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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for physical therapy and occupational therapy in the home setting. Findings:  The physician reviewer found that Prader-Willi syndrome is a genetic disorder characterized by early feeding difficulties and failure to thrive, as well as significant hypotonia. Hypothalamic dysfunction may be the basis for short stature and hypogonadism. It may also contribute to problems with temperature regulation. Later on, hyperphagia leading to obesity and learning disabilities are characteristic. Respiratory problems include obstructive apnea and central hypoventilation and/or apnea. Chronic gastroesophageal reflux and aspiration also contribute to respiratory difficulties. Upper respiratory infections are often more serious than initially expected. This patient has been experiencing significant hypotonia since birth, as evidenced by her feeding difficulties. Because of her hypotonia, she may also have difficulty managing secretions. Because of her age, she is at risk for the myriad of respiratory illnesses currently in play across the country, specifically influenza A, influenza B, respiratory syncytial virus, human metapneumovirus, and the many rhinovirus subspecies. Any of these respiratory viruses could cause severe illness in this patient, including bronchiolitis and pneumonia. Limiting her exposure is important in maintaining her health in general, and her feeding regimen specifically. Therapy gyms that service young children present great exposure risk. For the duration of the respiratory viral season (at least through June to cover influenza B), home based therapy is medically necessary and appropriate. All told, physical therapy and occupational therapy in the home setting is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested therapy 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 pediatrics 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 reimbursement for DecisionDx-Melanoma assay. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma.Findings:  There is a lack of support for the superior efficacy of the services at issue in this clinical setting. DecisionDx-Melanoma test claims to determine risk of recurrence for early melanoma, as in this patients case who is diagnosed with stage 1a. However, there is a lack of data to support using immunotherapy in early stage melanoma regardless of the recurrence risk. Furthermore, prospective randomized data for determination of recurrence risk is lacking for this test.  In sum, DecisionDx-Melanoma test was not likely to have been superior over the other standard modalities of evaluating this patients medical condition. Final Result: All three reviewers determined 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left transtibial prosthesis for treatment of the enrollees left transfemoral amputation. Findings:  The physician reviewer found that in this case, the patients prosthesis is aged and due for replacement. The clinical notes document that the provider anticipates an increase in the patients functional level with replacement of the prosthesis and addition of a microprocessor component. In the medical literature, the authors reported that transfemoral amputees using a microprocessor-controlled knee have significant improvements in gait and balance. As this patients functional improvements are expected to be ongoing, the requested upgrade to microprocessor is justified. For these reasons, the requested left transtibial prosthesis is supported as medically necessary for treatment of this patients transfemoral amputation. Final Result: The physician reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a reimbursement for occipital nerve block injection. The Health Plan has denied this request indicating that the services at issue considered investigational for treatment of the enrollee who has a history of vertigo and dizziness. Neuralgia is a type of neuropathic pain. It can be lightening like, burning, dull or ache type pain that follows a peripheral or cranial nerve area that can also spread to other areas. There cannot be a neurologic deficit correlating with the nerve affected. Attacks either can be spontaneous or provoked by direct stimulation or palpation of other trigger point zones. Occipital neuralgia can specifically refer to pain and/or headache in the occipital region in the greater, lesser, or third occipital nerve areas, which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. On examination, the provider documented tenderness with palpation over the occipital area. Another key element to the diagnosis is response to occipital nerve blocks, which the patient also exhibits. The treatment of choice for occipital neuralgia is a local occipital nerve block due to its ability to relieve pain and act as a diagnostic marker as well as being a relatively safe procedure. Considering the information provided by the provider, the patient has several neurological diseases, one being occipital neuralgia. The treatment she has undergone has served as a diagnostic aid as well as therapeutically. According to the current data, guidelines, and recommendations the occipital nerve block injection provided was likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services 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: All three reviewers are board certified in neurology 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: A 29-year-old male enrollee has requested authorization and coverage for acupuncture for treatment of Tinnitus.  Findings:  The physician reviewer found that Tinnitus is a subjective sensation of hearing a sound in the absence of an external stimulus, which significantly worsens the quality of life of affected patients. A recent randomized clinical trial demonstrated the effects of acupuncture on tinnitus, and this modality was found to be effective in reducing the loudness and severity of tinnitus as well as in cases of non-pulsatile chronic tinnitus.  A comparative study demonstrated that different acupuncture techniques, including systemic manual acupuncture, periauricular electroacupuncture, and digital electroacupuncture, are effective in treating tinnitus. Therefore, in this patient with sensorineural hearing loss and tinnitus, the requested acupuncture is medically necessary. 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 otolaryngology 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 40 hours of per week of applied behavioral analysis (ABA). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder. The request for 40 hours of per week of ABA is not medically necessary for treatment of the enrollees autism spectrum disorder. Medical literature shows both intensity and duration of ABA therapy positively influences a favorable outcome in autistic patients, but the authors indicate that after the age of 12 the outcome of ABA therapy is not influenced by either duration or intensity. In addition, researchers found support community inclusion and development of social and living skills for the treatment of adults with autism. Given the medical literature cited above, the request for 40 hours per week of ABA therapy has not been established as 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 pediatrics and neurology with special qualification in child 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: There is support in the medical literature for an eight week course of IOP services in this patients case. A study infers improved functionality and decreased mortality associated with individuals who complete IOP programming.  In this case, the patients alcohol use was complicated by co-occurring depression, anxiety and trauma related symptoms.  This is of particular relevance since it has been established in both clinical practice and the medical literature that anxiety ridden mood disorders, without the complication of addictive illness, are difficult to treat and in general have poorer outcomes. Although the patient showed signs of steady improvement as evidenced by her two months of sobriety, medication adherence and ability to visit the patients workplace, she had not completed the time limited program. As the patient had not yet consolidated the issues that prompted the admission. The patient had significant psychiatric co-morbidity and unresolved issues generating distress. The patient lived alone. The patient was anxious and overwhelmed when visiting her workplace.  The patient was not sleeping well.  The patient was having urges to drink.  The patients mood was poor and sad, and the patient was frequently crying.  It appears that the patient was actively engaged in her treatment program, which included individual therapy, an array of groups and psychiatric services.  The patient was also mobilizing her social supports to buoy her recovery and autonomy, and developing an aftercare plan.  In sum, considering the relevant peer reviewed literature, current practice guidelines and the case in its entirety, service delivery at the IOP level of care was safe, appropriate and consistent with good medical practice. A two month treatment course aligns with community standards and would be reasonably expected to improve the patients condition, bolster relapse prevention efforts and prevent a more serious episode of illness.   Based on an admission date, the medical necessity for IOP services provided have been demonstrated as medically necessary, but not thereafter.  Given these findings, a portion of the services at issue was medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Vemlidy 25 mg tablets. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B virus. Findings: The physician reviewer found that the guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for treatment of hepatitis B but is associated with lower incidence of side effects such as osteopenia and renal disease. For this reason, Vemlidy 25 mg is medically necessary for the treatment of this patients hepatitis B. 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 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 the Novolog FlexPen. Findings: The physician reviewer found that insulin analogs such as Novolog, differ from human insulin and between each other by the substitution of one amino acid of the insulin molecule. Although current rapid-acting insulin analog products have met the threshold criteria for chemical and physical stability as set by the U.S. Food and Drug Administration (FDA), these formulations are susceptible to physical and chemical degradation above room temperature than are comparable wild-type formulations. The medical literature related to biosimilar medications of non-insulin products have required studies not only related to efficacy, but also related to immunogenicity. The records provided for review in this case demonstrate that the patient requires Lantus basal insulin and Novolog meal insulin. The patients hemoglobin A1C is at goal. In this case, the patients diabetes control is at goal with current therapy. The provider indicated in the medical record that patient had failed Humalog in the past. Thus, a change of insulin to a preparation that has failed in the past is contraindicated and would place the patient at risk of losing control of their diabetes. Based on the information provided, the requested Novolog FlexPen is medically necessary 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100 mg/40 mg three times per day for eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus (HCV), genotype 1a.According to the most 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. A clinical trial showed that only eight weeks of treatment is needed, not 12 weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100 mg/40 mg three times per day for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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: An enrollee has requested authorization and coverage for Repatha Pushtronex 420 mL once a month. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of hyperlipidemia.The submitted documentation fails to demonstrate the medical necessity of the requested medication. Based on the records provided the patient has a history of hyperlipidemia on maximum tolerated statin medication and increased coronary risk but no documented cardiovascular disease. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL-cholesterol.  This patient does not fit either of these categories. The diagnosis of heterozygous familial hyperlipidemia requires not only elevated LDL-cholesterol levels that significantly exceed 180 mg/dL but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomatas), a strong family history of coronary disease (younger than 50 years in second degree relative or aged younger than 55-60 years in first degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria. The records do not support this patient has either heterozygous familial hyperlipidemia or clinical cardiovascular disease.  There is a lack of literature supporting the use of  inhibitors in patient populations such as this patient. For these reasons Repatha Pushtronex 420 mL once a month is not medically necessary for treatment of the patients medical condition. Given these findings, the requested medication is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with 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. Findings:  The physician reviewer found that Findings:  The physician reviewer found that