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 Wakix 17.8 mg tablets. The documentation provided for review supports a diagnosis of idiopathic hypersomnia. The patients multiple sleep latency test (MSLT) demonstrated sleep latency of eight minutes but no sleep onset rapid eye movement (SOREM), which is consistent with idiopathic hypersomnia. The records do not demonstrate a diagnosis of narcolepsy. Moreover, the records do not specify the patients previous treatment doses, if higher doses were attempted, and the patients response. Wakix is a new medication U.S. Food and Drug Administration (FDA) approved for the treatment of patients with narcolepsy. Studies are promising on the effects of Wakix on patients with idiopathic hypersomnia. However, the FDA has not approved Wakix for the treatment of excessive daytime sleepiness for idiopathic hypersomnia and there is limited medical literature to support its use in this clinical setting. All told, the requested Wakix 17.8 mg tablets are 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 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 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 Prolia injections. Although the patient is being treated with Femara, the records provided for review do not document that she has tried and failed bisphosphonate therapy. In addition, there is no report that the patient has developed an intolerance or has a contraindication to first-line therapy with either an oral or an intravenous bisphosphonate. The literature does not support the use of Prolia over bisphosphonates for treatment of this patients osteoporosis or bone pain. Becorpi and colleagues concluded that, bisphosphonates reduce the risk of vertebral fracture by 30-70% in people with osteoporosis. Researchers noted that, bisphosphonates are utilized routinely in breast cancer. However, the authors concluded that, In patients with osteolytic lesions or hypercalcemia, zoledronic acid is superior to pamidronate. In this clinical setting, the medical literature supports treatment with a first-line therapy available on the Health Plans formulary such as alendronate, Boniva, Actonel, or Reclast. For these reasons, the requested Prolia injections are 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 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

The enrollee requested authorization and coverage for bilateral insertion of Latera absorbable nasal implant stents. This enrollee has a septal deformity and nasal valve collapse. She returned to her otolaryngologist and reported she was still having difficulty breathing. She reported Breathe Right strips helped. The impression was nasal obstruction, secondary to septal deformity, turbinate hypertrophy, and nasal valve collapse. The enrollee wants to avoid surgery; therefore, the otolaryngologists recommendation was for placement of Latera stents in the otolaryngologists office. The physical examination shows this enrollee has bilateral nasal valve collapse and narrowing. The enrollee also has clinical symptoms of nasal obstruction and has failed medical therapy. Though there is a deviated septum, the Latera implant would still be an option since the external and internal nasal valve are narrowed and the Breathe Right strips improved the enrollees symptoms. This indicates the Latera implants would accomplish the same goal, permanently. Therefore, this enrollee meets criteria for being a good candidate for bilateral insertion of Latera absorbable nasal implant stents. The Latera implant was approved by a governmental body.  It is approved for the use intended for this enrollee.Final Result: The reviewer determined that the requested service is likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is board certified in otolaryngology and are actively practicing. The reviewer is 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 enrollee is requesting reimbursement for substance abuse residential treatment center level of care. The enrollee has diabetes mellitus, bipolar disorder, post-traumatic stress disorder, major depressive disorder, and opioid use disorder. She was admitted to a residential treatment center for treatment of her substance use. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. The enrollees composite LOCUS score correlates with Level IV; however, due to the enrollees scores in Dimension 3 and Dimension 4, Level V, Medically Monitored Residential Services, is needed for this enrollee.Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollees parent requested reimbursement for the Tryptase blood test. The enrollee has a food allergy to corn and corn derivatives. He underwent a tryptase blood test. The tryptase test, fluorescent immunoassay, measures both the alpha and beta forms of tryptase; measuring both forms increases sensitivity for the diagnosis of mastocytosis, and mast cell degranulation as a cause of anaphylaxis. Tryptase is ordered to evaluate acute anaphylaxis and mast cell disorders. This was not the case in this enrollee. This enrollee was not a good candidate for the tryptase blood test. Medical records did not support acute anaphylaxis or mast cell disease activation.Final Result: Three of the three reviewers determined that the requested service was not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in allergy and immunology 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: 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 services. Applying CALOCUS, this patient meets the criteria for RTC services. The patient has been at significant risk of harm (score 3) due to a recent history of risky behaviors. The records document behavioral issues including aggression, running away, substance use, and inappropriate relationships with older men. The patient has exhibited serious functional impairment (score 4) considering the ongoing conflict with her parents and repeated altercations with peers in the structured treatment settings. She also has a recent pattern of excessive substance use resulting in harmful behaviors. The patient has significant comorbidities (score 3) due to substance use, mood swings, and PTSD symptoms. The patients recovery environment is moderately stressful (score 3). The patient has issues with substance abuse, legal and school difficulties, and conflict with her parents. The patients environment is described as supportive (score 2) as her parents have attempted to arrange for treatment and support the patients recovery with family therapy. The patient has demonstrated poor response to treatment (score 4), as the providers reference multiple prior RTC admissions and lack of progress in the current RTC. The patient has been incompletely engaged in treatment (score 3). She has experienced difficulty opening up in treatment and with being honest. This gives the patient a composite score of 22, which is consistent with medically monitored community based services. However, the patients score of 4 on functional impairment and scores of 3 and 2 on recovery environment support Level 5: medically monitored residence based services, such as RTC level of care. Furthermore, the patient meets criteria for Level 5C: long-term medically monitored residence based services, due to minimal past response to treatment and inability to maintain any gains achieved outside an intensive and highly structured setting (Klaehn, et al.). Given these findings, the RTC 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

The parent of an enrollee has requested authorization and coverage for an Emfit MM Movement Monitor.The submitted documentation does not support that the requested device is medically necessary. The patient has a history of generalized seizures. As the patient is currently seizure free and there is no documentation that the patient is not taking medications on a regular basis, there is no documentation that the patient requires continuous monitoring for seizure activity. While the requested device may be necessary for an individual who is currently having intractable seizures, this is not apparent from the documentation provided for the patient. Under these circumstances, the requested Emfit MM Movement Monitor is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested device 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 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

An enrollee has requested authorization and coverage for surgery to fuse bones in base of spine to pelvis. This patient presents with complaints of low back and right hip/buttock pain. She underwent L4-5 laminectomy with resolution of her radicular symptoms, but persistent SI joint pain. Functional limitations are noted in activities of daily living, ambulatory ability, and work ability. The records document that she underwent SI joint injection. The patient reported this injection was not successful, and the provider noted up to 25% pain relief. She underwent right S1-4 radiofrequency ablation injection with some relief and improvement with mobility. She has reportedly failed all available conservative treatment options. She has been diagnosed with SI pain, lumbar post-laminectomy syndrome, lumbar spondylosis and chronic pain. There is imaging evidence of L5-S1 disc protrusion with abutment of the right L5 nerve root. According to the International Society for Advancement of Spine Surgery (ISASS), there are specific indications for spine surgery. In this case, there is no evidence of confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period. In addition, there is no imaging study presented to evidence SI joint spondyloarthropathy, degenerative sacroiliitis, or SI joint disruption. Given these findings, the requested surgery to fuse bones in base of spine to pelvis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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, and 3 are board certified in orthopedic surgery 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

The patient has requested authorization and coverage for chiropractic services. Research has shown that spinal manipulation therapy (SMT) is safe and beneficial for chronic low back pain, and comparable in effectiveness to standard medical care. Per the submitted documentation, this patient has a history of chronic low back and neck pain. He was involved in an accident, which likely exacerbated his pain condition. The patient underwent multiple sessions of physical therapy, which did not alleviate his pain or improve his function. Given the supported literature for chiropractic in the treatment of low back pain and neck pain, a course of chiropractic treatment is appropriate. For these reasons, 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 board certified in chiropractic 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

An enrollee has requested reimbursement for the DecisionDx-Melanoma assay gene test. The DecisionDx-Melanoma test is not within the standard of care for the evaluation and treatment of patients with melanoma. In addition, the National Comprehensive Cancer Network (NCCN) guidelines do not support use of the DecisionDx-Melanoma results to direct patient treatment. There is a paucity of clinical trials demonstrating the clinical utility of the results to improve patient health outcomes. Moreover, the test results would not have changed this patients management. Based on current peer-reviewed medical literature and guidelines, the recommendation for this patient includes a wide local excision and follow-up skin surveillance. Given these findings, the DecisionDx-Melanoma assay gene test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  The reviewers found the DecisionDx-Melanoma assay gene test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting reimbursement for a Prolia injection. The enrollee has osteoporosis. The provider ordered Prolia, 60 milligrams subcutaneously, every six months. The enrollee received the first injection. The enrollee reports her dexa scan concluded she was a high fracture risk; with additional bone loss in the left hip and spine seen when compared to the previous dexa scan. The enrollee underwent an esophagogastroduodenoscopy, which revealed a Schatzki Ring. This enrollee was an appropriate candidate for Prolia and it was medically necessary; given her diagnosis of osteoporosis and her high fracture risk. Notably, despite treatment with her previous medication, she continued to experience bone loss. The formulary medications listed are all bisphosphonates.  Prolia (denosunab) was appropriately prescribed for this high-risk enrollee. Literature reports bisphosphonates and denosumab reduce the risk of hip, nonvertebral, and vertebral fractures. A professional society reports clinicians offer treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women with known osteoporosis.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 (insert specialty) 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 authorization and coverage for three-dimensional (3D) mammogram (breast tomosynthesis). The standard of care for detection and work-up of breast calcifications is high quality two-dimensional (2D) digital mammogram with spot compression magnification. There is no known advantage to 3D tomosynthesis over standard 2D digital mammography in this clinical setting. 3D tomosynthesis mammograms are useful for detection and characterization of masses, especially in dense breasts. This patient has undergone a thorough work-up with mammogram, ultrasound, and biopsy. Currently, there is no indication for the requested 3D mammogram with breast tomosynthesis based on the available imaging findings. Therefore, the requested 3D mammogram (breast tomosynthesis) is not medically necessary for 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 diagnostic 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for the medication Trulicity. Trulicity is a member of the Glucagon-like peptide 1 (GLP-1) analogues, a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. This class of medications has shown significant improvements in glycemic, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors. While all of these medications may be efficacious with regard to improvement of glycemic control, Trulicity is unique in that it has demonstrated potential to reduce the likelihood of cardiovascular events in patients with type 2 diabetes who do not have a known history of cardiovascular disease. In this case, while the patient does not have known cardiovascular disease, he is on statin therapy for dyslipidemia, which is a cardiovascular risk factor. Under these circumstances, Trulicity is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the 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 endocrinology, diabetes and metabolism, 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.