Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The enrollee requested authorization and coverage for the LINX procedure. The enrollee has a history of gastroesophageal reflux disease. His symptoms include regurgitation, belching, nausea, bloating, and heartburn. The enrollee continues to experience daily reflux. Medications only provide partial relief of his symptoms. The LINX procedure has been recommended for the enrollee. A professional society noted the LINX procedure requires minimal dissection and relatively few technical steps, when compared to Nissen fundoplication. The LINX procedure may provide an option for those with gastroesophageal reflux disease who have not progressed to end-stage disease and its associated complications. The conclusion was the LINX procedure should be an available option to manage those with medication-resistant symptoms. Studies of the LINX procedure showed individuals continued to demonstrate symptom improvement one and two years after the procedureFinal Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gastroenterology and are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a brain single photon emission tomography (SPECT) scan with dopamine transporters (DaT) scan (CPT 78607 and HCPCS A9584). Parkinsons disease is a clinical diagnosis characterized by asymmetric onset of tremors, slowed movement, stiffness, and altered gait. In patients with equivocal signs and symptoms of Parkinsonism, or those who do not respond to treatment, SPECT with DaT can help confirm a diagnosis. SPECT with DaT can help image dopamine transporter in the brain, which is lost in Parkinsons disease. In this case, the patients clinical features described in the records are concordant with the clinical diagnosis of Parkinsons disease. In addition, the patients treatment regimen includes medical therapy for Parkinsons disease that has been adjusted based on her response. Results from additional imaging would not likely lead to a different diagnosis or an alteration in the patients current treatment plan. For these reasons, the requested brain SPECT scan with DaT scanning (CPT 78607 and HCPCS A9584) is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for laparoscopic esophageal sphincter augmentation with placement of sphincter augmentation device. The enrollee has a history of gastroesophageal reflux disease. The enrollee reports a primary symptom of chronic cough for six years. He underwent testing, which showed class B esophagitis. Other test results were consistent with chronic gastritis. During a surgery consultation the general surgeon recommended treatment with the LINX Reflux Management System. The LINX Reflux Management System may provide a way to treat gastroesophageal reflux disease for people who have not improved with medication. Studies show this procedure can improve symptoms and help people lower their medication use. This enrollee meets the criteria for the requested procedure.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gastroenterology and are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC).  Applying LOCUS, this patient did not meet the criteria for the RTC level of care services. The patient was at moderate risk of harm (score 3), as he voiced suicidal ideation without intent or conscious plan, and he had no prior history of suicide attempts. The patient demonstrated mild functional impairment (score 2) due to conflict in his marital relationship. The provider noted that the patients hygiene, level of activity, sleep, and appetite were normal. In addition, the patient was able to participate in socially constructive groups while on the unit. In terms of comorbidities, the patient has stable non-insulin dependent diabetes mellitus (score 3). There was no concern for active substance use or withdrawal. The patients recovery environment was highly stressful (score 4) given his serious marital conflict. The provider noted concern regarding the patient returning to live at home due to this tension. The level of support available to the patient was minimal (score 4), as his primary support was his wife and they were experiencing discord. He did have therapeutic support, as he was engaged in outpatient therapy. The patient demonstrated limited response to treatment (score 3), as the current RTC did not help him achieve optimal control of his symptoms. The patients fear of leaving the RTC facility intensified his symptoms of depression and anxiety. The patient was constructive in treatment (score 2) with positive engagement. The provider described the patient as an active participant in treatment groups. He was cooperative with his medications and capable of developing therapeutic relationships with his providers at the RTC. He had also previously developed therapeutic relationships with his outpatient mental health providers. This gives the patient a composite score of 21, which is consistent with medically monitored community-based services. Given these findings, the RTC services were not medically necessary for treatment of this patient.Final Result: The reviewer 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: 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement and prospective authorization and coverage for Venclexta (venetoclax) 200 mg daily. A phase 1 study of Venclexta monotherapy in 66 patients with relapsed or refractory multiple myeloma with an average of five prior lines of therapy, reported an overall response rate in 21% of patients. In addition, the response rate was higher among the patients with t(11;14) genetic abnormality when compared with non-t(11;14) patients. The U.S. Food and Drug Administration (FDA) placed a hold on this study until adjustments, including the administration of prophylactic antibiotics, were instituted. Overall, Venclexta monotherapy exhibited an acceptable safety profile and evidence of single-agent activity in patients with heavily pre-treated relapsed or refractory multiple myeloma, predominantly in patients with t(11;14) abnormality. This patient has aggressive disease that carries the t(11:14) mutation. Therefore, Venclexta (venetoclax) 200 mg daily was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Findings:  Two of the three physician reviewers found Venclexta (venetoclax) 200 mg daily, was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the medication at issue was and 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty 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

The patient has requested authorization and coverage for Otezla. Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. Otezla is an oral phosphodiesterase-4 (PDE-4) inhibitor that provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Researchers reported that three recent larger, double-blinded randomized multicenter studies have demonstrated that Otezla is efficacious in the treatment of psoriasis and psoriatic arthritis compared to placebo. The authors observed mild to moderate side effects, with a 75% reduction compared to baseline in Psoriasis Area and Severity Index (PASI-75) or American College of Rheumatology-20 scores. This patient presents with psoriasis and psoriatic arthritis that require systemic treatment. The physical limitations and risks associated with injectable biologics support the use of Otezla for treatment of this patient. Given these findings, the requested Otezla 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 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for post-acute care rehabilitation center services. The records provided for review do not support the medical necessity of post-acute care rehabilitation center services for treatment of this patient. The patients current nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is no indication for inpatient rehabilitation services with close physician or nursing supervision. The patients vital signs are stable and the provider has recommended discharge to a non-acute inpatient rehabilitation program. The patient may benefit and participate in additional physical and occupational therapy on an outpatient basis. The patients functional status does not require that these services be provided in an intensive rehabilitation facility. All told, the requested post-acute care rehabilitation center services are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Actemra (tocilizumab) 8 mg/kg (maximum dose 800 mg) intravenous (IV) monthly for six months. Researchers found that Actemra reduced total IgG and IgG1-3, and anti-HLA-total IgG and IgG3 levels in patients with chronic antibody mediated rejection (AMR). Medical literatures reported Actemra provided positive long-term results in patients with chronic poAMR. The authors noted that treatment with Actemra resulted in significant reductions in donor specific antibodies (DSAs) and stabilization of renal function at two-years. The records provided for review document chronic AMR. Testing has been consistent with persistent DSAs and a biopsy confirmed the presence of AMR. The provider recommended treatment with Actemra, IVIG, and a course of pulse steroids. Given the support in the medical literature, the requested Actemra (tocilizumab) 8 mg/kg (maximum dose 800 mg) IV monthly for six months is medically necessary for treatment of this 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 surgery with expertise in transplant 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Remicade 400 mg infusions at a frequency of every five weeks. The U.S. Food and Drug Administration (FDA) has approved Remicade for the treatment of ankylosing spondylitis. However, the requested dosage of Remicade 400 mg infusions at a frequency of every five weeks exceeds the FDA recommendations. Moreover, the records provided for review do not support that this patients neck and finger pain is due to ankylosing spondylitis. Radiographs demonstrated that the patients symptoms are consistent with degenerative arthritis. There are no radiographs confirming the presence of ankyloses or inflammatory erosive changes. In addition, there is a lack of clinical history and findings consistent with ankylosing spondylitis. Objective findings include a normal ESR and C-reactive protein. The patient reports incomplete improvement two weeks after Remicade treatment and the effects wear off prior to four weeks. Therefore, Remicade every five weeks is not expected to be beneficial. All told, Remicade 400 mg infusions at a frequency of every five weeks is not medically necessary for treatment of this patient. 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 internal medicine with subspecialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for chiropractic services. Researchers state that spinal manipulation therapy (SMT) produces similar effects to recommended therapies for chronic low back pain. Medical literature states that there is moderate quality evidence supporting SMT and mobilization to reduce pain and improve function for patients with chronic low back pain. This patient has a history of lower back, neck, and right shoulder pain. Current research has shown that SMT is safe and beneficial for chronic low back pain, and comparable in effectiveness to medical care. The patient reported that chiropractic care has been the only proven and non-invasive medical service that relieves her chronic pain. Given these findings, the requested chiropractic services are medically necessary for 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 a licensed chiropractor, board certified in oriental 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:  The enrollee is requesting authorization and coverage for monitored anesthesia care (MAC) during an upcoming colonoscopy procedure. The enrollee has a past medical history of drug rash eosinophilia systemic syndrome, lupus and arthritis, chronic stomach pain, chronic bloating, and difficulty swallowing. The enrollee was evaluated for bloating and pain. The provider advised a colonoscopy. The medical records describe a enrollee report of an anesthesia history of problems with anesthesia; therefore, the provider recommended monitored anesthesia care (MAC) for the procedure. This enrollee does not meet professional society criteria for monitored anesthesia care (MAC). The medications used for the colonoscopy do not cause the type of problems the enrollee reported in her history. The medical records do not support the enrollees history of difficult airway to support the need for monitored anesthesia care (MAC).Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The records document that the patient has a history of delirium tremens. In addition, the patients biomedical conditions placed her at risk of recurrent seizure from alcohol and benzodiazepine withdrawal. During prior withdrawal, the patient experienced an episode of delirium tremens. The patient has comorbid anxiety and depression diagnoses. In terms of readiness to change, the patient was willing, but not yet able or ready to find ways to connect with a sober community and manage her anxiety without self-medicating. Given the patients continued use despite negative consequences and her history of relapses, she was at high risk for repeated relapse. The patients recovery environment was supportive, but she would have likely returned to isolation if prematurely discharged. Overall, the patient required a safe and stable living environment in order to develop her recovery skills. Based on the available documentation, the patient qualified for ASAM Level III treatment, similar to what patient received at the RTC facility. For these reasons, the RTC services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 expertise in addiction 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 enrollee is requesting authorization and coverage for the medication, brand name Lo Loestrin Fe. The enrollee has a history of menstrual cramps since the age of 12, and has been on birth control since then. She has tried a number of different birth control pills and reports they have caused abdominal cramps, nausea and weight gain.  A progress note describes an enrollee report that the generic version of Lo Loestrin Fe caused severe nausea, irregular menstruation and fatigue.  She reports that Lo Loestrin Fe is the only medication that has been effective for her. The enrollees obstetrics and gynecology doctor is requesting authorization of Lo Loestrin Fe. Literature reports many types of birth control are beneficial for the treatment of menstrual cramps; including combined oral birth control pills, the patch, ring, or implant, and an injection, among others.  This enrollee has tried the patch, the injection, and several oral birth control pills.  She has used two of the oral birth control pills on the formulary.  She has had side effects to all of them except for Lo Loestrin Fe.  Therefore, since she has tried and failed on of the formulary medications, and there are no generic versions of this medication, Lo Loestrin Fe is medically necessary.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 obstetrics and gynecology and reproductive endocrinology 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.