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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xultophy 100-3.6 100 unit-3.6 mg/mL (3 mL) insulin pen. The records provided for review document that this patient has type 2 diabetes mellitus that has not been adequately controlled with multiple diabetic agents including glucagon-like peptide 1 (GLP-1) and basal insulins. The patient has since been started on Xultophy and is tolerating the medication well with improvement in his glycemic control. Xultophy is a combination of insulin degludec and liraglutide that has been U.S. Food and Drug Administration (FDA) approved to improve glycemic control in patients with type 2 diabetes as an adjunct to diet and exercise. Based on this patients failure to respond to multiple diabetic agents, Xultophy is consistent with the recommendations from the American Diabetes Association (ADA). Continued treatment with Xultophy is important to help this patient maintain adequate glycemic control. All told, the requested Xultophy 100-3.6 100 unit-3.6 mg/mL (3 mL) insulin pen is medically necessary for treatment of this patients type 2 diabetes. 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 diabetes, endocrinology 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Trabectedin for treatment of Kaposis Sarcoma. According to a study published in 2017, Trabectedin is currently approved for unresectable or metastatic liposarcoma or leiomyosarcoma after an anthracycline containing regimen.  Further, a study published in 2017, did not show any benefit of a neoadjuvant histotype-tailored chemotherapy regimen over the standard chemotherapy regimen. Trabectedin is an approved option for treatment of advanced liposarcoma and leiomyosarcoma (LMS) in patients who have been previously treated with at least an anthracycline-containing chemotherapy combination. Experience with this agent has also underscored the relevance of stable disease as a beneficial endpoint for metastatic soft tissue sarcoma. In this case, the enrollee has not received prior therapy. Per current peer review literature and guidelines Trabectedin is being reserved for second or third line.  For these reasons, Trabectedin is not likely to be more beneficial than any available standard therapy.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.Credentials/Qualifications: One reviewer is board certified in Hematology and Oncology and is actively practicing. Two reviewers are board certified in Oncology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for a custom, myoelectric elbow-wrist-hand-finger orthosis (EWHFO), the MyoPro. There is adequate data supporting the efficacy of myoelectric orthoses for use with brachial plexopathy. In addition, there is a small volume of literature with limited numbers of patients that show the benefit of using the MyoPro for stroke patients. However, there is a paucity of evidence to support a myoelectric orthosis as the standard of care. Colleagues published a clinical case series report with fewer than 10 patients. Colleagues found benefits in stroke patients using the myoelectric orthosis in 18 patients. Overall, larger prospective randomized studies are needed to support the use of the MyoPro in stroke patients. Furthermore, this patients condition is noted to include spasticity, which may complicate the use of the device. All told, the requested custom, myoelectric elbow-wrist-hand-finger orthosis (EWHFO), the MyoPro, is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested custom, myoelectric elbow-wrist-hand-finger orthosis (EWHFO), the MyoPro, 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 custom, myoelectric elbow-wrist-hand-finger orthosis (EWHFO), the MyoPro, 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: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services. Based on the documentation presented, the patient meets the criteria for medical necessity at the IOP level of care. Using the American Society of Addiction Medicine (ASAM) criteria for IOP, on dimension 1, the patient demonstrated a minimal risk of severe withdrawal as evidenced by multiple providers notes from stating that he was not experiencing withdrawal symptoms. On ASAM dimension 2, the patient demonstrated a minimal risk for biomedical conditions as evidenced by multiple entries from stating that he was feeling physically okay with adequate sleep and appetite. On ASAM dimension 3, the patient demonstrated mild severity for emotional or behavioral conditions as his depression and anxiety that ranged from a four out of 10, to as high as a seven out of 10, with no evidence of suicidal ideation, intent, or plan. On ASAM dimension 4, the patient demonstrated variable treatment engagement that required a structured program as evidenced by the providers notes. The provider noted the patient expressed anxiety about transitioning out of IOP. The notes state the patient appeared disengaged. The patient began sharing in the group more openly. He struggled to imagine living a sober life. The patient displayed a negative attitude with sarcastic comments in group therapy. On ASAM on dimension 5, the patient demonstrated a high likelihood of relapse without the structured program as evidenced by staff documentation of his craving for alcohol as six out of 10. The records report the patients cravings reached an intensity of seven out of 10. On ASAM dimension 6, the patient demonstrated an unsupportive environment as evidenced by his lack of a sponsor and a lack of a sober social network as reported in the documentation. All told, the records support the medical necessity of the IOP services for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with 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

Nature of Statutory Criteria/Case Summary: At issue in this case is whether the inpatient behavioral health services that were provided were medically necessary for the patients condition.  Upon admission, she reported hearing voices telling her to harm herself. Diagnoses include schizoaffective disorder. The progress notes indicate that the patient was open to discussion of her depression and anxiety symptoms. The patient did not exhibit any suicidal or homicidal ideation or signs of psychosis during the dates in questionThe Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults, to ensure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The composite score was 14, which is consistent with low intensity treatment services.Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laser treatment to destruct cutaneous vascular lesions. Facial erythema is a common chronic disorder characterized by periods of exacerbation, remission and possible progression. Individual subtypes are likely a result of different pathogenic factors and respond best to different therapeutic regimens. The non-pharmacologic approach to therapy is adequate skin care, trigger avoidance and photoprotection. In addition, there are several topical, herbal, systemic and light based therapies available. U.S. Food and Drug Administration (FDA) approved treatments include Metrogel and azelaic acid. Combination of azelaic acid or topical metronidazole with anti-inflammatory doxycycline appears to have a synergistic effect. Light-based therapies with pulsed dye laser and intense pulsed light are also effective in treatment of erythema and telangiectasias in patients with rosacea. Laser treatment can be used in combination with medical and topical treatments. The standard approach is to combine systemic anti-inflammatory effect of tetracycline antibiotics with topical anti-inflammatory and bactericidal treatments. Since this patient has failed treatment with tetracycline, a multifaceted approach to therapy that includes laser treatment is warranted. Accordingly, requested laser treatment to destruct cutaneous vascular lesions is likely to be more beneficial than any other available standard therapy for the patients facial erythema.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology 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:  The enrollee has congestive heart failure and dyslipidemia. Authorization and coverage for Entresto were requested. Findings:  The physician reviewer found that Stress echocardiogram showed exercise tolerance to be normal. Last scan prior to initiation of Entresto indicated ejection fraction of 50%. Scientific evidence does not support the medical necessity for Entresto in those with ejection fraction greater than 40%.Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in Cardiovascular Diesase and is actively practicing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transforaminal epidural steroid injection. Epidural steroid injections can be beneficial for lumbar radicular pain. In this patients case, physical examination showed right lower extremity sensory deficits and positive straight leg raise test. With regards to epidural injections, the current medical evidence supports no more than three to four injections in one location of the body in a 12-month period. Additionally, the patient should experience at least 50% benefit for six to eight weeks in order for repeat injections to be medically necessary. The patient should not be on blood thinners. If the patient is on blood thinners, this medication should be held accordingly to the type of blood thinner the patient is on. Although the records do not document the patients pain relief following the most recent procedure, he had at least 50% benefit from his prior injections. The patient received the injections in 2018, and it has been greater than three months since his last injection. Therefore, transforaminal epidural steroid injection is 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 anesthesiology with sub-specialty certificaiton in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee underwent a total knee arthroplasty. She then underwent an x-ray of the knee for persistent knee pain.  There was no acute fracture identified.  A request for Revision of Right Knee Surgery and Scanogram of the Right Knee was requested. In regard to the Revision of Right Knee Surgery, scientific literature indicates twice as many patients have pain after revision surgery compared with patients after primary total knee replacement surgery.  Patients after revision total knee replacement have reduced function and poorer quality of life and higher pain intensity compared with patients after primary total knee replacement.  Re-operation may be needed for a variety of problems related to total knee replacement surgery that may lead to implant/joint failure or patient dissatisfaction. The diagnostic studies that were performed included an x-ray, which revealed the alignment was normal and the device was in place.  Therefore, the requested Revision of Right Knee Surgery would not be medically necessary for the treatment of this enrollees medical condition. In regard to the Scanogram of Right Knee, the literature indicates leg-length discrepancy should be assessed with a full-length standing AP radiograph of the lower extremities ideally with use of a magnification marker or three distinct exposures centered over the hip, knee, and ankle (scanogram or orthoroentgenogram).  As bone length discrepancy had already been proven by physical examination, the Scanogram of the Right Knee would not be medically necessary to treat the enrollees medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in Orthopedic Surgery and is actively practicing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued treatment by an infectious disease specialist who specializes in chronic fatigue syndrome. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records document that this patient has been diagnosed with chronic fatigue syndrome. There are only a few clinics in the United States that concentrate on chronic fatigue syndrome, one of which is the clinic at Stanford. Most therapy used for patients who meet the diagnosis of chronic fatigue syndrome is unproven. Published studies do not provide evidence of clinical benefit from the antiviral treatment. There is a lack of published data that suggest better outcomes as a result of care at a clinic which specializes in chronic fatigue syndrome. Treatment is largely based on the patients symptoms. An infectious disease specialist who specializes in chronic fatigue syndrome is not necessary in order to effectively treat this patient. Therefore, continued treatment by an infectious disease specialist who specializes in chronic fatigue syndrome is not medically necessary in this patients case.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 sub-specialty certification in infectious 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: Overturned Decision of Health Plan

An enrollee requested Humira for treatment of severe disseminated psoriasis. Findings:The physician reviewer found that the patients psoriasis has reportedly been recalcitrant to first-line topical treatment with corticosteroids. A progress note reported the patient has psoriasis noted on the arms, legs and trunk with involvement of 10% or more of the patients body surface area (BSA). The patient reported joint pain in the hands. According to Mentor and colleagues, the American Academy of Dermatology (AAD) guidelines do not specify when to start a patient with psoriasis on biologics. There is consensus that patients with BSA of 5-10% and more should be treated systemically. The U.S. Food and Drug Administration (FDA) states that Humira has been approved for the treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy, and when other systemic therapies are medically less appropriate. In addition, open prospective studies and randomized controlled trials have shown the short-term efficacy of Humira in psoriatic arthritis and psoriasis. Moreover, Humira has been shown to be effective therapy when used either continuously or intermittently at subcutaneous injections every other week. Trials have shown marked improvement in skin conditions with the use of Humira. Therefore, the Humira is medically necessary to treat the patients medical conditionFinal 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

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with gender identity disorder. She began hormone therapy in 2016. On 3/6/19, the patient was noted to have thick male pattern facial hair growth. The facial hair was noted to exacerbate her gender dysphoria. At issue in this case is whether hair removal of the face is medically necessary for the treatment of this patients medical condition. Facial hair is a major feature of masculine development. In a transgender woman, the presence of masculine facial hair can lead to significant distress. Most transgender women indicated that their face was most imperative to have changed (Ginsberg, et al.). Of women's facial procedures, hair removal is predominant. In this case, the patient was diagnosed with gender identity disorder and experiences distress relating to her masculine facial hair. The patient was noted to have thick hair on her face, and her provider recommended hair removal with electrolysis. Therefore, hair removal of the face is medically necessary for this patient. 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 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.