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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Shoemaker Protocol including office visit with qualified provider experienced with the Shoemaker Protocol once every four to six weeks until the Shoemaker Protocol is completed (approximately six months); Welchol 625 mg three tablets daily; liposomal vitamin C 500 mg four times daily; vasoactive intestinal peptide nasal spray, epinastine HCL 0.05% two drops twice daily; neuroquadrant magnetic resonance imaging (MRI) without contrast; macron biofilm analysis; nares culture; Singulair 10 mg once daily; Cromolyn 4 ampules twice daily; and cholestyramine non-saccharine 4 grams. CRIS is a controversial constellation of symptoms, which is not currently accepted as a diagnostic disorder. Mast cell activation syndrome is a recent diagnosis of signs and symptoms related to mast cell release to include urticaria, angioedema, headache, and abdominal pain, as well as fatigue and memory issues. The current recommended therapy includes treatment to inhibit mast cell release and blocking symptoms. Histamine 1 (H1) and histamine 2 (H2) blockers are first-line therapy followed by leukotriene receptor blockers and Cromolyn sodium. This patients records do not document that he has failed treatment, or has a contraindication to H1 and H2 blockers. Thus, the requested Shoemaker Protocol including office visit with qualified provider experienced with the Shoemaker Protocol once every four to six weeks until the Shoemaker Protocol is completed (approximately six months); Welchol 625 mg three tablets daily; liposomal vitamin C 500 mg four times daily; vasoactive intestinal peptide nasal spray, epinastine HCL 0.05% two drops twice daily; neuroquadrant magnetic resonance imaging (MRI) without contrast; macron biofilm analysis; nares culture; Singulair 10 mg once daily; Cromolyn 4 ampules twice daily; and cholestyramine non-saccharine 4 grams are 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 and medications 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 internal medicine with subspecialty certification in allergy and immunology 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 been diagnosed with psoriasis vulgaris. In the Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted clobetasol, lidex foam, and betamethasone had provided mild control of the patients psoriasis. The provider noted that the patient had a history of skin cancer and breast cancer. The provider noted biologic injectables would compromise the patients immune system. Per the records, the patient has been taking Otezla, with decreased flares. the records indicated that the patient had been treated with photodynamic therapy for her face. The patient has requested authorization and coverage for Otezla tablets. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Otezla tablets are medically necessary for the treatment of the patients medical condition. Studies  reported, As elevated levels of tumor necrosis factor-alpha (TNF-) are associated with disease severity in psoriasis and psoriatic arthritis, TNF- antagonists are being used to treat moderate to severe disease in patients who have contraindications, fail to respond or develop side effects to conventional systemic therapies. Per the authors, Some of the common side effects include infusion and injection site reactions, infections  particularly reactivation of tuberculosis, autoantibody formation and drug induced lupus erythematosus, liver function abnormalities, hematological, and solid organ malignancies. A study revealed, Apremilast demonstrated significant improvements in mean percentage change in the Psoriasis Area and Severity Index (PASI) score and in pruritus. PASI response was maintained over 52 weeks with continued apremilast treatment. In addition, apremilast demonstrated improvements in nail and scalp psoriasis, both difficult-to-treat forms of psoriasis. Researchers reported, Apremilast was effective in the treatment of psoriatic arthritis, improving signs and symptoms and physical function. Apremilast demonstrated an acceptable safety profile and was generally well tolerated. In this case, the patient has chronic plaque psoriasis that requires systemic treatment. She has a history of skin and breast cancer. Immunosuppressive medication can increase the risk for infection and malignancy. The medical evidence supports the requested medication in this clinical setting. Therefore, Otezla tablets are medically necessary for the 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: Overturned Decision of Health Plan

The patient has requested reimbursement for embryo biopsy. Chromosomal microarray (CMA), as used in this case, has become accepted as the first-line evaluation of multiple congenital anomalies in pregnancies via prenatal testing. CMA has also been shown to be effective in improving rates of successful pregnancy for patients with poor prognosis undergoing in vitro fertilization. One study showed a rate of implantation and clinical pregnancy of 63.2% after preimplantation genetic screening via CMA compared to 26.2% for patients who did not have CMA. CMA of embryo can reduce rates of multiple births, risks during pregnancy and premature births. As this patient has a history of a first trimester spontaneous miscarriage, two chemical pregnancies, and three unsuccessful intrauterine inseminations, CMA of embryo was indicated in this clinical setting. All told, the embryo biopsy was medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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 enrollees parent has requested reimbursement for magnetic resonance spectroscopy (MRS) of the brain (CPT 76390). In this case, MRS was performed as part of a diagnostic work-up in this patient with global developmental delays and microcephaly. Miscevic and colleagues noted that proton MRS, is one of the few techniques for in vivo assessment of neurometabolic profiles. The authors further describe the value of MRS in the discovery of neurochemical trends for clinical diagnosis and treatment monitoring in neurometabolic disorders in children. This patients global developmental delay, microcephaly, and hypotonia were highly suggestive of an underlying neurometabolic disorder and supported an indication for MRS. All told, the MRS of the brain (CPT 76390) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the MRS of the brain (CPT 76390) was 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 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 reviewer 1 is board certified in neurology with special qualification in child neurology and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 3 is board certified in neurology with special qualification in child neurology 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: The patient has requested authorization and coverage for Saxenda. This patient with obesity and the comorbid hyperlipidemia has not had success with multiple U.S. Food and Drug Administration (FDA) approved therapies for the treatment of obesity. She is at risk for developing additional comorbidities such as hypertension, diabetes, obstructive sleep apnea, and joint disease due to her obesity. Guidelines for the pharmacological management of obesity from the Endocrine Society state that patients unable to successfully lose and maintain weight loss are candidates for medical therapies. Pharmacotherapy is recommended in patients with a body mass index (BMI) higher than 30 kg/m2. Saxenda is FDA approved for chronic weight management in patients with BMI over 30 kg/m2. Saxenda has been shown to be effective in a randomized controlled trial with 63% of patients achieving weight loss of over 5% of body weight over 56 weeks. This patient has a BMI of 32.6 kg/m2 and elevated cholesterol and LDL cholesterol levels. She has failed to lose weight with Qsymia, Belviq, and Contrave. The alternatives phentermine and diethylpropion lack long-term data on safety and efficacy. Moreover, the patient failed Qsymia, which contains phentermine. All told, Saxenda is medically necessary for the 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 internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for bilateral eyelid revision surgery. Based on the patients history and diagnoses, additional eyelid surgery would not improve the patients ptosis related to myasthenia gravis. Similarly, the brow scars from previous surgery would not be improved with additional surgery. There is a lack of evidence in the medical record that this patient has undergone a thorough ophthalmological evaluation supporting the need for additional surgery. Given these findings, the requested bilateral eyelid revision surgery is 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 ophthalmology 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 electrocardiographic recording. The diagnostic utility of prolonged ambulatory cardiac monitoring for diagnosing arrhythmias causing cryptogenic stroke and unexplained syncope is well established. Multiple trials have also evaluated the diagnostic utility of such monitoring in evaluating recurrent atrial fibrillation following radiofrequency ablation and in other settings. This patient presented with a history of intermittent palpitations but no other symptoms of arrhythmic significance. An ambulatory monitor was performed demonstrating insignificant, asymptomatic sinus pauses up to 2.4 seconds in duration. Repeat monitoring was not indicated given the findings on the prior study. Therefore, the electrocardiographic recording 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. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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

The patients parent has requested authorization and coverage for food allergy desensitization/tolerance induction program services and prospective authorization and coverage for 15 additional future dates of service for the food allergy desensitization/tolerance induction program services. While oral food desensitization has been achieved in the majority of patients in randomized controlled studies, few patients have been found to develop sustained tolerance in the long-term. Moreover, proceeding with oral desensitization to a multitude of foods to which there is no history of anaphylaxis is not supported in the current medical literature. It is within the standard of care to measure immunoglobulin E (IgE) levels to specific foods for a patient. However, an extensive array of blood tests examining foods to which a patient has not experienced a reaction has not been demonstrated to improve patient health outcomes in this clinical setting. All told, the requested food allergy desensitization/tolerance induction program services and prospective authorization and coverage for 15 additional future dates of service for the food allergy desensitization/tolerance induction program 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 internal medicine with subspecialty certification in allergy and immunology 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 patients parent has requested authorization and coverage for two hours of social skills group treatment per week, five hours of direct social skills supervision and treatment planning per month, and one hour of social skills parental training per month. The guidelines set forth by the Behavior Analyst Certification Board (BACB) and medical necessity criteria outlines by Papatola and Lustig support the medical necessity of 1.5 hours of social skills group treatment per week and 4.5 hours of direct social skills supervision and treatment planning per month for treatment of this patient. The BACB highlights that treatment intensity, or dosage, will vary with each client and should reflect the goals of treatment, specific client needs, and response to treatment. The provider has set the intensity based on the goals of treatment, patient needs, and response to treatment. Moreover, a portion of the request for additional hours does not meet the definition of medical necessity, as outlined by Papatola and Lustig. This definition of medical necessity includes health-care services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on these criteria, the caregiver request does not meet criteria (c), as the BCBA has requested the services that are in type, frequency, and duration of treatment based on scientific guidelines and medical research, where the request is based on a previous authorization. After speaking with caregivers, reviewing previous documentation, and conducting their own assessment, the BCBA set a specific treatment intensity that should be utilized. Based on these findings, 1.5 hours of social skills group treatment per week and 4.5 hours of direct social skills supervision and treatment planning per month are medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is licensed B.C.B.A, board certified in psychology, 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 Rituxan infusion treatment. Transverse myelitis is a neurological disorder of the spinal cord caused by inflammation. Further work-up includes evaluation for demyelinating, autoimmune, inflammatory, and infectious etiologies. When an underlying autoimmune or demyelinating condition in transverse myelitis is suspected, intravenous (IV) corticosteroids are supported as first-line therapy followed by plasma exchange. Immunosuppressants medications are used for neuromyelitis optica and recurrent episodes of transverse myelitis not caused by multiple sclerosis. Per the American Academy of Neurology (AAN) guidelines, Rituxan may be effective in reducing transverse myelitis attacks in patients with neuromyelitis optica. Researchers found that Rituxan might decrease the number of relapses in patients with transverse myelitis due to neuromyelitis optica. In this case, the patient has a diagnosis of idiopathic transverse myelitis. The records do not specify the patients treatment history including information on her relapses or exacerbations. In addition, there is a lack of documentation of a thorough diagnostic work-up including imaging to support an indication for Rituxan. Given these findings, the requested Rituxan infusion treatment is 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient had been diagnosed with bilateral knee osteoarthritis. The patient reported bilateral knee pain. Physical examination findings included tenderness to palpation over the right knee medial and lateral joint lines. Tenderness to palpation was noted over the anterior medial aspect of the left knee. The patient had been treated with oral anti-inflammatory medication, corticosteroids, and physical therapy. In an application for independent medical review, the patient noted that prior hyaluronic acid knee injections provided favorable results. The patient has requested authorization and coverage for Supartz injections to both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Supartz injections to both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of favorable results from prior viscosupplementation injections. Furthermore, the patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Supartz injections to both knees are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.