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 transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that the majority of the evidence based literature on TMS is dedicated towards the treatment of major depressive disorder. The evidence for TMS in the treatment bipolar I disorder is minimal. The literature also indicates that there have been instances where treatment with TMS, in individuals with bipolar I disorder, has induced dangerous symptoms of mania.  Overall, the evidence base does not support the use of TMS for bipolar I disorder. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for 100 days of residential treatment for behavioral health at the Centre for Neuro Skills. Findings:  The physician reviewer found that the records do not contain evidence that the patient would likely permanently improve due to treatment. The records indicate that the patient has a pathologic dysfunction of his frontal and temporal lobes. The records demonstrate that the patient temporarily improves with structure, but the results are not sustained. There is a lack of evidence to support that additional treatment would alter the patients outcome. 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 physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services.  Findings:  The physician reviewer found that the patient had participated successfully in the groups which he had attended, demonstrated useful insight, had established therapeutic alliances and was not demonstrating evidence of significant depression, suicidality, or others serious indications of deteriorating function. Treatment of addictive disorders, especially in the setting of long periods of abstinence, can be successfully accomplished in the outpatient setting. Social anxiety disorder as well as mild eating disorder are also typically treated in the outpatient setting. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg, one tablet daily for 12 weeks for the treatment of her 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. This patient should be considered treatment-naive, as she was previously treated with interferon rather than PEG-interferon with ribavirin.  The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage.  The current 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for narrowband UVB. Findings:  The physician reviewer found that this patient presents with chronic pruritus of unknown etiology which is responsive to topical and systemic steroids, but unresponsive to oral antihistamines. Chronic pruritus is difficult to treat and may result from atopic dermatitis or other underlying conditions. Narrowband UVB phototherapy has been shown to be an effective therapy which helps to minimize the risk of long-term topical or systemic steroid use. The patient has established that this is negatively impacting her quality of life. Final Result: The reviewer determined that the requested service 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 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: an enrollee has requested authorization and coverage for Stelara injection.  Findings:  The physician reviewer found that the patient has tried and failed therapy with topical steroids, methotrexate, and Enbrel.  Per the Health Plans guidelines, Stelara may be covered if the patient has tried and failed both Enbrel and Humira.  As these medications work by a similar mechanism of action, inhibition of tumor necrosis factor signaling, it is not expected that use of one would be successful when there is poor efficacy of the other.  The patient has failed topical therapies, ultraviolet light, an oral systemic agent and an anti-tumor necrosis factor biologic.  The patient has already had a treatment trial with Stelara injections, and it has been efficacious.  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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for azithromycin 250 mg tablet per day for lifetime for treatment of her chronic obstructive pulmonary disease (COPD). Findings:  Three physician reviewers found that he requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Patients diagnosed with COPD are colonized with multiple organisms. Daily use of azithromycin for lifetime as requested in this case will select out the organisms that are resistant to azithromycin. There is no documentation that azithromycin provides any additional anti-inflammatory effect for a patient already treated with prednisone. In addition, the use of daily azithromycin for lifetime is not the standard of care for patients with COPD. For the reasons provided, the request for azithromycin 250 mg tablet per day for lifetime is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in pulmonary disease 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene testing for evaluation of her oligodendroglioma.  Findings:  Two physician reviewers found that FoundationOne gene testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers that can help guide therapy decision making. Per the National Comprehensive Cancer Network guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis other than KRAS, NRAS, and BRAF mutations. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. However, the medical evidence has not established that FoundationOne gene testing was likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 medical oncology 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 38 hours per week of direct applied behavioral analysis (ABA) therapy (Code H2019), 10 hours per month of supervision (Code H0032) and two hours per week of parent training (Code S5110) for treatment of his autism. Findings:  The physician reviewer found that The request for 38 hours per week of direct ABA therapy (Code H2019), 10 hours per month of supervision (Code H0032) and two hours per week of parent training (Code S5110) have not been established as medically necessary for treatment of the patients autism. ABA therapy is a well-established effective treatment for the behavioral features of autism spectrum disorder, but the optimal intensity and duration have not been established. Goals of therapy are directed towards generalization of mastered skills. According to the documentation submitted for review, the patient is not exhibiting aggressive behavior, and his self-injurious behavior in the form of ear pulling is mild. Aside from an increase in behaviors when he was undergoing assessment for high school placement, the patient has had a decrease in verbal outbursts reported, and behavioral and verbal stereotypies have remained constant. The Health Plans authorized amount of ABA therapy is medically reasonable and appropriate for 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing called Foundation One for the evaluation of her recurrent metastatic clear cell uterine cancer. Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Adenocarcinoma of the endometrium (lining of the uterus) is the most common type of uterine cancer. This patients pathology was consistent with a serous-clear cell morphology. Serous is the second most common histology of endometrial cancer whereas clear cell is uncommon. Both of these histologic types are associated with a worse prognosis and frequently present with extrauterine disease at the time of diagnosis. Serous and clear cell endometrial cancers are not stimulated by estrogen and have a different genomic profile when compared to typical endometrioid carcinomas. Serous tend to demonstrate human epidermal growth factor receptor 2 amplification and p16 alterations. Clear cell carcinomas tend to have a tumor profile more akin to clear cell carcinomas of the kidney than endometrioid carcinomas. In this patients case, she presented with an aggressive uncommon histologic type of endometrial cancer, serous, clear cell, and sarcomatoid. The literature at this time suggests that molecular genotyping of these tumors will help better characterize the phenotype, prognosis and therapeutic options. Although most of the molecular therapeutic options are not a standard of care, the use of somatic genotyping in this case further clarified phenotype and prognosis. The thorough analysis preempted the use of Herceptin given other molecular characteristics that suggested likely resistance. 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine 15 mg, four times per day for treatment of his chronic pain. Findings:  The physician reviewer found that the Centers for Disease and Control and Prevention (CDC) guidelines suggest that chronic opiate maintenance is associated with elevated risks. The CDC also indicate that a consultation with pain management is necessary before tapering the patient. The general approach is to taper 10% per week while replacing the opiate with another non-narcotic pain therapy. The patient was treated with morphine 15 mg with a total dose of 60 mg. His morphine prescription has been cut in half. A 50% reduction is not a gradual taper. He is currently on a sub therapeutic dose of gabapentin. The clinical documentation does not include a plan for changing the dose of gabapentin or adding any other analgesics. There is also no treatment plan documented for adjunctive medications to deal with withdrawal symptoms. In addition, there is no treatment plan documented for psychosocial support as recommended by the CDC. The patient should be tapered off of morphine but this needs to be done slowly and carefully. A 50% reduction is not the standard of care. Final Result: The reviewers determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or 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 hormone pellet implantation. Findings:  The physician reviewer found that subcutaneous hormone replacement therapy (HRT) is considered a bioidentical hormone treatment. Bioidentical hormones are plant-derived hormones that are biochemically similar or identical to those produced by the ovary or body. The steroid hormones most commonly compounded include testosterone and estradiol. Studies evaluating subcutaneous HRT contain small subject numbers. For this reason, HRT is not adequately supported in the peer-reviewed medical literature. Further, subcutaneous HRT is not considered a first-line treatment in the selection of HRT, as it has not been demonstrated to provide a significantly increased benefit over oral HRT. Given the lack of evidence in randomized, peer-reviewed, published studies, the hormone pellet implantation provided in this case was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: All 3 reviewers determined that the service at issue was 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 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 reimbursement for residential treatment center services provided. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The Level of Care Utilization System (LOCUS) is commonly used to determine appropriate levels of care.  Applying LOCUS, the patient presented with a moderate risk of harm, scored as 3. She had no prior history of any suicide attempts. She denied suicidal ideation. However, the patient had a history of excessive alcohol use resulting in harmful behaviors. In terms of functional status, her score was 3. The patient had moderate impairment. She had a tumultuous relationship with her husband. The records document moderate comorbidity, which scored as 3. The patient had a diagnosis of alcohol use disorder and continued to drink despite negative consequences. She also had anxiety and depression as psychiatric comorbidities.  The records noted a moderately stressful environment, scored as 3. The patient had discord in her current marriage, and there was access to alcohol.  Regarding the patients support, the records indicate a score of 2.  The patient had support from her children, extended family, and sober friends. In terms of treatment history, her score was 2. She previously displayed significant response to treatment and recovery management. The patient was able to maintain sobriety for a four mouth period.  In terms of engagement, the records indicate a score of 2. Per the records, the patient was engaged in her recovery. She was participating in group sessions. Based on the records, the patients total score was 18. Thus, partial hospitalization program or an intensive outpatient program level of care would have been appropriate.  The medical evidence does not support residential treatment level of care in this clinical setting.  All told, residential treatment center services provided were not medically necessary for the treatment of this patient. Final Result: The reviewers 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: Physician 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.