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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Hylatopic Plus Cream and Tetrix Cream. The Health Plan has denied this request indicating that the requested medications are not medically necessary for treatment of the patients atopic dermatitis. The submitted documentation supports the medical necessity of the requested medications. The patient is requesting coverage for hylatopic plus cream and Tetrix cream for the treatment of persistent atopic dermatitis and xerosis. The medical records indicate that these topical emollients have been significantly beneficial in controlling the patients disease. The documentation provided notes that the patient has used the requested medications through 2017 without incident. It is reasonable to approve the coverage of hylatopic plus cream and Tetrix cream for this patient. The medical records indicate that these topicals are the effective and useful agents to control this patients skin condition. As the patient has been successfully treated with these topicals in the past, their use is considered medically necessary. Therefore, Hylatopic Plus Cream and Tetrix Cream are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the ice machine combined cooling/heating device. Review of current medical literature does not indicate that the ice machine combined cooling/heating device provided was likely to be more beneficial for the treatment of the patients condition than any standard available therapy. While researchers reported that continuous flow cold is superior to crushed ice for outpatient ACL [anterior cruciate ligament] reconstruction pain and should not be considered an equivalent modality, there is a paucity of data demonstrating that the device results in superior health outcomes in bunion surgery. Thus, the ice machine combined cooling/heating device was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the ice machine combined cooling/heating device was 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 ice machine combined cooling/heating device was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Medical professional reviewers 1, 2 and 3 are board certified in podiatry 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a cardiac computed tomography (CT) scan (coronary calcium without contrast). Findings:  Two of three physician reviewers found that this patient presented with increased coronary risk but no documented chest pain, cardiovascular physical examination abnormalities or electrocardiographic changes. In this circumstance, current guidelines on the evaluation and management of cardiac risk do not recommend routine performance of coronary CT scanning to help guide further management. Treatment change based on CT results has not been shown to incrementally improve outcome when compared to outcomes from treatment based on clinical risk and standard lipid analysis alone. In sum, CT scan (coronary calcium without contrast) is not likely to be of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the requested services are 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 sub-specialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for diclofenac sodium 1% gel. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients posterior tibial tendinitis with plantar fasciitis secondary to pathomechanics. The submitted documentation supports the medical necessity of the requested medication. The current literature supports the use of topical NSAIDs for musculoskeletal pain. Topical NSAIDs provide significant levels of pain relief in painful musculoskeletal conditions such as plantar fasciitis, as well as traumatic conditions, which can be similar to that provided by oral NSAIDs. Gel formulations of diclofenac, also known as the brand name, (as Emugel), ibuprofen, ketoprofen, and some diclofenac patches, provide the best effects. These treatments are recommended by the U.S. Food and Drug Administration. Adverse events related to their use are usually minimal. It is well documented that the patient is unable to tolerate oral NSAIDs. As such, diclofenac sodium 1% gel is reasonable, appropriate, and 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for doxorubicin hydrochloride liposome injection for treatment of the enrollees multiple myeloma. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication. The use of Doxil in combination therapy with dexamethasone and Velcade is reserved for relapsed or refractory multiple myeloma. Per National Comprehensive Cancer Network guidelines, doxorubicin, not pegylated-doxorubicin or Doxil, is considered a standard first-line therapy for high-risk multiple myeloma patients who are eligible for transplant in combination with dexamethasone and Velcade. There is no rationale why the patient requires the substitution of Doxil for doxorubicin. Therefore, the requested doxorubicin hydrochloride liposome injection is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine 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 Repatha SureClick 140 mg/mL Pen. The submitted documentation supports the requested medication in this clinical setting. In this patients case, the records document coronary disease, hyperlipidemia and marked intolerance to statin medications. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein (LDL) cholesterol. This patient fits the latter criteria. Several prospective randomized trials have demonstrated the safety and efficacy of the requested medication at lowering LDL cholesterol and improved cardiac outcomes in this setting. Therefore, Repatha SureClick 140 mg/mL Pen 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for inpatient hospital stay The submitted documentation supports the medical necessity of the services at issue. This patient had several stroke risk factors, including hypertension and hyperlipidemia. In the acute setting, risk stratification tools are relied on to help guide decision making. A nationally accepted tool included in American Heart Association/American Stroke Association (AHA/ASA) guidelines is the ABCD2 score. This patients ABCD2 score was a 3, placing her at high risk for an ischemic event and warranting further evaluation and inpatient monitoring. Recommendations include admission for patients with an ABCD2 score greater than or equal to three. Additionally, with speech complaints, a cardiac and vascular source must be considered, and the patient was identified to have a large middle cerebral artery aneurysm that required treatment. Therefore, the inpatient hospital stay was medically necessary for the treatment of this patient. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services. The submitted documentation fails to demonstrate the medical necessity of the requested services. In an application for independent medical review, the patient reported that prior acupuncture services assisted in lowering his prostate-specific antigen levels. However, the records do not document the number of sessions already completed and the specific, measurable, sustained, objective, functional improvement obtained with previous acupuncture to support the necessity of the additional acupuncture requested. There is a lack of support for the requested services in this patients case. Therefore, the requested acupuncture services are not medically necessary for the 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 oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg tablets. The submitted documentation supports the medical necessity of the requested medication. Psoriasis has a negative impact on quality of life, especially in patients with moderate or severe disease. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. This patient requires systemic treatment. The immunosuppressant and anti-tumor necrosis factor drugs recommended by the Health Plan can increase the risk for infection and malignancy. The medical evidence supports Otezla in this clinical setting. Therefore, Otezla 30 mg 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for use of a continuous positive airway pressure (CPAP) machine and supplies. The submitted documentation supports the medical necessity of the equipment at issue. In this case, the patient was prescribed CPAP for home use. The medical evidence supports the use of CPAP as the first-line treatment in severe OSA. It is well-established within current practice guidelines that CPAP supplies should be replenished on a periodic basis. This is in part to maximize patient therapy with the devices. Per the records, this patient was noted to have been compliant with the use of his CPAP. Compliance is generally defined as use for four or more hours on 70% of nights within a 30-day period. Therefore, the use of a CPAP machine and supplies was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was 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 neurology with sub-specialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for procedure described by the treating provider, surgical resection of the femoral nerve tumor, with nerve stimulation and electromyography (EMG) for further evaluation of functional services related to the pelvic tumor in a joint surgery. The submitted documentation supports the requested services in this patients case. The tumor is causing pain and may ultimately result in a severe neurological deficit as it continues to increase in size. These tumors are more safely excised when they are smaller, and continued delay will increase the risks involved with this surgery. These tumors should generally be removed when they are discovered, as some of these tumors will become malignant over time. Therefore, the procedure described by the treating provider, surgical resection of the femoral nerve tumor, with nerve stimulation and electromyography (EMG) for further evaluation of functional services related to the pelvic tumor in a joint surgery 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 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 Mavyret 100-40 mg three tablets daily for eight weeks. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The guidelines recommend that non-cirrhotic treatment naive genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100-40 mg three tablets daily 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing. Foundation One assay is a molecular assay that explores the mutations of an individuals cancer cells. However, at this time, there is a lack of convincing evidence that the assay adds to the decision making ability or yields a result that is reliably clinically beneficial. A randomized trial by researchers failed to demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. Additionally, finding a mutation does not guarantee that a treatment directed at the mutation will produce a clinically meaningful response. Therefore, gene panel testing was not likely to have been superior over other methods of evaluating this patient.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 sub-specialty certification in medical oncology 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 patient has requested authorization and coverage for EpiPen 2-pak 0.3 mg/0.3 mL injection auto-injector. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients shellfish allergy, anaphylaxis. The submitted documentation supports the medical necessity of the requested medication. According to the Joint Task Force on Practice Parameters from the American Academy of Allergy, Asthma & Immunology and the American College of Allergy, Asthma and Immunology guidelines for the treatment and management of food allergies, injectable epinephrine is the treatment of choice for an anaphylactic reaction, regardless of the cause. For this reason, patients who have experienced immunoglobulin E-mediated reactions to a food or their caregivers should be educated and provided with injectable epinephrine to carry with them at all times. Because anaphylactic reactions may be prolonged or biphasic, it is reasonable to instruct the patient to carry more than one epinephrine injector, to seek immediate medical care after a reaction, and to be monitored for an appropriate period. It is well documented by the patient and the provider that this patient has a history of anaphylaxis with exposure to seafood. The patient has been carrying two packs of Epi-Pen in case of emergency. In sum, in light of the patients medical condition and the recommendation from general guidelines, the requested medication is medically necessary and appropriate. Therefore, EpiPen 2-pak 0.3 mg/0.3 mL injection auto-injector 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 sub-specialty 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.