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

Nature of Statutory Criteria/Case Summary:A 60-year-old male enrollee has requested authorization and coverage for Uloric 40 mg tablet for treatment of the enrollees stage III chronic kidney disease and foot pain. Findings:  The physician reviewer found that As noted by Becker and colleagues, an indication for pharmacologic urate-lowering therapy in patients with a diagnosis of gout is gout with renal insufficiency. Thus, it was reasonable to attempt first-line therapy with a xanthine oxidase inhibitor (XOI), such as allopurinol, for this patient. However, since the medication was not tolerated, an alternate agent is required. Uloric has also been effective in safely reducing the serum urate in patients with moderate to severe renal impairment, as shown in a randomized 12-month trial involving 96 such patients who were treated with 30 mg twice daily, 40 mg once daily (increased after one month to 80 mg once daily if serum urate was  6 mg/dL after 14 days of therapy), or placebo (Saag, et al). Although uricosuric agents are another option for urate lowering, probenecid is likely to be ineffective in patients with moderately impaired kidney function. Thus, this agent would not be ideal for this patient. Further, Becker and colleagues noted that Colcrys is generally given as short-term therapy (ie, for periods not exceeding six months duration) to prevent acute attacks during the initiation of antihyperuricemic therapy because it is potentially toxic. In summary, the available evidence and current recommendations support the medical necessity of the requested Uloric 40 mg tablet 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 nephrology 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 a functional electrical stimulation cycle ergometer (FES-CE) for treatment of the enrollees spinal cord injury.Findings:  The physician reviewer found that there is a lack of peer-reviewed literature demonstrating significant health or functional benefit of exogenous neurostimulation therapy of paralyzed muscles using FES cycle.  There have been a number of case reports and small series published over the years providing some preliminary data suggesting possible benefits, but larger studies designed to evaluate the actual clinical efficacy of passive exercise such as FES in the setting of spinal cord injury are lacking. While repeated bouts of exogenous neurostimulation of paralyzed muscle may potentially retard or reverse muscle atrophy in paralyzed muscle, there is no significant health or functional benefit of this achievement in spinal cord injury because the muscle tissue that is gained or spared does not protect against pressure ulcers or provide any other clinically or functionally relevant benefit.  It does not obviate the need for pressure relief. For the reasons provided, the requested FES is an exercise device that provides passive exercise, not active exercise and it is not an appropriate substitute for active exercise using any residual musculature that is still under volitional control. Final Result: Two reviewers determined that the requested equipment is 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: Two physician reviewers are board certified in physical medicine and rehabilitation and are actively practicing. One physician reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in spinal cord injury and is 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: An enrollee has requested authorization and coverage for Otezla 30 mg for treatment of the enrollees psoriasis vulgaris. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has tried and failed treatment with topical steroids and topical vitamin D analogs. The medical information indicates that the use of methotrexate is contraindicated due to alcohol use. However, there is no documentation of trial failure or contraindication to the use of the preferred formulary agents, Enbrel, Humira, Stelara, or Remicade. The records do not document a clear contraindication to the use of the preferred formulary alternatives. All told, Otezla 30 mg 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical fusion surgery for treatment of the enrollees neck pain. Findings:  The physician reviewer found that the request for cervical fusion surgery has not been established as medically necessary for treatment of the patients medical condition. In this case, the patient presents with axial neck pain. She has no symptoms or signs of a cervical radiculopathy or cervical myelopathy. In addition, there is no evidence of failed conservative management. Given the lack of documentation demonstrating cervical radiculopathy, cervical myelopathy and failure of conservative management, cervical fusion surgery is not clinically indicated for this patient. Final Result: The reviewer determined that the requested surgery 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 neurological 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 genetic testing (HHT panel) for evaluation of the enrollees capillary malformation arteriovenous malformation (CM-AVM). Findings:  The physician reviewer found that HHT is a genetic disease that causes multiple arteriovenous malformations in various organs. Common presentations include epistaxis, mucocutaneous arteriovenous malformations, and/or gastrointestinal bleeding. The genetic testing as recommended by this patients provider is for diagnostic purposes. The panel chose is appropriate and focused. In considering the specific of this patients clinical situation, the requested genetic testing (HHT panel) is reasonable and medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested testing is 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 internal medicine with sub-specialty certification in medical oncology 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 for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to the 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 or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for orthopedic shoes (orthopedic footwear L3221 x 2) and orthotics (L3020 x 2; foot insert) for treatment of the enrollees ankle joint pain, knee pain, and plantar fasciitis. Findings:  The physician reviewer found that based on the available documentation the requested biomechanical orthotics are not medically necessary for treatment of this patients foot pain. Review of guidelines indicate orthopedic foot wear including shoes, inserts, or modifications to shoes for patients without diabetes are not supported as medically necessary. Some bracing is considered necessary if on a shoe that is an integral part of a medically necessary leg brace. These criteria are not documented in the records provided for review. Moreover, the requested foot orthotic is not likely to alleviate the patients foot pain. All told, the requested orthopedic shoes (orthopedic footwear L3221 x 2) and orthotics (L3020 x 2; foot insert) are not medically necessary for treatment of this patients diffuse foot and metatarsal head pain. Final Result: The reviewer determined that the requested equipment 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 podiatry 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: A female enrollee has requested authorization and coverage for Xeljanz 5 mg for treatment of the enrollees alopecia.  Findings:  The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting.  This patient has experienced full regrowth of her hair with Xeljanz therapy, having already failed treatment with oral steroids, topical steroids, intralesional steroids and anthralin.  Xeljanz is a janus kinase inhibitor approved by the U.S. Food and Drug Administration for the treatment of rheumatoid arthritis. There is increasing evidence of its utility in the treatment of severe cases of alopecia areata, a disease for which few useful therapies exist. This patient has already tried and failed the standard therapies with steroids and anthralin. There is very limited treatment options for her type of alopecia and she has already shown excellent response to Xeljanz. Therefore, Xeljanz 5 mg 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: enrollee has requested reimbursement for the wearable cardioverter defibrillator (WCD) for evaluation of the enrollees diabetes, hypertension, and non ST elevation myocardial infarction (STEMI). Findings:  The physician reviewer found that current data from multiple trials and registries have advocated the use of a WCD after an initial diagnosis of severe left ventricular dysfunction as demonstrated by an ejection fraction less than 35%. This patients ejection fraction was estimated at 15%. The American College of Cardiology (ACC) and American Heart Association (AHA) recommend against placing an implantable cardioverter defibrillator within three months of the initial diagnosis of heart failure, within 40 days of myocardial infarction, or within three months of coronary revascularization. Moreover, this patient demonstrated a high risk for sudden cardiac death due to the presence of clinical congestive heart failure. All told, the WCD provided on 4/12/17 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service at issue was 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 number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) for treatment of the enrollees major depressive disorder, recurrent, severe without psychotic features.Findings:  The physician reviewer found that as noted in the medical literature, TMS is approved by the U.S. Food and Drug Administration (FDA) for patients with major depressive disorder when medications are ineffective. However, from the given documentation, the provider reports that the patient responded well to Nardyl without side effects. In the documentation, it was the patients preference not to take medication for major depressive disorder. As at least one medication was effective for this patient without side effects, the patients condition has not been refractory to medical therapy. Final Result: The reviewer determined that the requested service 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the Level of Care Utilization System (LOCUS) criteria, as of 6/19/17, the patients risk of harm score is four (4), serious risk of harm. The patient recently overdosed on her prescription medications due to marital conflicts at home. The patient has a history of prior suicide attempts. Per documentation, the patient has dependent personality disorder, and if husband continues to talk about divorce, it is likely that the patient will again attempt suicide. The patients functional status score is three (3), moderate impairment. The patient has a recent conflicted relationship with her husband. She has been unable to fulfill her responsibilities at home and has been depressed and isolating. There have been some improvements while she has been hospitalized in regards to her mood. However, when the patient was told that she would be discharged from the RTC, she was described as hysterical. The patients medical, addictive, psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of major depressive disorder and a history of breast cancer. She has a history of many prior inpatient hospitalizations and prior suicide attempts. The patients recovery environment score is four (4), highly stressful environment. The husband threatened divorce which led the patient to overdose on medications. The patients level of support score is three (3), limited support in the environment. The patients husband is supportive, but their marriage is currently under distress. The amount of support he can provide is limited, though he does seem willing to participate in martial therapy treatment. The patients treatment history score is three (3), moderate response to treatment and recovery. The patient did have some modest gains while in the inpatient unit as far as improving her mood. However, the patients partial recovery has only been maintained for moderate periods of time with strong social support and in structured settings. The patients engagement and recovery status score is three (3), limited engagement in recovery. The patient at times will cooperate with treatment if she feels that her needs have been met. Based on these criteria, the patient has a total score of 23 and met criteria for a RTC level of care. 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 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: A female enrollee has requested reimbursement for the blood test (tumor necrosis factor (TNF) antagonists) and testing for antibodies (substances in the blood that help with immunity) for evaluation of the enrollees Crohns disease. Findings:  The physician reviewer found that testing trough levels of infliximab during induction as well as maintenance has proven to be useful. In addition, infliximab levels and antibody levels also help in optimizing the infliximab doses and has strong correlations with the clinical presentation and laboratory results. Moreover, this testing can help predict a patients future response to therapy. Immunomonitoring is being increasingly used to optimize response rates in inflammatory bowel disease and has become the standard of care. All or most patients treated with infliximab have trough levels sampled either during the induction period or during a clinical relapse to determine whether they have adequate drug levels that may need to be adjusted or if they have antibodies requiring a change in the biologic therapy. Given this support, the blood test (TNF antagonists) and testing for antibodies (substances in the blood that help with immunity) performed on 4/26/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was 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 number one is board certified in pediatrics with sub-specialty certification in pediatric 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.Physician reviewer number two is board certified in pediatrics with sub-specialty certification in pediatric 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.Physician reviewer number three is board certified in pediatrics with sub-specialty certification in pediatric 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.