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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Tremfya.Medical literature supports the use of the requested medication in this case. Tremfya (guselkumab) works by blocking the binding of IL-23 to the IL-23 receptor on cell surfaces (NK cells and T cells), thus blocking the subsequent IL-23-receptor-mediated signaling pathway, therefore leading to the reduction and/or inhibition of down-stream production of different pro-inflammatory cytokines involved in the development of psoriasis. Guselkumab has been shown to be able to reduce serum levels of IL-17A, IL-17F and IL-22 relative to pretreatment levels in subjects with psoriasis. Guselkumab has been recently approved by the U.S. Food and Drug Administration (FDA) for the treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy. Guselkumab represents a very promising therapy, as it provides an alternative mechanism of action with high efficacy and safety profiles, sustained total skin clearance, and rapid onset of effect for psoriasis patients who have previously failed or experienced an inadequate response to anti-TNF- or anti-IL12/23 agents.Findings: In this case, the patient has extensive plaque psoriasis that has been non-responsive to topical corticosteroids, UVB, tar and Otezla. The patients dermatologist has recommended injections of Tremfya at this time. As noted above, Tremfya is a promising therapy that provides an alternative mechanism of action with high efficacy and safety profiles, sustained total skin clearance, and rapid onset of effect for psoriasis patients who have previously failed on medications such as Otezla. Under these circumstances, Tremfya is medically necessary to treat the 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for applied behavioral analysis (ABA) services four (4) hours per month of assessment & treatment, four (4) hours per month supervision by BCBA, and ten (10) hours per week of direct 1:1 ABA services by paraprofessional.  The enrollee has a diagnosis of autism. He has currently been in treatment for his autism for five years, with previous applied behavioral analysis (ABA) at a different provider, for a total of fourteen years. The enrollee had been receiving ten hours per week, which has been gradually reduced over time. Therapy goals include communication, self-advocacy, and safety skills. Progress has been slow due to the limited hours. The enrollees mother is involved in all sessions and implements recommendations. He had been displaying higher levels of improvement when receiving 7.5-10 hours per week, as he was meeting 50% of his goals. At five hours per week, he was meeting 30% of his goals. There are no goals addressing vocational skills. The enrollee has a severe prompt dependency, which has been shaped gradually over time. Case notes indicate for ABA therapy to be effective for this enrollee, he requires consistency and repetition in order to learn and effectively meet goals that have been prescribed for supporting his independence. The enrollee requires a systematic generalization of skills across environments, stimuli, instructions and people (including parents). A study indicated that a diagnosis of autism is made when DSM-V symptoms are present and other disorders have been adequately ruled out.  The literature describes applied behavior analysis (ABA) therapy as a behavioral intervention used to treat autism spectrum disorder in which the enrollee's progress is tracked and measured.  This therapy emphasizes communication, play, academics, social, work, community, and self-care. ABA therapy is widely accepted among healthcare professionals and is widely used because it encourages positive behavior and has demonstrated benefits for enrollees with autism.  ABA therapy programs are commonly recommended for 25-40 hours per week, with family support to encourage skill utilization outside of the program. Case notes indicate the enrollee has been displaying higher levels of acquisition when receiving 7.5-10 hours/week; whereas, at 5 hours/week, he was only meeting 30% of his goals. This supports the need for continued intensive therapy for this enrollee with autism. 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 psychiatry and child & adolescent 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for Lyrica.Submitted documentation does not support that Lyrica is medically necessary. The off-label use of gabapentin and Lyrica was studied, and they have noted that Lyrica is used off label for many neuropathic pain conditions. They have indicated that one agent should be optimized before changing agents. Other studies have noted that Lyrica was beneficial for neuropathic pain conditions that included neuropathy. They found that maximizing one agent is recommended before changing to an alternate agent. Another study has also noted that Lyrica was beneficial for neuropathic pain conditions that included neuropathy. They, too, indicated that maximizing one agent is recommended before changing to an alternate agent. In this case, the submitted documentation reflects that the patient has peripheral neuropathy but does not have diabetes. The patient has not been diagnosed with postherpetic neuralgia (PHN), fibromyalgia, or spinal cord injury-related nerve pain, and there is no indication of seizure disorder. Records indicate that the patient is being treated with lower dose of gabapentin per day, while dosage guidelines in peer reviewed references recommend maximizing gabapentin dosage  per day to achieve therapy, or unless side effects occur. The submitted records do not, however, identify any side effects that the patient experienced from gabapentin or indicate any contraindication to further dosage titration of gabapentin. As such, the medical records do not support a change to Lyrica from the current medication gabapentin. Therefore, Lyrica is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology, with subspecialty certification in pain management, 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 patient has requested authorization and coverage for Aimovig Autoinjector. The records provided for review indicate that the patients condition improved with Botox treatment. Combined treatment with Botox and Aimovig provided further benefit without problematic side effects. A recent presentation for the American Headache Society (AHS) showed that in patients on Botox who were experiencing end of treatment cycle wear-down, the addition of Aimovig appeared to boost Botox efficacy and result in sustained effects in a significant proportion of patients. Cohen and colleagues reported that fremanezumab is a safe and effective add-on treatment for migraine patients being concomitantly treated with other migraine preventive medications. Thus, there is evidence in favor of combined therapy with a medication of the same class as Aimovig. Given these findings, the requested Aimovig Autoinjector  is 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 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: The patient has requested authorization and coverage for combination therapy of Erbitux and Votrient (pazopanib). As noted in the medical literature, there are limited proven therapies for the treatment of metastatic squamous cell cancer of the urethra. Various agents have been studied in the clinical trials and are consistent with this patients prior systemic therapies. Erbitux is a monoclonal antibody, which has been U.S. Food and Drug Administration (FDA) approved for use in metastatic colon cancer, and along with radiation therapy for squamous cell head and neck cancers. Votrient is FDA approved for use in soft tissue sarcomas, renal cell carcinoma, gastrointestinal stromal tumors, and certain thyroid cancers. Since there is a lack of data to support the use of this combination therapy in this patients squamous cell urethral cancer, the requested combination therapy of Erbitux (cetuximab)  and Votrient (pazopanib) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested combination therapy 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a blood pressure monitoring device. This patient presents with potential end organ disease from hypertension with CKD and proteinuria. Management of hypertension is critical in preventing ongoing renal injury. Researchers ambulatory blood-pressure measurements were a stronger predictor of all-cause and cardiovascular mortality than clinic blood-pressure measurements. The authors noted that ambulatory blood-pressure data provide a more comprehensive assessment of blood pressure over the course of a day and have been reported to better predict health outcomes than blood pressure measured in the clinic (clinic blood pressure) or at home. This patient has well-documented attempts to measure her blood pressure in the clinic and at home. Therefore, the requested blood pressure monitoring device is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 subspecialty certification in nephrology 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 patient has requested authorization and coverage for immune globulin therapy. The records provided for review state that the patients cognition and pain have improved with immunoglobulin replacement therapy. However, there is a lack of evidence in the current medical literature to support the treatment of decreased cognition, severe fatigue and neuropathy with immunoglobulin replacement therapy. The patients records do not document a specific diagnosis to support an indication for immune globulin or recurrent sinopulmonary infections. In addition, although the patient had inadequate pneumococcal antibody titers two years ago, she had adequate response with greater than 70% protective antibody titers a year ago. Given these findings, immune globulin therapy is not medically necessary for 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 subspecialty certification in allergy and 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Using CALOCUS criteria, the patients risk of harm score is a two, due to history of suicide attempts, and suicidal ideation that diminished in RTC. Her functional status score is a three due to being suspended from school, conflict with her mother, and a lack of awareness of the effects of her drug use on her physical health. Her comorbidity score is four due to PTSD, GAD, and depressive disorder, as well as polysubstance use disorder, an atrial septal defect, and Graves disease. The patient is also a victim of rape. Her recovery environment stress score is a four due to lack of involvement with her father and her mother has health issues. The patients recovery environment support scores a three since her mother is involved and she has the ongoing support of her aunt and cousins. Her resiliency in treatment score is a two as she made progress since admission to RTC level of care. The treatment acceptance of the patient score is a three due to obstructive behavior in therapy with her mother, and fixation on her relationship with her boyfriend rather than on her own health. The treatment acceptance of the parent is a score of two due to mothers involvement in treatment. These findings support a CALOCUS score of 23, which is consistent with medically monitored residential services, such as RTC level of care. Therefore, the RTC level of care services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with subspecialty certification in child and adolescent 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: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Per CALOCUS, the patient does not meet the criteria for RTC level of care services. Although this patient is demonstrating difficulty functioning, the RTC setting is not considered the most effective treatment modality for patients with oppositional defiant disorder. He requires pharmacological, psychological and environmental treatment, but the documentation does not support RTC level of care services. The records suggest the patient is at low potential for risk of harm The physician reviewer found that  due to self-harm by cutting with recurrent suicidal ideation. The patient has demonstrated moderate impairment of functioning (score 3). He has significant comorbidities including bipolar disorder, ADHD, and GAD (score 3). The patients recovery environment is moderately stressful (score 3) given his contentious relationship with his father. The patients recovery environment includes his mother, who has been supportive (score 2). The patient has demonstrated poor response to treatment and recovery management (score 4). The patient has been obstructive to treatment (score 3). The providers notes state that the patient continues to display poor judgment and combativeness. His mother has been constructive with the patients treatment (score 2). This gives the patient a composite score of 21, which is consistent with medically monitored community based services. Therefore, the RTC level of care services were not and are not medically necessary for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for gene panel testing.  Testing for common recessive genetic disorders during pregnancy is beneficial to the patient because it allows the patient to make important medical decisions in the event that she is a carrier for a serious recessive genetic disease. If the patient is positive for a particular mutation, then her partner can also undergo testing. This allows for determining the potential to have an affected offspring with a serious genetic disorder.  Having this information is certainly more beneficial than not having the information. Moreover, the American College of Obstetricians and Gynecologists (ACOG) and other professional reproductive medical organizations support carrier testing in this clinical setting. For this patient, the provider recommended genetic carrier testing, including evaluation for SMN1 and SMN2, consistent with the ACOG recommendations. Therefore, the gene panel testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for a continuous positive airway pressure (CPAP) machine. The enrollee has a history of loud snoring and an Epworth Sleepiness Scale greater than nine, for which consultation with a sleep specialist is suggested. The provider diagnosed the enrollee with severe obstructive sleep apnea (OSA). He ordered a continuous positive airway pressure (CPAP) machine and mask with in-line humidity. The literature indicates OSA as a chronic disease; requiring long-term, interdisciplinary management. Options for treating OSA can be medical, surgical or behavioral, but the standard of care and treatment of choice remains the use of CPAP. This treatment is applicable for mild, moderate or severe OSA. This treatment has long been considered the standard of practice. Literature notes it remains so. The testing performed on the enrollee demonstrates he falls within acceptable clinical guidelines for this treatment; his continued adherence to program parameters provides support for its continued use. Medical records show a three-month compliance rate of 70%. The care provided to this enrollee was consistent with current practice guidelines and standards of care.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 sleep 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 similar medical condition.