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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the brand name medication, Exforge 5 mg/160 mg two tablets per day. Medical records provided indicate the patient has been taking Exforge since 2/11/08. Based on the limited medical records provided, there is no indication that the patient has had an allergic reaction or is intolerant to the generic form. Generic forms of this medication are rated by the Food and Drug Administration (FDA) to be equivalent and equally effective to the brand name. The requested dose for the medication is more than the highest dose approved by the FDA. This patient has a history of hypertension and has been taking the medication Exforge since 2008. He is taking a daily dose which includes 10 mg of amlodipine and 320 mg of valsartan, which is the maximum dose recommended for this medication. The documentation and medical records provided for review did not provide any information concerning other drugs that the patient may have tried which might have been effective. In conclusion, due to the lack of medical records and documentation provided and literature review recommendations, the denial of coverage for the brand name medication, Exforge 5 mg/160 mg, two tablets per day was not found medically necessary for this patient. The generic version of the medication can be used to treat this enrollees medical condition. Final Result: The reviewer determined that the requested medication/treatment is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in internal medicine and 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for tofacitinib. This pediatric patient has a five-year history of alopecia areata that has substantially affected her quality of life. The records document that the patients condition has persisted despite treatment with long-term topical steroids, which over time has caused atrophy of her skin. She was also treated with topical anthralin and topical squaric acid. She previously experienced some improvement with these agents. However, these medications are no longer effective for her, and she is exhibiting areas of atrophy from chronic steroid use. Her provider recommended tofacitinib due to the failure of typical first- and second-line therapies. There are recent studies demonstrating successful patient health outcomes with use of tofacitinib in resistant alopecia areata. As this patients alopecia areata has been refractory to multiple standard therapies, the requested tofacitinib is 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 requested tofacitinib is 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 medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in dermatology with subspecialty certification in dermatopathology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology with subspecialty certification in dermatopathology and is 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 psoriasis and psoriatic arthritis. The patient is complaining of stiffness to her fingers and wrists in the morning, has dystrophic nail changes over the last three months, and psoriasis for the last two years. The provider reports the patient has plaque psoriasis affecting about ten percent of her body surface area (BSA). The provider also reports that treatment with methotrexate, cyclosporine, acitretin or ultraviolet B is contraindicated. The provider reports oral disease-modifying anti-rheumatic drugs are suboptimal as the patient wishes to have a child. Drugs that are teratogenic such as methotrexate, cyclosporine, and acitretin should be avoided in this patients situation. Authors reviewed the non-biologic agents available to treat psoriasis and found that methotrexate, cyclosporine and acitretin all have significant adverse effects related to pregnancy. They also note that there are no adverse reports of the use of Otezla during pregnancy. The reviewer states that Otezla would be preferable considering this situation with this patient's need for psoriasis treatment and the desire to conceive a child. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an ultrasound of kidneys (CPT-76770).Renal medullary carcinoma is a rare kidney cancer that affects adolescents and young adults. Renal medullary carcinoma occurs almost exclusively in people with sickle cell trait. The most common presenting symptoms include gross hematuria, flank pain, and abdominal masses, with males disproportionately affected. Renal medullary carcinoma is characterized by early and widespread metastatic disease and resultant poor prognosis. One hallmark of the tumor itself is the loss of SMARCB1/INI1, a feature shared with a number of childhood cancers. Treatment generally involves nephrectomy and systemic chemotherapy. Clinical trials remain the mainstay of treatment for this disease. Authors noted, No evidence points to the benefit of screening individuals with sickle cell trait for renal medullary carcinoma because currently, no feasible schedule and modality of screening would have a likelihood of identifying the presentation of disease at an early stage. In addition, no effective measures exist for the prevention of renal medullary carcinoma. Per researchers, ultrasound imaging is insufficient for the diagnosis of renal medullary carcinoma or medullary renal lesions. Therefore, the requested ultrasound of kidneys (CPT-76770) is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics, with subspecialty certification in pediatric critical care 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

An enrollee has requested authorization and coverage for Gel One (hyaluronic acid) injection to bilateral knees. Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried and the options are limited. In this case, the patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties. Under these circumstances, the requested Gel One (hyaluronic acid) injection to bilateral knees is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for 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

The patient has requested authorization and coverage for valganciclovir one to two weeks a month every three months x 2, gammaglobulin injections, antivirals for HSV 6 gastrointestinal infection, and/or voriconazole for 30 days. The patients records report a variety of non-specific symptoms including fatigue, headache, and neck pain. There is a lack of clinical findings consistent with a diagnosis of Epstein-Barr virus (EBV), a gastrointestinal infection, or aspergillosis. There is a report of an elevated EBV immunoglobulin G (IgG), which is a common finding that suggests a past infection. There is inadequate clinical documentation of a current EBV infection. The provider referred to the patients diagnosis as colitis, which is not supported in the records provided for review. Moreover, although aspergillosis causes several types of pulmonary infections, this patients records do not include evidence of a clinical aspergillus infection. Overall, there is an absence of an indication for valganciclovir, gammaglobulin, antivirals, and voriconazole. Therefore, the requested valganciclovir one to two weeks a month every three months x 2, gammaglobulin injections, antivirals for HSV 6 gastrointestinal infection, and voriconazole for 30 days are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications 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 subspecialty 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services.The medical literature supports that the requested services are medically necessary. Researchers performed data analysis of randomized controlled trials and concluded that acupuncture appears to be a promising therapeutic approach for cervical vertigo. Authors conducted a randomized control trial to evaluate the effectiveness of a multimodal approach to the management of cervical vertigo. They concluded that the multimodal approach using manual therapy in combination with acupuncture and vestibular rehabilitation showed the maximum therapeutic effect on elimination of musculo-tonic disorders, reduction of a pain syndrome with a complete regression of vertigo and postural instability. Chiu and colleagues conducted a controlled clinical trial involving 60 participants and concluded that acupuncture demonstrates a significant immediate effect in reducing discomforts of both dizziness and vertigo. In this case, the patient has right ear pain and dizziness and has a history of vertigo that has been relieved by treatment with acupuncture. The patient has requested acupuncture treatment for vertigo at this time, and this treatment is supported in the medical literature. Accordingly, the requested acupuncture services are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is licensed in acupuncture, with board certification 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for psychiatric inpatient care. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. Applying the LOCUS framework, this patient did not meet the criteria for psychiatric inpatient care. For dimension 1, the patient was at moderate risk of harm (score 3) given his profound decline in function and his inability contract for his safety. The records indicate that the patient could not agree to keep himself safe outside of the inpatient hospital setting. For dimension 2, the patient demonstrated serious functional impairment (score 4) since he was not able to work, bathe or change his clothes due to his severe depression. For dimension 3, the patient has minor comorbidities (score 2) with a history of obesity and obstructive sleep apnea. For dimension 4, the patients recovery environment was moderately stressful (score 3) given his marital discord with his wife. In addition, the patients recovery environment provided limited support (score 3) due to the patients relationship issues with his wife. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4). The records document that the patient has failed treatment at the outpatient, intensive outpatient program (IOP), and partial hospitalization program (PHP) levels of care. Moreover, the patient has not experienced substantial improvement with medications including Zoloft, Paxil, Lexapro, and amitriptyline. For dimension 6, the patient was optimally engaged in his recovery (score 2). The provider reported that the patient was adherent and cooperative with his treatment. These findings give the patient a composite score of 21, which is consistent with medically monitored community-based services. Per LOCUS, the patients score of 4 on functional status meets the requirement for Level 5 medically monitored residence based services, but he does not meet the criteria for Level 6 medically managed residence based services. Therefore, the psychiatric inpatient care was not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue 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 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 has requested reimbursement and authorization and coverage for residential treatment center services. The American Society of Addiction Medicine (ASAM) criteria is a validated placement tool. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Based upon the above analysis of the six dimensions, it is clear that patient meets criteria for a 3.5 level of care for the period of time under consideration. Accordingly, the requested residential treatment center services provided during the period at issue were, and are, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat 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 addiction 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

An enrollee has requested authorization and coverage for autonomic nervous function testing. In autonomic nervous system dysfunction, patients may present with a myriad of symptoms including orthostatic intolerance, labile blood pressure, disorders of sweating and thermoregulation, neurogenic bladder, and gastrointestinal dysmotility. Although autonomic symptoms may be among the most debilitating features of many progressive conditions, they are often treatable. Given the complexity of the autonomic system there is no single test that precisely reflects the function of a specific branch of this system. Autonomic testing is grouped into general categories of autonomic activity including cardiovagal tests, adrenergic tests, and sudomotor tests. Therefore, it is common to order perform several tests based on diverse autonomic reflexes. According to the American Academy of Neurology, autonomic function tests are safe and have an extremely high value-to-risk ratio. In this case, the patient has symptoms suggestive of autonomic nervous system dysfunction with complaints of gastrointestinal pain and dysmotility, thermoregulatory, orthostasis, and paresthesias. Based on the current medical literature, autonomic testing is safe, non-invasive and required for accurate diagnosis of underlying autonomic system dysfunction and subsequent treatment of debilitating autonomic symptoms. Therefore, the requested autonomic nervous function testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 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: The patient has requested authorization and coverage for referral for evaluation to an intestinal transplant program. Current guidelines recommend intestinal transplantation in patients with ultrashort bowel syndrome, defined as having residual bowel measuring 20 cm and patients with unwillingness to accept long-term total parenteral nutrition (TPN). This patient has a history of total enterectomy with ultrashort bowel as well as a desire to end TPN as her source of intake. The use of intestinal transplant can result in rapid return of the patients nutritional autonomy, and avoid complications of TPN such as bacteremia or sepsis, fluid and electrolyte imbalances, liver and bile duct disease, and bone disease. Moreover, this patient does not have any reports of significant ongoing renal dysfunction. Given these findings, the requested referral for evaluation to an intestinal transplant program is 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 internal medicine with subspecialty 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.