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 Repatha 140 mg/mL SureClick injectable medication for treatment of the enrollees arteriosclerotic cardiovascular disease (ASCVD).Findings:  The physician reviewer found that The records indicate that this patient has been able to take Lipitor 10 mg daily while other statins have not been tolerated. The patients LDL cholesterol is less than 100 but not less than 70, which is desirable in patients with established coronary artery disease. However, the American College of Cardiology (ACC) guidelines recommend a retreat from specific goals with more emphasis placed on taking moderate or high intensity statin. There are advocates for both approaches but there has been less emphasis on achieving an exact LDL cholesterol level. Repatha is generally reserved for patients with much higher LDL cholesterol levels than this patients LDL cholesterol of 100. Moreover, there is no documentation of this patients baseline LDL cholesterol prior to treatment. Considering all of these factors, the requested Repatha 140 mg/mL SureClick injectable medication is not supported as medically necessary for treatment of this 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sclerotherapy for treatment of the enrollees varicose veins of the right leg. Findings:  2/3 of the physician reviewers found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, there is no superficial reflux, and there are large symptomatic varicose veins. As such, it is medically reasonable to address those veins. This is especially true for this patient who is symptomatic. The proposed services are the standard of care in this clinical setting. All told, the request for sclerotherapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in interventional radiology with sub-specialty certification in vascular radiology 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.Physician reviewer number two is board certified in vascular 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.Physician reviewer number three is board certified in vascular 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: A female enrollee has requested authorization and coverage for weekly individual therapy sessions and year-long dialectical behavior therapy (DBT) group therapy for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the records reflect the fact that the patient has symptoms consistent with borderline personality disorder and has recently expressed suicidal ideation. The records appear to indicate the patient has been seen by her psychiatrist recently who has recommended psychotherapy for her condition. It is not clear from the records when the last time the patient has attempted a full course of DBT. The standard of care for DBT includes individual and group therapy for approximately one year.  Borderline personality disorder can be a very recalcitrant illness. One of the mainstays of treatment for borderline personality disorder is DBT, which can occur in a less restrictive setting once patients are free from safety concerns, which was the case for this patient.  This therapy is effective for borderline personality disorder and is provided in the outpatient setting on a regular basis. Due to the fact that borderline personality disorder tends to be difficult to treat, it is possible that individuals with this condition may need multiple trials of therapy for multiple years. The records indicated that the patients apparent functional impairment problems are due to her borderline personality disorder. In sum, weekly individual therapy sessions and year-long DBT group therapy is medically necessary for the treatment of this patient. 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 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: A female enrollee has requested authorization and coverage for Zepatier 50-100 mg tablets for 12 weeks for treatment of the enrollees 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 (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier with ribavirin for 16 weeks when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for a duration of 12 weeks (as requested) when NS5A resistance is present. When NS5A resistance is present, Zepatier and ribavirin for 16 weeks is recommended by the guidelines.  In this case, the prior treatment history is not clearly documented, so the appropriate regimen cannot be determined.  However, it is clear that in the setting of NS5A resistance, 12 weeks of Zepatier requested would not be sufficient, as 16 weeks would be needed.  If the patient has been treated before, even this may not be sufficient. For these reasons, although treatment is needed regardless of fibrosis stage, Zepatier 50-100 mg tablets for 12 weeks is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Marinol for treatment of the enrollees chronic obstructive pulmonary disease. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  There is little to no literature on the role of marijuana or cannabinoids in the management of breathlessness as a complication of advanced lung disease, largely because research on this family of drugs is limited. To date, the evidence demonstrates some benefits for cannabinoids in symptom relief for chronic neuropathic pain, cancer pain and multiple sclerosis related spasticity, otherwise the data was graded as low or very low quality. Further, the reported adverse effects often were more debilitating than  the disorder being treated. There is also limited evidence that cannabis differed from cannabinoids in effect or adverse effect. Lastly, regarding the issue of breathlessness, the scientific data is limited to the single cited study, which evaluated 224 normal and 68 COPD subjects exposing them to room air and varying concentrations of carbon dioxide to induce a sensation of breathlessness. Cannabinoids, in this case a nasal spray combination of tetrahydrocannabinol and cannabidiol, led to no changes in breathlessness or sensitivity to carbon dioxide. However, patients with COPD when asked to describe their breathlessness related some amelioration of the unpleasantness of breathing. In total, the investigators summarized that cannabinoids had no effect on simulated breathlessness. In this patients case, there is a lack of evidence in his medical records to support a prescription for Marinol. Moreover, the medical literature indicates that he runs a reasonable risk of suffering adverse effects from the drug. Breathlessness is common in advanced lung disease. As such, the standard treatment for this condition is a multistep approach in its management which may include aggressive bronchodilator therapy, consideration of immunomodulators (azithromycin), pulmonary rehabilitation, evaluation for sleep disordered breathing, optimization of cardiac disease (congestive heart failure or ischemia) and treatment of any comorbid depression or anxiety. Therefore, based on current medical evidence and this patients documentation, Marinol is not medically necessary for treatment of this 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 internal medicine with sub-specialty certification in pulmonary 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: A male enrollee has requested authorization and coverage for bariatric patient battery operated lift for treatment of the enrollees myoneural disorder. Findings:  The physician reviewer found that the requested bariatric patient battery operated lift is not medically necessary for treatment of this patients medical condition. Although an appropriately fitted lift device may be required by this patient, the records do not document extenuating factors that would necessitate a battery operated lift over an electric lift. There is no physician or therapist evaluation of the patients current lift mechanism for his wheelchair with detailed measurements that would indicate what the best lift device for this patient. The documentation does not reveal failure of an appropriately fitted non-electric lift or a detailed evaluation by a therapist indicating failure of his current lift mechanism. Moreover, there are no detailed physician progress notes with a physical examination of the patient including a detailed musculoskeletal and neurological examination to support the medical necessity of this device. Thus, the requested bariatric patient operated battery lift is not medically necessary.  Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 57-year-old female enrollee has requested authorization and coverage for 200 units of Botox every ten (10) weeks for treatment of the enrollees chronic migraine. Findings:  The physician reviewer found that there is support that this patient may benefit from treatment with Botox at 12 week intervals. However, there is a lack of support in the medical literature for the requested ten week regimen. Botox is a tool in the management of chronic migraine which has shown effectiveness in the PREEMPT trials. PREEMPT I showed, significant reductions from baseline were observed for onabotulinumtoxinA for headache and migraine days, cumulative hours of headache on headache days and frequency of moderate/severe headache days, which in turn reduced the burden of illness in adults with disabling chronic migraine. PREEMPT 2 concluded that onabotulinumtoxinA is effective for prophylaxis of headache in adults with chronic migraine. Botox has been approved by the U.S. Food and Drug Administration (FDA) for use in prophylactic management in chronic migraine defined as greater than 15 days per month. Repeated onabotulinumtoxinA treatments were safe and well tolerated. However, in these trials, which led to FDA approval, therapy was provided at 12 week intervals and not for ten weeks. Trial evidence to support a ten week dosing regimen is lacking. The documentation provided indicates that this patient meets criteria for treatment with Botox and as such, may benefit from a 12 week regimen. However, 200 units of Botox every ten weeks is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication dosage 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 expertise in episodic and chronic migraine 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: A 48-year-old female enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services for treatment of the enrollees malignant neoplasm of breast and cerebellar degeneration. Findings:  The physician reviewer found that the records provided for review do not demonstrate that the patient has needs for SNF services. The documentation does not reveal complex wound care, enteral feeds or ventilator dependence. The patient does not require skilled nursing services to prevent a deterioration in her condition or skilled nursing services to establish a safe and effective maintenance program. The patient does not require skilled therapy services on a daily basis or skilled nursing services on a daily basis. The patient has been limited by severe dizziness and fatigue with very slow progress in therapy. Therefore, she would not be expected to make measurable gains within a reasonable and predictable period of time or require inpatient skilled daily therapy to prevent deterioration with mobility and/or activities of daily living or establish a safe maintenance program. The patients therapy needs can be met at a lower level of care such as custodial care. Thus, the SNF services were not and are not medically necessary for treatment of this patients medical condition.  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 overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for long acting morphine or one of the following long lasting opioids: Avinza, Exalgo, Nucynta, OxyContin, Palladone, and oxymorphone HCL for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications. This patient appears to have opioid-induced hyperalgesia rather than tolerance since her pain has been increasing on higher dosages of potent opiates.  She has several risk factors that put her at increased risk for opiate complications, such as suicidal ideation, depression and self-escalation of medications, and these factors support the need for non-opiate pain therapy. Switching to extended release opiates to do a taper is not medically appropriate. All told, long acting morphine or one of the following long lasting opioids: Avinza, Exalgo, Nucynta, OxyContin, Palladone, and oxymorphone HCL are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 137 hours per month of applied behavioral analysis (ABA) Findings:  The physician reviewer found that According to the documentation submitted for review, the patient continues to demonstrate significant problematic behaviors which include elopement, aggression, noncompliance and tantrums. The failure to address these behaviors puts the patient at an increased risk for injury, and makes it increasingly difficult to be successful in more generalized environments. The Behavior Analyst Certification Board indicate that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Given the medical necessity of ABA for children with autism, the request for 137 hours per month of ABA therapy was and is medically necessary for treatment of the patients autism. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for hyaluronan/derivative Euflexxa IA injection per dose for treatment of the enrollees hip pain.  Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services. Piccirilli and colleagues performed a systematic review and meta-analysis regarding hyaluronic acid (HA) injections in hip disorders. The authors concluded that there is a lack of standardization of HA injections for hip conditions. Their results suggested that this is the best conservative therapy before surgery and it can act on pain relief and function. However, the authors noted there is no evidence to prove its ability to modify the morphological structure of the pathological hip and the natural history of the disease. There are few data about the use of HA in other hip disorders rather than osteoarthritis. Leite and colleagues did not recommend viscosupplementation for hip osteoarthritis. This patient presents with chronic left hip pain with functional limitations in work and activities of daily living noted. She has been diagnosed with left hip arthralgia, adductor muscle strain, degenerative acetabular labral tear, and femoroacetabular impingement. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. However, there is no radiographic evidence documented of osteoarthritis of the left hip. There is limited support in current evidence-based literature for viscosupplementation (hyaluronic acid injections) as an option for patients with severe hip osteoarthritis to delay total hip replacement. There is a lack of evidence to support the use of viscosupplementation in other hip disorders. Therefore, hyaluronan/derivative Euflexxa IA injection per dose are not medically necessary for the 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 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 a similar medical condition.