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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara 90 mg/mL. Findings:  The physician reviewer found that the current literature suggests that Stelara is safe and may have long-term efficacy for patients with moderate to severe arthritis. However, there are no guidelines to recommend one biologic over another for use in this clinical setting. In this case, the records document that the patient has been treated with one non-steroidal anti-inflammatory drug (NSAID) for therapy. He is noted to be unable to take methotrexate due to increased liver function tests (LFTs) with documentation of an elevated alanine aminotransferase (ALT) of 65. Overall, the medical records fail to demonstrate that the patient has persistently elevated LFTs, which would support a contraindication for methotrexate. The provider did not include documentation that the patient has been treated with and failed an adequate trial of sulfasalazine, cyclosporine, leflunomide, or Otezla. Moreover, there has been no trial of a tumor necrosis factor inhibitor. Although patients taking tumor necrosis factor inhibitors are at increased risk of contracting coccidiomycosis, according to the U.S. Food and Drug Administration (FDA), only current invasive fungal infections are contraindicated. Residence in an endemic area is not considered a contraindication to treatment with a tumor necrosis factor inhibitor. For these reasons, the request for Stelara 90 mg/mL is not medically necessary for treatment of this patients psoriatic arthritis and psoriasisFinal 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 rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for occipital nerve block injections provided and forward. Findings: The physician reviewer found that a diagnostic greater occipital nerve block may have a role in differentiating between cervicogenic headaches, migraine headaches, and tension-headaches. In this case, the patient has a diagnosis of headache which is poorly described in terms of location, character, frequency, or duration. The initial greater occipital nerve block procedure performed  was clinically indicated. However, therapeutic greater occipital nerve blocks are under study in the medical literature for treatment of occipital neuralgia and cervicogenic headaches. There is a lack of evidence in the peer-reviewed literature that therapeutic greater occipital nerve blocks provide sustained relief and current reports of success are limited to small, non-controlled case series. As such, the occipital nerve block injection provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, however not thereafter. Final Result: Two of the three  reviewers determined that portion of the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer number one is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. Physician reviewer number two & three are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for mental health intensive outpatient program (IOP) services for treatment of the enrollees major depressive disorder, severe. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). The patient met the criteria for treatment at the intensive outpatient program (IOP) level of care. The records indicate the patient is at serious risk of harm (score 3) with a history of a suicide attempt or gesture by cutting her wrists with a razor. On evaluation, the patient did not have any suicidal ideation, homicidal ideation, psychosis, or hallucinations. The patient demonstrated moderate functional impairment (score 3) and was able to continue to perform well in home school, but has become more isolative and depressed. The patient presents with significant co-morbidity (score 3) with obesity, sinus tachycardia, and major depressive disorder. Although the patient had sinus tachycardia, this did not require intensive monitoring. The patients recovery environment is moderately stressful (score 3) given the serious interpersonal conflicts with her parents. The patients parents are supportive (score 2) but also a source of conflict for the patient. The patient has demonstrated significant response to treatment (score 2) and was described as cooperative with staff and constructive in treatment (score 2). This composite score of 18 is consistent with IOP level of care services. Given these findings, the IOP services were and are medically necessary for treatment of this patients medical condition. 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 sub-specialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block. Findings:  The physician reviewer found that : The physician reviewer found the current medical evidence has not established the superior efficacy of the services at issue. While occipital nerve blocks have been used for diagnosis of occipital neuralgia, randomized controlled trials are still in process. The literature supporting occipital nerve blocks is mostly anecdotal, open-label and case series reports lacking an active comparator. All told, occipital nerve block was not likely to have been more effective than other treatment options in this patients case. Final Result: Two of the three  reviewers determined that the services at issue were 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 & 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for whole exome sequencing. Findings:  The physician reviewer found that Whole exome sequencing (WES) is a newer technology but there is sufficient support in the medical literature for its efficacy in this clinical setting. Based on the patients documentation, she would be an ideal candidate for WES, given her multi-system disease, with renal agenesis, cortical dysplasia of the brain, biochemical abnormalities, and language delay. These multi-system findings increase the likelihood of an underlying single gene disorder, which can be identified by WES. Identification of a specific diagnosis in this patient may provide guidance for management in the future, including proper dietary management, which may be indicated for an inborn error of metabolism. A unifying diagnosis may also provide insight into helpful treatments for skeletal, renal, and developmental manifestations. Yang and colleagues identified causative diagnosis in 25 percent of 250 probands studied with WES. This yield is higher than genetic technologies previously considered standard, such as karyotype analysis or chromosomal microarray. A study  found similar detection rates. For these reasons stated above, WES is likely to be more effective than the available standard modalities for the evaluation of this patients medical condition. Final Result: All three reviewers determined that the requested services are 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 & 3 are board certified in pediatrics and genetics 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for rapamycin or Depakote for treatment of the enrollee's history of tuberous sclerosis, epileptic spasms, intractable focal epilepsy and global developmental delay. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested medications. Depakote is a reasonable next option for anticonvulsant management in this patient. This medication may improve his seizure control. Per the records, increasing the dose of levetiracetam further would be unlikely to improve seizure control. As noted by the patients provider, polymerase-gamma testing is important prior to initiating this treatment. At present, the approved indication for rapamycin in pediatric and adult patients with tuberous sclerosis complex is for those patients who have subependymal giant cell astrocytomas that requires therapeutic intervention but cannot be curatively resected. The literature on its use in young children with intractable epilepsy who do not have potentially obstructive subependymal giant cell astrocytomas is mixed. A study enrolling 23 children between the ages 1.8 years and 10.9 years and concluded that although seizure frequency decreased, especially in children reaching target trough levels, we could not show a significant benefit. Larger trials or meta-analyses are needed to investigate if patients with tuberous sclerosis complex (TSC) with seizures benefit from rapamycin complex 1 (mTORC1) inhibition. Further studies are needed before rapamycin can be viewed as medically necessary for children under the age of three without enlarging subependymal giant cell astrocytomas. All told, the requested medication Depakote is medically necessary for the treatment of this patient. However, the medical records fail to demonstrate the medical necessity of rapamycin for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested medications 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 neurology with special qualification in child 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for occupational therapy treatment of the enrollees severe oral motor apraxia. Findings:  Three physician reviewers found that sensory integration disorder is a complex symptom profile that is not fully understood. There is some medical literature supporting sensory based activities. A study showed that many children with known or suspected childhood apraxia of speech benefitted from occupational therapy. In addition, there is research showing that occupational therapy is beneficial for children with childhood apraxia of speech. Many children with oral motor problems also have other motor dyspraxias and coordination problems.  In this case, the patient would benefit from occupational therapy to help with fine motor skills and sensory needs due to the diagnosis of childhood apraxia of speech. In sum, the request for occupational therapy has been established as 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 service is 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: Reviewer 1 is board certified in pediatrics and child neurology and is actively practicing. Reviewers 2 and 3 are board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a durable medical equipment, the Pedicraft Homecare Canopy Bed for treatment of the enrollee's congenital ganglioneuroblastoma.  Findings:  The physician reviewer found that there is support in the medical literature for the requested durable medical equipment in this clinical setting. This patient has cerebral palsy and global developmental delay as a result of congenital ganglioneuroblastoma and central nervous system recurrence. The patient is unable to clearly communicate the patients wants and needs. The patient is able to pull to stand but cannot walk independently. The patient has outgrown his current sleeping situation, and is able to put one leg over the side rail even when it is in the highest position. In addition, he has history of hitting the patients head on the side rails. Because of the patients increasing size, neurologic deficits, and developmental delay, he is no longer safe in his current sleeping environment. The patient requires a canopied bed without side rails or other metal surfaces to prevent injury. The patients current crib does not offer this. The Pedicraft Canopy enclosed crib bed provides a safe environment that this patient requires as the patient continues to grow and develop in a least restrictive environment. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the gene test provided. Findings:  The physician reviewer found that when fine needle aspiration (FNA) cytopathology is indeterminate, repeat FNA and or thyroid surgery were the standard options to obtain a definitive pathological diagnosis. Afirma gene expression classifier can help to identify benign thyroid nodules in patients with indeterminate FNA cytology . In this particular case, when the patients initial FNA cytology came back as benign, FNA could have been repeated, and if cytology was still indeterminate, surgical resection should have been considered. All told, the gene test was not 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 testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1,2 & 3 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 authorization and coverage for Norco 10/325 mg two tablets daily for treatment of the enrollees back, neck, abdomen, and shoulder pain.  Findings:  The physician reviewer found that Guidelines offer specific requirements for the ongoing use of opiate pain medication to treat chronic pain. Recommendations state the lowest possible dose should be used as well as ongoing review and documentation of pain relief, functional status, appropriate medication use and its side effects. In addition, providers of opiate medication should provide documentation of the patients response to pain medication including the duration of symptomatic relief, functional improvements, and the level of pain relief with the medications. This patients records do not include documentation that the use of the prescribed opioid medication did or will decrease the level of pain reported from one visit to the next. In addition, there is no noted functional improvement or improved pain noted during the duration of the prescription for Norco. Moreover, there is no indication that first-line agents such as non-steroidal anti-inflammatory drugs (NSAIDs) have been trialed and failed to provide adequate pain relief. Final Result: The reviewer determined that the requested medication quantity 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 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 Decision Dx-Melanoma test for evaluation of the enrollees melanoma. Findings:  Three physician reviewers found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit more to these statistics. By Balch staging, this melanoma would be classified as stage 1A, with an expected ten-year survival of greater than 89%. Decision Dx-Melanoma test is a study of 31 genes in an individuals melanoma cells. It then classifies that melanoma as either Class 1 (with a 90 to 92% rate of being disease-free at five years), or Class 2 (with a 65 to 80% rate). Researchers reported on 217 cases, with good correlation between prognosis and Decision Dx-Melanoma test classification, in patients undergoing sentinel node sampling, which this patient has not had. It is not clear how the five-year Decision Dx-Melanoma test data compares to the ten-year Balch data, and importantly whether Decision Dx-Melanoma test classification can be used to make clinical decisions. 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 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.