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 Continuous Positive Airway Pressure (CPAP). She has witnessed apnea, morning headaches and daytime somnolence.  She was referred to the sleep clinic for evaluation for obstructive sleep apnea (OSA). The sleep study report revealed mild OSA, with an apneahypopnea index (AHI) of 5.9. Respiratory events consisted of episodic clusters of obstructive apneas and hypopneas. Nadir oxygenation was 87.0 percent. Time spent with an oxygenation level of less than 90 percent was 0.9 minutes. Continuous positive airway pressure (CPAP) therapy was recommended at a follow-up visit. The therapy data summary noted the enrollee had an insufficient trial on auto CPAP therapy due to less than four hours of use. A repeat CPAP trial was recommended. Professional society guidelines note treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) therapy should be based on a diagnosis of OSA; established using objective testing. The member meets this diagnosis based on her symptoms of witnessed apnea, morning headaches, and daytime sleepiness; scoring 11 out of 24 on the Epworth Sleepiness Scale, and having an unattended home sleep test using a portable respiratory sleep monitor that showed an apnea-hypopnea index of 5.9 per hour. Once the diagnosis of OSA is established, positive airway pressure therapy should be initiated, using either Automatic Positive Airway Pressure (APAP) at home or an in-laboratory PAP titration study, where this test would be used to demonstrate that PAP can treat the OSA as well as to determine what pressure settings are needed to achieve proper treatment.  The member had an at-home APAP study, but tolerated it for only one hour. The data obtained was inadequate data to determine efficacy. Therefore, CPAP is considered not medically necessary until there is data from a successful at-home or in-laboratory PAP titration study.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 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 Ofev. This patient has multiple lung issues, including probable hepatopulmonary syndrome. The provider noted that the patients interstitial lung disease could be hypersensitivity pneumonitis, secondary to working in an aluminum factory. The computed tomography (CT) scan report does not describe the typical appearance of idiopathic pulmonary fibrosis, which is the U.S. Food and Drug Administration (FDA) approved indication for Ofev. The patients forced expiratory volume per one second (FEV1) and forced volume capacity (FVC) are close to normal range. The patients pulmonary function tests show a severe reduction in the diffusing lung capacity for carbon monoxide (DLCO), which is likely related to the shunting. The records do not rule out the patients PFO and pulmonary shunts as the causes of his persistent shortness of breath. Overall, there is a lack of data supporting Ofev in patients with fibrotic hypersensitivity pneumonitis, severe liver disease, and other causes of shortness of breath. All told, Ofev is not medically necessary for the treatment of this patients medical condition. 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 subspecialty certification in pulmonary 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a Humatrope cartridge kit 24 mg-1.8 mg daily. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether a Humatrope cartridge kit 24 mg-1.8 mg daily is medically necessary for the treatment of the patients medical condition. The Lawson Wilkins Pediatric Endocrinology Society Drug and Therapeutics Committee reported the guidelines for the use of growth hormone in children indicate that considerable variability exists in the diagnosis of GH deficiency, which remains a clinical challenge. This is related to the continuum between severe GH deficiency and normality, marked variability in GH assays, arbitrary cutoffs conventionally used to define GH deficiency on the basis of GH stimulation tests, and the lack of reproducibility of GH stimulation tests. In addition, the patients physical examination indicates that he is already in the midst of his pubertal growth spurt, suggesting less benefit from recombinant GH. The medical evidence does not support the requested medication in this clinical setting. Therefore, a Humatrope cartridge kit 24 mg-1.8 mg daily 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 trigeminal nerve injections and greater occipital nerve injections. Current data on occipital nerve blocks remains mixed. Dilli and colleagues concluded that greater occipital nerve blocks did not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. Inan and colleagues and found that greater occipital nerve blocks were safe and demonstrated greater efficacy than placebo in the treatment of chronic migraine. This patient has a history of chronic migraine since second grade. She has been managed with Botox, but reports incomplete symptomatic relief around the seventh week of the treatment cycle. During pregnancy, treatment with trigeminal and occipital nerve blocks reportedly provided a substantial improvement in pain and ability to function. Oral medications carry a potential risk during breastfeeding. Current literature supports trigeminal and occipital nerve blocks during pregnancy and breastfeeding, for relief of migraines, as interval therapy for Botox. Therefore, trigeminal nerve injections and greater occipital nerve injections (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 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

The patients parent has requested authorization and coverage for continuous passive motion (CPM) machine. Colleagues reported their findings suggested that CPM reduces arthrofibrosis requiring manipulation under anesthesia in pediatric patients after anterior cruciate ligament (ACL) reconstruction. The authors noted that future studies might better define the clinical utility of CPM in rehabilitation after this type of surgery in pediatric patients. Colleagues concluded that CPM has beneficial effects on pain reduction during the first two postoperative days, on knee flexion during the first to the sixth postoperative weeks, and on swelling between the fourth and the sixth postoperative weeks. The authors cautioned that the risk-of-bias scores did not support a high level of evidence for their findings. Overall, the current evidence-based medical literature provides limited support for the use of CPM following cruciate ligament reconstruction. However, this patients case represents an exception. The physician reviewer found that the records document that the patient presented with a chronic isolated left knee posterior cruciate ligament (PCL) injury, medial meniscus tear, and chronic posterior instability. She failed long-term reasonable and comprehensive conservative treatment. She underwent left knee PCL reconstruction with allograft, double bundle technique, and medial meniscus tear debridement. Considering the combination of intraarticular procedures and inherent deep dissection, the patient is at increased risk of severe disruptive adhesions. The CPM will provide ongoing movement and reduce the risk of the patient developing adhesions and range of motion deficits (Bram, et al.). Therefore, the request for a CPM machine is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested device is 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

The patient has requested authorization and coverage for right shoulder surgery (CPT 29824 distal claviculectomy, CPT 29823 debridement and CPT 29826 coracoacromial ligament release). The request for distal claviculectomy is medically necessary for this patient based on the clinical and imaging evidence of severe acromioclavicular arthritis with impingement. The physician reviewer found that records document that the patient has been symptomatic for over one year. Some studies have shown that among patients undergoing distal clavicle excision for acromioclavicular joint pathology, those having an arthroscopic procedure can expect a faster return to activities while obtaining similar long-term outcomes compared with the open procedure (Pensak, et al.). With regard to the request for subacromial decompression, several studies present positive long-term results compared to conservative treatment in patients with isolated impingement syndrome (Lerch, et al.). The request for debridement will depend upon the operative findings and is likely to be medically necessary based upon the documented decreased range of motion, chronic pain, and rotator cuff tendinitis. All told, right shoulder surgery (CPT 29824 distal claviculectomy, CPT 29823 debridement and CPT 29826 coracoacromial ligament release) 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for the ReWalk Personal 6.0 Lower Extremity Robotic Exoskeleton System. The enrollee has a spinal cord injury (SCI) due to a stab wound. This resulted in T6 incomplete paraplegia. She trialed the ReWalk System. The enrollee is currently unable to ambulate due to incomplete lower extremity paresis and is relegated to prolonged sitting due to the absence of capable products and treatments which can help restore her walking abilities. She has lower extremity spasticity that interferes with her sleep and with her safety during transfers. She is at risk for secondary medical complications associated with chronic sedentary behavior and spinal cord injury. Her physician indicates she is already experiencing the positive benefits of walking in a rehabilitation robotic exoskeleton and would greatly benefit from continued use in the home and community setting with the ReWalk. A meta-analysis on the clinical effectiveness and safety of powered exoskeleton systems for individuals with spinal cord injuries concluded the devices allow them to safely ambulate in real-world settings.  However, the outcomes displayed considerable variation in consistency.  A literature data review concluded consistent benefit from rehabilitation using an exoskeleton versus a variety of conventional methods in individuals with chronic spinal cord injury was not demonstrated; adding that trials were needed comparing later-generation exoskeletons. Literature notes the ability of these devices to improve fitness and address the secondary medical complications of SCI remains to be determined. Evidence suggests the devices and benefits significantly differ from bionic to bionic. Current use of these devices occurs primarily within rehabilitation facilities because of limited accessibility and the need for assistive personnel. The practical use of these devices requires technological improvements to provide safety and independence in walking at velocities approaching those of persons without disabilities. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in physical medicine and rehabilitation and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz tablets. The patient carries a diagnosis of seronegative rheumatoid arthritis. However, she also has dip involvement and there is a question of some other inflammatory arthritis or erosive osteoarthritis. The patient has failed or not tolerated multiple disease modifying anti-rheumatic drugs (DMARDS). The patient has been treated with biologic therapies, including Enbrel, Humira and Simponi. The American College of Rheumatology (ACR) recommends the use of anti-tumor necrosis factor (TNF) agents after the failure of DMARDS, or combination DMARDS with or without low dose steroids (Singh, et al.). The requested therapy is not superior to the Health Plans formulary anti-TNF therapies in terms of efficacy or safety. Additionally, all biologics require that the patient be tested for latent tuberculosis and hepatitis B and C, which has not been documented in this case. Finally, there is no documentation that the patient has an absolute neutrophil count (ANC) greater than 1000 cells per mm3, lymphocyte count greater than 500 cells per mm3, and a hemoglobin greater than 9 grams per dL. Therefore, Xeljanz tablets is not medically necessary for the treatment of this patients medical condition. 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 subspecialty certification in rheumatology 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:  The enrollee requested authorization and coverage for a Transoral Incisionless Fundoplication (TIF) procedure utilizing the EsophyX device. The provider recommended an esophagogastroduodenoscopy (EGD), colonoscopy and upper gastrointestinal (UGI) series. The UGI showed severe GERD while supine, potential retropharyngeal component and a small, sliding type HH. EGD results from showed a mildly irregular z-line, mild gastritis and a normal appearing lower end esophagus.The provider does not believe the patient has any contraindications for the procedure. Professional societies note the Transoral Incisionless Fundoplication (TIF) utilizing the EsophyX device can be performed with an acceptable risk in appropriate individuals. The medical literature indicates the safety profile of TIF and its effectiveness in eliminating typical and atypical gastroesophageal reflux disease supports the adoption of this treatment as an alternative treatment for selected individuals with inadequate symptom control on PPI therapy. TIF can be used to achieve long-term control of chronic GERD symptoms, healing of esophagitis, and improvement in esophageal acid exposure. Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gastroenterology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for the medication Synvisc-One injection to the left knee. The enrollee has a diagnosis of osteoarthritis of the left knee. She has received cortisone injections to both knees. At an office visit six months after a left knee cortisone injection, the physical exam demonstrated moderate vastus medialis obliquus (VMO) atrophy to the left knee. There was no effusion. Range of motion was 0-130 degrees. There was mild lateral joint line tenderness and a normal neurovascular examination. There was a three-quadrant patellar glide with a soft endpoint. Apprehension test was negative, patellar grind test was significantly positive, and Bassetts sign was mildly positive. Due to the enrollees decreased benefit from cortisone injections, her physician recommended Synvisc One injection for the left knee. Documentation notes the x-ray of the left knee revealed no acute osseous abnormality. This enrollees diagnosis is osteoarthritis (OA). Viscosupplementation injections are not recommended for treatment of moderate to severe knee osteoarthritis. Professional society clinical practice guidelines (CPG) for knee OA were released in 2013; revising earlier guidelines of 2008. The revision was based on the systematic review of evidence. The subsequent appropriate use criteria stated the use of viscosupplementation is excluded for non-arthroplasty treatment of knee OA. Studies note the use of preparations such as Synvisc-One is not a beneficial treatment for OA; furthermore, such preparations did not demonstrate significant differences compared to an injection of physiological saline in individuals with knee OA.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in orthopedic sports medicine and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for intensity modulated radiation therapy (IMRT). This patient presents with metastatic epidermal growth factor receptor (EGFR) positive, non-small cell lung cancer (NSCLC). The standard of care radiation modality in this patients clinical setting is a course of three-dimensional conformal radiation therapy (3D-CRT). There is a lack of evidence to support improved patient health outcomes with IMRT per the current peer-reviewed medical literature. Moreover, the American Society for Therapeutic Radiation Oncology (ASTRO) does not support IMRT for palliation of metastatic lung cancer. The data suggest that 3D-CRT is adequate to provide normal tissue sparing for delivery of palliative radiation doses in this clinical setting. All told, the requested IMRT is not medically necessary for 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 radiation 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.