fraction of 35% and prior congestive heart failure that was not classified. In addition, the reports did not document congestive heart failure symptoms. The medical evidence does not support the requested medication in this clinical setting. Therefore, Entresto 24 mg-26 mg twice daily 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 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

The enrollee is requesting authorization and coverage for Otezla 30mg tablets. The enrollee has scalp psoriasis. A progress note showed the psoriasis had spread to her face and the provider ordered Otezla. An evaluation by the provider showed the scalp was itchy, inflamed and scaling. The enrollee also demonstrated a rash on the chin and both cheeks. The medication was found medically necessary because other treatment options are not medically appropriate for this patient. Firstly, ultraviolet B phototherapy can't reach the scalp and this is not practical. Secondly, this enrollee is of child-bearing age, and drugs that can cause potential birth defects such as methotrexate, cyclosporine or Soriatane should be avoided. Additionally, methotrexate and cyclosporine cause immune suppression, which can dramatically increase an otherwise healthy individuals risk of contracting a viral infection. This enrollee has a history of hair loss and Soriatane can cause hair loss. Thirdly, the enrollee has already started Otezla and it cleared her condition. This condition flared when the Otezla was discontinued. Lastly, Otezla is a safe drug and does not need any additional monitoring. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

At issue is whether the requested medication, Emgality 120mg/ml pen injector is medically necessary to treat the patients medical condition. This is a patient that has been diagnosed with chronic migraines since childhood. The provider indicated that with Botox injections, this patients migraines have reduced. Prophylactic medications tried include topiramate, amitriptyline, and propranolol. Abortive medications include Sumatriptan, ibuprofen and Vicodin. A letter of medical necessity from the provider detailed that with the addition of Emgality, the patients migraine days have reduced per month and are less intense. The reviewer states that Emgality, in clinical trials, has been demonstrated to reduce the frequency and severity of medical refractory migraine headaches. In a recent clinical study, there was clinical benefit (without adverse side effects) with concurrent use of Botox injections with inhibitors such as Emgality. In this case, given the patients medical history and recent clinical studies, the combination of Botox and Emgality together is warranted and medically appropriate for this patient. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for the brand name medication Tricor. The patient has been diagnosed with mixed hyperlipidemia, hypertension and type 2 diabetes. Researchers reported in adults with severe hypertriglyceridemia (fasting triglycerides greater than or equal to 500 mg/dL and especially fasting triglycerides greater than or equal to 1000 mg/dL), it is reasonable to identify and address other causes of hypertriglyceridemia, and if triglycerides are persistently elevated or increasing, to further reduce triglycerides by implementation of a very low-fat diet, avoidance of refined carbohydrates and alcohol, consumption of omega-3 fatty acids, and, if necessary to prevent acute pancreatitis, fibrate therapy. Medical literature noted that in patients with severe or very severe hypertriglyceridemia, a fibrate should be used as a first-line agent. In this case, the patient had marked hypertriglyceridemia that has been treated with various medications in addition to treating comorbid exacerbating conditions (diabetes and obesity). There is mention of remote use of fenofibrate, but the details of tolerance and response to that medication are not included. There is no indication the patient had an intolerance to previous fenofibrate treatment that would require substituting that medication for the brand name Tricor. The medical evidence does not support the requested medication in this clinical setting. Therefore, the brand name medication Tricor 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 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

The patient has been diagnosed with bilateral knee osteoarthritis, and is requesting authorization for Orthovisc injections in both knees.  Findings: Medical literature finds the use of HA is not supported due to the fact that most studies show that it does not show superiority over other treatments. Although current evidence-based research includes literature that does not strongly and definitively support the use of HA for the treatment of osteoarthritis, the medical records and documentation in this case supports improvement for this patients medical condition based on the previous viscosupplementation treatment.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollees parent is requesting authorization and coverage for AUVI-Q epinephrine injector for infants 0.1mg. The enrollee experienced an allergic reaction. The progress note from that incident reported the enrollee experienced lip and facial swelling, and tachypnea. The enrollee was administered an Epi junior pen, and vomiting followed. Physician orders instructed the parents to keep two Epi-pens available at all times. The enrollees mother requested an order for AUVI-Q for babies. The request is appropriate, as a governmental body has approved a 0.1 milligram dose for infants 7.5 to 15 kilogram. The current literature indicates this is the only approved medication in this age/weight group.  Also, the needle length is shorter in this device to be safely administered to infants.  This enrollee has a history which includes a prior allergic reaction, with severe systemic reactions. Therefore, the requested medication is appropriate.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The enrollee requested reimbursement for the blood test to measure antibodies to vedolizumab. The enrollee has a history of Crohns disease. She was admitted as an in-enrollee for abdominal pain from Crohns disease with complications. The provider instructed the enrollee to follow-up with the Entyvio drug levels. Literature reports that in enrollees with Crohn's disease who are being treated with biologic medications, the use of therapeutic drug monitoring leads to a personalized approach to optimize treatment. Measurement of drug concentrations and anti-drug antibodies can be used to improve treatment outcomes. Therapeutic drug concentrations and absence of antibodies are associated with improved clinical and endoscopic outcomes. In clinical practice, therapeutic drug monitoring has been shown to be clinically useful in enrollees experiencing a loss of response to treatment.Final Result: The reviewers determined that the requested service was likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The reviewers are board certified in gastroenterology 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.