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

Nature of Statutory Criteria/Case Summary: The patient is a 62-year-old who is overweight and has prediabetes. Laboratory results dated 4/15/22, noted a HbA1c of 5.9. On 6/7/22, the patient reported weight gain while being treated with Prednisone 5 mg for a prior kidney transplant. On 6/21/22, the patients body mass index (BMI) was noted to be 28.34 kg/m. Their physician has prescribed therapy with Ozempic. The Health Plan indicates that the requested medication is not medically necessary for the treatment of the patients medical condition. At issue in this case is whether an Ozempic 0.25/0.5 mg pen is medically necessary for the treatment of this patient. Gadde and colleagues note that obesity continues to be among the top health concerns across the globe. While lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. There are currently multiple pharmacologic therapies which are available for weight management. Knudson and Lau note, Ozempic (semaglutide) is a member of a class of medications known as GLP-1 analogs. These medications improve glycemic control, reduce body weight and decrease cardiovascular risk. Cornell stated that multiple studies have demonstrated GLP-1 receptor agonists ability to promote weight loss, via reduced appetite and energy intake, and delayed gastric emptying, and the likelihood of health risks associated with these medications are low. In this case, the patient is overweight with documented weight gain and prediabetes for which the effects of the Ozempic could be beneficial. Therefore, an Ozempic 0.25/0.5 mg 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 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: The patient is diagnosed with osteoarthritis of the left knee. The patient reported lateral left knee pain; the provider noted an MRI revealed evidence of degenerative arthritis of the left knee lateral compartment and a large defect of the anterior horn of the lateral meniscus. The provider noted a previous left knee steroid injection, administered it, and did not result in any improvement. The provider noted the patient had also been treated with other conservative treatments including acetaminophen, acupuncture, chiropractic treatment, physical therapy, and activity modification without substantial improvement. The physical examination revealed an antalgic gait when getting up from a seated position, and slight limitation of knee flexion. The provider recommended viscosupplementation with Durolane to the left knee. The Health Plan denied the request, indicating that the requested treatment is not medically necessary for treatment of the patient's medical condition. At issue is whether a Durolane Injection (J7318) in the left knee is medically necessary for the treatment of this patient. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited.In this case, there is documentation of chronic left knee pain with failed treatments including corticosteroid injection, acetaminophen, acupuncture, physical therapy, chiropractic, and activity modification. The only other alternative is a total knee arthroplasty. As such, the provider has recommended viscosupplementation with a Durolane injection into the left knee. Therefore, a Durolane Injection (J7318) in the left knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopaedic 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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for a second cranial orthotic band. Positional plagiocephaly and deformational brachycephaly are broad terms used to encompass abnormal head shape due to a wide variety of etiologies. Prenatal causes may include the resting of the fetal head against a hard surface, such as the mothers pelvis or the limb of a sibling in a multiple gestation pregnancy, for a prolonged period, while postnatal causes are more common and may include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep positions. Presentation ranges from mild or moderate cases, that may respond to mechanical adjustments and exercises, to severe cases that are refractory to repositioning and may require surgery for correction. Jung and Yun note that conservative treatments involve a variety of treatments, such as change of positions, physiotherapy, massage therapy, and helmet therapy. Current treatment of mild head shape abnormality includes repositioning, physical therapy, and increased time in the prone position. Cranial orthoses are recommended for infant patients with moderate-to-severe skull deformity based on data in current medical literature showing the long-term distinct benefits from helmeting when compared to repositioning. In a longitudinal cohort study design comparing helmeting with repositioning by following 100 infants with deformational plagiocephaly and/or brachycephaly for ten years, Naidoo and colleagues concluded, Infants will have more improvement in head shape with a helmet than with repositioning. The Congress of Neurological Surgeons guideline on the role of cranial molding orthosis, or helmet, therapy for patients with positional plagiocephaly states, Helmet therapy is recommended for infants with persistent moderate to severe plagiocephaly after a course of conservative treatment (repositioning and/or physical therapy). In this case, the patient was prescribed a DOC band and used it for the recommended time for the treatment of plagiocephaly. The patient continued to manifest an abnormal head shape, and anthropometrics revealed a persistent asymmetry of ten mm. The patient outgrew the first DOC band before optimal results could be obtained. Based on the severity of the patients head shape abnormality, the providers recommendation of a second, larger DOC band is medically indicated. Therefore, a second cranial orthotic band 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for iStent Trabecular Micro-Bypass Stent. The patient demonstrates the findings typically seen in patients with early glaucoma. The provider noted that the patient has shown some issues with medication compliance. The provider has recommended intervention with the iStent procedure. On review of the current peer-reviewed medical literature, there is data that the iStent has been found to be a safe and effective treatment modality for this patients ocular hypertension with improvement in intraocular pressure (IOP). Malvankar-Mehta and colleagues noted that, Both iStent implantation with concurrent phacoemulsification and phacoemulsification alone result in a significant decrease in IOP and topical glaucoma medications. However, the authors concluded that, In terms of both reductions, iStent with phacoemulsification significantly outperforms phacoemulsification alone. Therefore, the requested iStent Trabecular Micro-Bypass Stent 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 services are 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox injections (100 units, 50 units per axilla). The records document that this patient has a history of moderate-to-severe primary axillary hyperhidrosis that is rated a score of 3 of 4 on the hyperhidrosis disease severity scale (HDSS). Per the clinic notes, and the providers letter, the patients condition is causing significant functional impairment. The patients provider has recommended continued treatment with Botox injections in the axillae. As noted in the medical literature, the treatment of patients with severe and/or refractory primary axillary hyperhidrosis must be individualized based on patient history, clinical findings, and the recommendations in the current guidelines (Gorelick and Friedman). The U.S. Food and Drug Administration (FDA) has approved Botox for the management of patients with primary axillary hyperhidrosis who have not obtained adequate relief of symptoms with topical agents. Recent literature supports treatment with Botox for patients with axillary hyperhidrosis with a score of 3 of 4 on the HDSS (McConaghy and Fosselman.). Moreover, this patient has reportedly experienced adequate clinical relief with prior Botox injections in the axillae (Nawrocki and Cha). Given the functional impairment caused by the patients condition and its severity, Botox is appropriate for treatment of the patients moderate-to-severe hyperhidrosis. Therefore, the requested Botox injections (100 units, 50 units per axilla) 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 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 authorization and coverage for Botox injections under sedation. On review of the available medical literature, Botox treatment of this patients pelvic pain, is not supported as likely to be more beneficial than standard available therapies. The records indicate that the source of the patients pelvic pain has not been identified. Botox has been shown to be promising in the treatment of certain pelvic pain situations. However, additional studies have been recommended to endorse treatment with Botox for specific pelvic pain indications. Dessie and colleagues concluded that pelvic floor Botox injections for myofascial pelvic pain were not more effective than saline injections at decreasing muscle pain on palpation. Although Meister and colleagues reported promising preliminary findings, the authors noted that large scale randomized controlled trials are needed to determine the safety and efficacy of Botox injections for the treatment of patients with pelvic floor myofascial pain. For these reasons, the requested Botox injections under sedation are not 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 reviewer 1 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology 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 patients parent has requested authorization and coverage for Quillivant XR 25 mg/5 mL. While literature supports methylphenidate as treatment for attention-deficit/hyperactivity disorder (ADHD) for young children, there are multiple formulations of this medication due to different requirements for each individual patient. Caballero and colleagues noted that with regard to the treatment of patients with ADHD, there are multiple formulations, including immediate release (administered two to three times/day), solid extended release (ER), or transdermal patch. The authors reported that methylphenidate extended-release oral suspension (MEROS) is a once daily, long-acting liquid preparation that has demonstrated favorable safety and efficacy in patients with ADHD. This young patient has reportedly failed an adequate trial of long-acting Ritalin due to not being able to swallow the capsule and experiencing adverse effects when the capsule was opened up and sprinkled on food. When treated with Quillivant XR, the patient was noted to have improved in compliance, reactivity, and control of ADHD symptoms. While the active drug, methylphenidate, is the same in capsule form and Quillivant XR, the delivery method is different as well as the absorption. Quillivant XR is appropriate for treatment of this patients ADHD given her inability to swallow pills and non-tolerance to capsule form of the methylphenidate when sprinkled on food. Moreover, the requested Quillivant XR 25 mg/5 mL is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given this support, the requested Quillivant XR 25 mg/5 mL is medically necessary for 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 with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Computed tomography (CT) of the chest and CT of the abdomen and pelvis. This patient presented with undifferentiated pleomorphic sarcoma of the left buttock. The patient underwent evaluation with CT of the chest and CT of the abdomen and pelvis. Basile and colleagues noted that, patients diagnosed with isolated lymph node metastases have a prognosis similar to that of patients diagnosed with localized American Joint Committee on Cancer stage III soft-tissue sarcomas, which also equates to a significantly better overall survival compared with patients with systemic metastases. The authors recommended modifications to the American Joint Committee on Cancer staging system to distinguish patients with isolated lymph node metastases to acknowledge their better prognosis compared with those with systemic metastases. For assessment of a patients condition for staging and treatment purposes, the National Comprehensive Cancer Network (NCCN) guidelines recommend a chest CT for initial staging for all patients with sarcoma for initial staging (von Mehren, et al.). Given the location of this patients soft tissue sarcoma, a CT of the abdomen and pelvis was also appropriate. The findings on these CT studies enables staging and treatment recommendations. For these reasons, the CT of the chest and CT of the abdomen and pelvis were medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation 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 certifications in medical oncology and hematology 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 Ajovy 225 mg/1.5 mL prefilled syringe. The U.S. Food and Drug Administration (FDA) approves the use of Ajovy, a calcitonin gene-related peptide (CGRP) antagonist, for the preventive treatment of migraines in adults. The American Headache Society (AHS) notes that treatment with monoclonal antibodies to CGRP may be indicated for patients with chronic migraines with an inability to tolerate topiramate and serotoninnorepinephrine reuptake inhibitor such as venlafaxine and duloxetine. The AHS recommends that clinicians and patients reassess the benefits of CGRP monoclonal antibody therapy after three to six months and continue treatment if benefits, such as a reduction in mean monthly headache days, can be documented. In this case, the patient has a history of chronic migraines that have not responded to multiple preventative medications including Topamax, venlafaxine, and duloxetine. The use of Ajovy has been effective in decreasing the frequency of the patients migraines from up to nine days per month to one day per month. Given that the patient fits AHS criteria for treatment with CGRP monoclonal antibody therapy, the requested medication is medically indicated. Therefore, Ajovy 225 mg/1.5 mL prefilled syringe 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 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: The patient has requested reimbursement and prospective authorization and coverage for Acthar Gel 400 units/5 mL vial. The records document that this patient presents with a diagnosis of IgA nephropathy. The patient has been treated with steroids, which the provider has recommended tapering, and switching to Acthar Gel. The U.S. Food and Drug Administration (FDA) has approved Acthar Gel for the treatment of patients with nephrotic syndrome (NS). Although Acthar Gel is not recommended for the treatment of patients with NS as first-line therapy, it is indicated as second-line therapy when initial treatment has failed or is not well tolerated. Madan and colleagues noted that, Acthar gel may meet an important treatment need in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. The provider noted that this patients condition has not substantially improved with steroid treatment. Given this support, Acthar Gel 400 units/5 mL vial was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was and 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 nephrology 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.