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 Qvar Aer w/adaptor.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has had asthma for a long period of time. The documentation provided does not include a report of symptoms associated with her asthma. The medication list indicates she is prescribed albuterol three times daily. However, the records do not include a review of symptoms that would reflect the need for rescue inhaler this frequently, nocturnal awakenings due to symptoms, limitation in normal activity or pulmonary function studies. Based on the clinical notes provided, the category of asthma severity is unclear. When treating a patient with asthma, the recommendations are for a stepwise approach to therapy. A low dose inhaled steroid is recommended when the patient has mild persistent asthma. For moderate persistent asthma, the preferred therapies are either low doses of an inhaled glucocorticoid plus a long-acting inhaled beta agonist, or medium doses of an inhaled glucocorticoid. In this case, it is unclear how severe the patients symptoms and disease are. Thus, the medical necessity for an inhaled glucocorticoid is not established. Therefore, Qvar Aer w/adaptor is not medically necessary for the 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 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:  An enrollee has requested authorization and coverage of Stelara 90 mg/ml subcutaneous solution to inject every 60 days.  Findings:  The physician reviewer found that the current literature suggests that Stelara is safe, effective and may have long term efficacy for patients with moderate to severe arthritis. In this case, the patient has a history of plaque psoriasis and refractory PsA. Systemic therapy would be recommended. The American Academy of Dermatology (AAD) does not recommend a specific agent over another. The AAD recommends ultraviolet A and ultraviolet B, systemic agents and biologic agents. A recent European update to the guidelines states We recommend ustekinumab as second-line medication for the induction and long-term treatment. In this case, the patient has failed phototherapy, conventional systemic agents (methotrexate and cyclosporine) and three TNFi . However, this patients psoriasis and PsA continue to be active. The studies show that Stelara is effective for PsA at the conventional, U.S. Food and Drug Administration approved doses of 45 mg and 90 mg every 12 weeks. In this patients case, the medical records support that Stelara is medically necessary. The patient has failed multiple medications to include three TNFi, methotrexate, and cyclosporine. For treatment of his skin condition, he has tried medications, as well as laser therapy and topical steroids, which have also failed. This patient has well documented failure of multiple therapies and the patient is responding well to Stelara. The patient has had a partial response to conventional dosing. In a review , they showed that dose escalation for ustekinumab (Stelara) to be efficacious and safe. Stelara is being used appropriately for treatment of this patients plaque psoriasis and PsA. As such, its use is consistent with standards of good medical practice. The records support continued damage despite traditional dosing. This patient is requesting a dosage increase of Stelara because conventional dosing produced a partial response. For the reasons noted above, the request for Stelara 90 mg/ml subcutaneous solution to inject every 60 days is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication dosage is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for dental anesthesia for treatment of the enrollees dental treatment. Findings:  The physician reviewer found that the request for dental anesthesia service is medically necessary for treatment of the patients medical condition. In general, intravenous sedation or general anesthesia is indicated for patients with acute situational anxiety due to immature cognitive functioning or for patients who are uncooperative due to physical or mental compromising conditions. In this case, the patient has moderate autism and intellectual disability. Due to the patients developmental disabilities, the patient has an extreme fear of dentistry which precludes conventional care. Given the patients documented impairment the requested dental anesthesia is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 dentistry 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: An enrollee has requested authorization and coverage for Euflexxa injections for treatment of the enrollees bilateral knee osteoarthritis.  Findings:  The physician reviewer found that hyaluronic acid injections for osteoarthritic knee pain are an established part of osteoarthritic knee pain treatment algorithms and generally considered a second-line treatment after exercise, weight loss and simple medications such as nonsteroidal anti-inflammatory medications and/or acetaminophen. Multiple studies have documented efficacy, although the magnitude of benefit varies between studies and individual patients. With long-term and widespread use, the injections have been confirmed to be safe without severe or systemic side effects. In contrast, nonsteroidal anti-inflammatory pain medications, acetaminophen, opioids and oral or intra-articular corticosteroids can all have serious systemic side effects and may not be reasonable treatment options for some patients. This patient reports consistent relief with hyaluronic acid injections and the medical records confirm these results. Thus, the requested Euflexxa injections are supported as medically necessary for treatment of this patients bilateral knee osteoarthritis. 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg one tablet by mouth for 16 weeks and Ribasphere 200 mg three tablets by mouth every morning and two tablets every evening for 16 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the 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, based on a 100% cure rate in the C-EDGE TE trial.  In this case, the patient has the M28 mutation, which is associated with reduced effectiveness of Zepatier unless ribavirin is used and treatment is extended to 16 weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is medically indicated in this patients case. Therefore, the requested treatment with Zepatier 50/100 mg one tablet by mouth for 16 week and Ribasphere 200 mg three tablets by mouth every morning and two tablets every evening for 16 weeks to treat hepatitis C is supported as medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a dermatology consultation for evaluation of the enrollees rosacea. Findings:  The physician reviewer found that there is sufficient support for the requested services in this patients case. This patient does not qualify for referral because the primary care physician did not prescribe oral antibiotics. However, dermatologists generally prescribe the tetracycline family of antibiotics for the treatment of rosacea.  The request for coverage of a dermatology referral should be approved, as dermatologists are the physicians who specialize in the care of acne and rosacea.  The medical evidence supports the requested services in this clinical setting. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center level of care services provided. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. In terms of her anorexia, the patients body mass index entered the range of normalcy by the slimmest of margins. However, she still had orthostatic changes and lightheadedness.  Further, she had continued urges to restrict and purge, along with co-occurring mood symptoms and anxiety. The patient remained in a precarious state and had not consolidated the treatment gains necessary to maintain a healthy weight in a less restrictive setting. Psychiatrically, diphenhydramine was added upon admission to address insomnia, while the bupropion was reduced. The patients nystagmus was thought to be due to the bupropion dose reduction, so the taper was temporarily suspended. The diphenhydramine was replaced with eszopiclone as the patient feared going to sleep, and the prazosin was increased.  Thus, the patients medication regimen was in the midst of significant reconfiguration. Symptomatically, the patient was depressed with anhedonia, hopelessness, anxiety and suicidal ideation. She was psychiatrically unstable. In sum, the services and setting were and are safe, appropriate and consistent with good practice. Additionally, the services provided were and are reasonably expected to improve the patients condition, prevent a more serious episode of illness and facilitate a seamless transition to comprehensive community-based programming.  All told, residential treatment center level of care services provided were and are medically necessary for the 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 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 external ambulatory infusion pump, insulin for treatment of the enrollees type 1 diabetes. Findings:  The physician reviewers found that insulin pumps are a major advance in diabetes management, making insulin dosing easier and more accurate and providing great flexibility, safety, and efficacy for patients with diabetes. As such, insulin pumps are often the preferred treatment for people with type 1 diabetes mellitus. Emerging studies have demonstrated that glycemic control and quality of life may be improved by insulin pump therapy when compared to multiple daily injections of insulin.  All told, the requested external ambulatory infusion pump, insulin is likely to be more effective than other treatment options in this patients case.  Final Result: All three reviewers determined that the requested device 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 reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a dermatologist referral for evaluation of the enrollee who presented with a suspicious mole. Findings:  The physician reviewer found that the request for coverage of dermatology referral should be approved. The size of the area is estimated at 2.5 cm. Dermatologists have specialized training in the evaluation of nevi and other skin growths. The medical literature shows that dermatologists are able to detect thinner lesions and are able to detect them at an earlier stage than those melanomas diagnosed by other physicians. Additionally, there is a family history of skin cancer, and the primary care provider recommended an evaluation by a dermatologist. Based on these considerations, a referral to dermatology department for evaluation and consideration for a biopsy is consistent with medical necessity. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for Testopel implants (subcutaneous testosterone implants, CPT code S0189 quantity 10 and CPT code 11980 quantity 1) for treatment of the enrollee who has a history of low testosterone level. Findings:  The physician reviewers found that there is sufficient support in the medical literature for the services at issue. Testopel has been approved by the U.S. Food and Drug Administration and has been commercially available since 1972.  The medical literature indicates that Testopel offers a longer acting time to maintain normal levels of testosterone.  It does not require a daily or biweekly application like testosterone gels or testosterone injection.  Testopel maintains a more steady level and availability of testosterone for months after insertion. Testopel has distinct advantages over other treatment modalities for low testosterone and should be considered as one of the available standard treatment options by which low testosterone in men can be treated. All told, the Testopel implants (subcutaneous testosterone implants, CPT code S0189 quantity 10 and CPT code 11980 quantity 1) were likely to have been superior over other standard methods available for the treatment of this patients medical condition. Final Result: Two of three reviewers determined that 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 overturned.Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in urology and 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 additional acupuncture services for treatment of the enrollees thoracic pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The patient has a history of chronic thoracic pain, shoulder pain and headache. The patient presented with reports of improved pain after his first acupuncture treatment. The patient presented with thoracic pain, shoulder pain and headache. The patient rated his pain at 3-4/10, stating that he felt better after the last acupuncture treatment. After the initial six acupuncture sessions, an additional acupuncture six sessions were authorized. The patient was then authorized for two more acupuncture visits. The acupuncture received by the patient have failed to demonstrate significant pain score changes, and measurable functional improvements in activities of daily living. Based on the lack of significant, measurable gains obtained with prior acupuncture, the request for additional acupuncture services are not medically necessary for treatment of the patients medical condition. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency volumetric tissue reduction (tongue surgery) for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewers found that long-term studies are lacking which demonstrate the superior efficacy of the requested services in this clinical setting. This patient has been documented to have mild sleep apnea based on the results of the prior polysomnogram. The patient had been on CPAP therapy with a relatively low pressure of 7 cm of water with some improvement and elimination of obstructive events during sleep. The multiple prior surgical procedures included nasal reconstructive septoplasty and maxilla mandibular advancement therapy. The patient has undergone drug induced sleep endoscopy and the interpretation of the results by the clinical surgeon did suggest narrow anteroposterior hypopharyngeal airway with a suggestion that radiofrequency tongue base reduction on sequential visits should improve symptoms.  Patients treated with greater frequency tongue base reduction had only a mild reduction of apnea hypopnea index.  Most of those patients were massively overweight.  Reductions in the respiratory disturbance index and Epworth sleepiness scale but that the degree of heterogeneity of the medical studies was difficult, as the patient evaluations did not show strong similarity and so, conclusions were difficult to obtain. Based on the above medically peer reviewed evidence, current treatment and use of tongue base reduction surgery is still undergoing further evaluation. Active references that demonstrate the efficacy of the use of this procedure are lacking. Consequently, radiofrequency volumetric tissue reduction (tongue surgery) is not likely to be superior to other methods of treating this patients medical condition. Final Result: Two of three 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 number one, two, and three are board certified in otolaryngology and actively practicing. The reviewers are expertsin 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.