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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with type 2 diabetes. The patient was being treated with Invokana, Janumet, and glimepiride. The patient reported his fasting blood glucose levels were between 130 and 150 mg/dL. The provider noted a hemoglobin A1c level was 7.7%. The provider noted the patient needed an increased frequency of blood glucose checks. The provider prescribed a OneTouch Verio meter; however, the Health Plan denied the request on the basis that the patient has not tried the True Metrix meter. The patient has requested authorization and coverage for a OneTouch Verio meter system. The Health Plan denied the request and reported that the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a OneTouch Verio meter system is medically necessary for the treatment of the patients medical condition. Researchers reported, Self-monitoring of blood glucose (SMBG) is recommended as a core element of self-management of diabetes when used appropriately following suitable training. There are many glucometers currently available for SMBG, and there is a high degree of variability among these meters. The OneTouch Verio is a glucometer (GM) that contains a color range indicator (CRI). Researchers reported, This recent randomized controlled trial confirmed previous studies that showed a reduction of hemoglobin A1c when using CRI-based GMs in both patients with type 1 diabetes mellitus and type 2 diabetes mellitus. The True Metrix glucometer does not have CRI capability. The medical evidence supports the requested equipment in this clinical setting. Therefore, the requested OneTouch Verio meter system is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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

The patient has requested reimbursement for thoracic epidural steroid injection and prospective authorization and coverage for thoracic epidural steroid injection. Although thoracic spinal pain is not as common as lumbar or cervical pain, researchers found that the degree of disability resulting from thoracic pain seems similar to other painful conditions with associated loss of function. In comparing thoracic epidural injections with injections of local anesthetics, the authors concluded, Based on the results of this trial, it is concluded that chronic thoracic pain of non-facet joint origin may be managed conservatively with thoracic interlaminar epidural injections with or without steroids. In this case, the patient reported 80 percent relief from the injection, indicating that the pain source had been adequately identified and that a repeat epidural steroid injection is likely to be effective. As such, and based on current medical literature, the injection previously rendered and a repeat injection was and is medically indicated to manage the patients chronic thoracic pain. Therefore, reimbursement for thoracic epidural steroid injection and authorization and coverage for future thoracic epidural steroid injection was and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for full body magnetic resonance imaging (MRI). The records do not describe placement of a metal clip during a breast biopsy. The presence of metal foreign bodies is occasionally a contraindication for MRI scanning. Researchers found that the presence of metallic implants in MRI can cause substantial image artifacts, including signal loss, failure of fat suppression, geometric distortion, and bright pile-up artifacts which may cause large resonant frequency changes and failure of many MRI mechanisms. The presence of a metallic foreign body or object may cause serious injury due to movement or dislodgment of the metallic foreign body in the presence of the MRI system. There is no indication for utilizing MRI to detect metal of any type, whether it is a clip or a sensor. MRI is not used to detect the type of sensors or to evaluate the symptoms that this patient suspects. In this case, as the records do not indicate a metal clip was placed during surgery and potential metal foreign bodies may pose a safety risk in an MRI scan, the requested service is not medically indicated. Therefore, a full body MRI is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for referral to a hematologist. Researchers discussed the European League Against Rheumatism (EULAR) 2019 update on the recommendations for management of patients with systemic lupus erythematosus (SLE). Per the authors, Patients with SLE should be assessed for their antiphospholipid antibody status, infectious and cardiovascular diseases risk profile and preventative strategies be tailored accordingly. The updated recommendations provide physicians and patients with updated consensus guidance on the management of SLE, combining evidence-base and expert-opinion. Based on these guidelines, this patients records do not support an indication for referral to a hematologist. There is no report of a significant hematological abnormality or other hematology issue requiring the training and expertise of a hematologist. Therefore, the requested referral to a  hematologist is not medically necessary for eval and treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene assay.  While gene expression profile (GEP) testing has been shown to accurately identify risk of metastasis for patients with cutaneous melanoma, there is a lack of  consensus on how this affects the treatment plan for patients. GEP testing is not considered routine standard of care and is not currently recommended under National Comprehensive Cancer Network (NCCN) guidelines. There is a lack of medical literature supporting its use for the evaluation of patients with thin melanomas. In this case, the course of treatment for this patient would not change based on the results of the GEP testing, as the recommended course of treatment would still be a wide local excision with follow-up skin surveillance and possible sentinel lymph node biopsy. Therefore, the DecisionDx-Melanoma gene assay was not likely to have been more beneficial than any other available standard therapy for the patients medical condition.Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma gene assay  at issue 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 service at issue was 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 dermatology 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 authorization and coverage for continuous glucose monitoring (CGM) system (external receiver, CGM system; disposable sensor, CGM system; and an external transmitter, CGM). A CGM system is one of several U.S. Food and Drug Administration (FDA)-approved devices that use interstitial glucose monitoring to display glucose concentrations frequently throughout the day. This regular surveillance allows for determinations of glucose trends and immediate feedback while omitting numerous daily finger stick blood glucose tests. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends and help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia. It can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, as well as evaluate how diet and exercise affect blood sugars. A CGM can be used as a precautionary device in order to prevent potentially dangerous consequences of uncontrolled diabetes. CGM systems have been shown to improve hemoglobin A1C levels in diabetic patients. This patient has type 2 diabetes mellitus without complications, hypertension, and dyslipidemia. She has been unable to optimize her glycemic control and the DexCom G6 CGM system is indicated to improve her blood glucose levels and decrease her risk of diabetic complications. Given these findings, the requested CGM system (external receiver, CGM system; disposable sensor, CGM system; and an external transmitter, CGM) is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Zoll LifeVest wearable cardioverter defibrillator worn for 60 days. The documented high risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter defibrillators in this group of patients. Data from multiple trials have advocated the use of a Zoll LifeVest wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction with an ejection fraction less than or equal to 35% (Kutyifa, et al.; Klein, et al.; Epstein, et al.). This patients ejection fraction was 15-20%. The recommended timing of placement of a LifeVest based on current American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) guidelines is within 40 days of an acute myocardial infarction or within 90 days of an initial diagnosis of CHF with a severely reduced ejection fraction, as this patient. Accordingly, Zoll LifeVest wearable cardioverter defibrillator worn for 60 days from was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the Zoll LifeVest wearable cardioverter defibrillator worn for 60 days from 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 services at issue 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for in-home occupational therapy services. Young patients with Dravet syndrome have been found to develop intellectual disabilities over time. Additionally, they have behavioral, sleep, and psychological issues that are problematic. These issues prevent with delays or inability to meet expected milestones in different domains of development. As a result, multidisciplinary team involvement including physical, occupational and speech therapies, is essential to maximize the quality of life and well-being for patients with Dravet syndrome and their family. Acquisition of effective motor skills is relevant for activities of daily living (ADLs) including communication and learning, social interaction, and self-care activities. Functional impairments can limit a patients ability to participate in age appropriate and meaningful activities of childhood. Occupational therapy is the discipline that trains children to effectively interact with their environment and engage in desired daily activities. In this patients case, occupational therapy is appropriate to maximize functional independence and participation in school, home, and community activities. The patients severe developmental limitations compromise his independence and participation in basic ADLs. Given these findings, the requested in-home occupational therapy services are medically necessary for 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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: The patient has requested authorization and coverage for an external ambulatory infusion pump for insulin with accessories (E0784, A4230, and A4232). Findings:  The physician reviewer found that Continuous glucose monitoring systems enable patients to effectively control and adjust their insulin therapy. Continuous glucose monitoring systems have been found effective in lowering hemoglobin A1c (HbA1c) significantly in adults with type 1 diabetes. In a comparison of the Dexcom G4 Platinum and the Medtronic Paradigm Veo Enlite system, the two most widely used continuous glucose monitoring systems, Kropff and colleagues found the Enlite system was noticeably less accurate than the Dexcom G4 sensor. In this case, the patient has type 1 diabetes and reports problems with the accuracy and reliability of his current continuous glucose monitoring system. Therefore, an external ambulatory infusion pump for insulin with accessories (E0784, A4230, and A4232) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lidocaine 5% patch (Lidoderm) medication. Findings:  The physician reviewer found that The U.S. Food and Drug Administration approves the use of Lidoderm for relief of pain associated with post-herpetic neuralgia. McColgan and colleagues found that topical lidocaine patches have not been proven effective for the treatment of musculoskeletal pain. They further found that a large proportion of inpatients were inappropriately prescribed topical lidocaine patches predominantly for musculoskeletal pain. In a systematic review evaluating the efficacy, effectiveness and safety of using of lidocaine patches for chronic low back pain, Santana and colleagues concluded, We found no randomized controlled trials with substantial evidence to support the use of 5%  transdermal lidocaine patch in chronic low back pain. In this case, the patient has chronic low back pain due to lumbar radiculopathy and knee pain. The documentation does not reflect any history of post-herpetic neuralgia. The patient has declined conservative management of his lumbar radiculopathy with epidural steroid injections. Given that current medical literature does not support the efficacy of lidocaine patches for the treatment of lumbar radiculopathy and knee pain, the requested medication is not medically indicated. Therefore, lidocaine 5% patch (Lidoderm) medication 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 anesthesiology with sub-specialty certification 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for the following branded prescriptions: Strattera 40 mg capsule, two times a day; Intuniv 4 mg tablet, one a day; and Abilify 30 mg tablet, one a day. The U.S. Food and Drug Administration has approved the use of Abilify to treat irritability associated with autistic disorder and agitation associated with bipolar mania, and has approved the use of Intuniv and Strattera to treat ADHD. LeClerc and Easley noted, Medications are often added to behavioral therapy to help patients with autism spectrum disorder function successfully.  In this case, the patient is clinically stable on her current medications. It is medically appropriate for the patient to continue with her current regimen. Therefore, branded prescriptions for Strattera 40 mg capsule, two times a day; Intuniv 4 mg tablet, one a day; and Abilify 30 mg tablet, one a day 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name medication, Wellbutrin XL 150 mg. Saiz Ruiz and colleagues found that patients who could benefit from the clinical effect of bupropion included patients with inadequate response to previous treatments. The U.S. Food and Drug Administration approves the use of Wellbutrin for the treatment of major depressive disorder. In this case, the patient has major depressive disorder. She has found Wellbutrin XL effective for stabilizing her symptoms such that she was able to reduce and stop medication. Given that she has tried and failed alternative medications, including generic bupropion, and has responded well to Wellbutrin XL in the past, the requested medication is medically indicated for this patient. Therefore, brand name medication, Wellbutrin XL 150 mg  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 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 ketamine infusion services.Researchers performed a meta-analysis study to examine the efficacy of ketamine in the treatment of complex regional pain syndrome (CRPS). They selected randomized clinical trials or cohort studies for meta-analyses, with the primary outcome being pain relief. Their findings suggested that ketamine infusion can provide clinically effective pain relief in short term for less than three months. Researchers conducted a retrospective review to ascertain if the use of subanesthetic inpatient infusions of ketamine provide meaningful improvements in pain scores, and thus, quality of life, in patients suffering from CRPS. They concluded that limited subanesthetic inpatient infusions of ketamine may offer a promising therapeutic option in the treatment of appropriately selected patients with intractable CRPS. In this case, records suggest that the patient has a brachial plexopathy due to the thoracic outlet syndrome that in turn has led to this CRPS condition. The patient has severe chronic pain and CRPS type 2, which usually involves a damaged nerve, with widespread disease throughout the patient's body. Records indicate that the patient had in the past had several months of pain relief with ketamine infusions. Ketamine infusions are a method of chronic pain management for individuals such as the patient. Given the patients CRPS diagnosis and her history of good relief from ketamine infusions, ketamine infusion services were medically necessary for the patient. Accordingly, the ketamine infusion services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty certification 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.