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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees knee pain.Findings:There is sufficient support in the medical literature for the requested services in this clinical setting. Studies concluded that hyaluronic acid is an effective pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Studies conducted a systematic review of overlapping meta-analyses (total 20,049 patients) comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. They reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network meta-analysis. Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. This patient presents with a history of persistent right knee pain and limited functional mobility. Clinical examination findings are consistent with radiographic evidence of moderate medial and patellofemoral compartment joint space narrowing and spurring. He has undergone multiple corticosteroid injections with inadequate relief of symptoms. Therefore, Synvisc injections have been demonstrated as medically necessary for treatment of the patients medical condition.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Vemlidy 25 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients chronic hepatitis B virus (HBV). The submitted documentation supports the medical necessity of the requested medication. Guidelines for the treatment of hepatitis B from an association recommends entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects, such as osteopenia and renal disease. As such, the request to switch the patient to Vemlidy to reduce the risk of tenofovir-related nephrotoxicity and loss of bone density is medically appropriate. For these reasons, Vemlidy 25 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center level of care for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the services at issue. In this case, the patients substance use had been central to his daily routine and contributed to significant impairment across multiple domains of functionality. The patient began abusing drugs in adolescence, which more than likely has compromised critical elements of psychological development, such as identity formation.  He had strained relations with his family.  He was isolated and had no meaningful sober support network.  He had failed outpatient-based substance use treatment. He had medical sequelae related to his drug use, including cellulitis and hypertension. He also had co-occurring severe mental illnesses and recent acute psychiatric hospitalizations.    Considering this patients condition and multiple treatment failures, ongoing attempts to deliver care in the outpatient setting would have been both inadequate and incongruent with community practice standards.  While in the program, the record indicates that the patient actively engaged in evidence-based treatment, including aggressive medication management, in accordance with a multidisciplinary treatment plan aimed at consolidating the gains necessary to succeed in a less restrictive setting.  In sum, the services and setting were safe, appropriate and consistent with good practice.  Additionally, the services provided were reasonably expected to improve the patients condition, prevent a more serious episode of illness and facilitate a seamless transition to comprehensive community-based programming. Further, the duration of services was consistent with community standards.  Considering the clinical presentation and perusal of the relevant peer-reviewed literature, residential treatment center level of care was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services provided during a colonoscopy. According to the American Society of Anesthesiologists guidelines for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures, such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care may be necessary in patients with failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, pregnancy, increased aspiration risk, ASA class III or higher, or morbid obesity. All told, anesthesia services provided during a colonoscopy were not medically necessary for the 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Prometrium. The Health Plan has denied this request indicating that the requested name brand medication is not medically necessary for treatment of the enrollee who has a history of menopausal syndrome and fibromyalgia syndrome. Findings: The enrollee and the enrollee's provider state that HRT is appropriate to manage the patients menopausal symptoms. This therapy is well supported by the American College of Obstetricians and Gynecologists (ACOG) and the North American Menopause Society.  In order to safely take estrogen to reduce symptoms, this must be balanced by a progesterone to protect the enrollees endometrium from the possible development of cancer. There are different progesterone preparations available for this purpose. However, evidence based recommendations support the use of micronized progesterone as the first choice as it the safest progesterone preparation currently available. The use of name brand medications is supported by ACOG in enrollees who have been unsuccessful with generic medications. Since this patient has tried and failed the generic form of micronized progesterone, it is medically necessary for the enrollee to use the name brand Prometrium. Therefore, Prometrium is medically necessary for the treatment of this enrollees medical condition.Final Result: The reviewer determined that the requested name brand medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 FoundationOne test. The Health Plan has denied this request indicating that the services at issue were considered investigational for the evaluation of the enrollees medical condition.Findings There is medical literature to support the efficacy of the services at issue in this patients case. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Researchers presented a study of 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. The patient has been on multiple regimens with disease progression. The documentation as well as the current medical literature support the use of molecular profiling in this clinical setting. Therefore, the FoundationOne testing was likely to be superior when compared to the available standard methods of evaluating this patients medical condition. Final Result: Two of the three reviewers determined that the services at issue were 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 22-year-old male enrollee has requested authorization and coverage for pelvic magnetic resonance imaging (MRI) for evaluation of the enrollees abdominal pain.   Findings:  The physician reviewer found that MRI enterography is often the procedure of choice for evaluation of possible inflammatory bowel disease, especially in younger patients of reproductive age due to lack of radiation exposure. In this patient with severe bowel dysfunction, MRI of the pelvis is medically necessary since the entire bowel, some of which lies in the pelvis, needs to be evaluated in order to complete the MRI enterography approved by the Health Plan. Failure to include the bowel within the pelvis would result in an incomplete study. Thus, the requested pelvic MRI is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Fiasp FlexTouch insulin pen. Until recently, three rapid-acting insulin analogues, Humalog, Novolog, and Apidra, were the only analogues which were available as prandial insulins. Fiasp is insulin aspart enriched with two excipients, of which niacinamide is responsible for accelerating absorption after subcutaneous administration. As such, it is the first mealtime insulin without a pre-meal dosing recommendation. For this reason, it may add potential benefits to a pre-existing insulin regimen. However, there is a lack of data which suggests that it may be superior in efficacy to the previous insulin analogues, such as Humalog. The Health Plans alternative is medically appropriate in this setting. Therefore, the requested Fiasp FlexTouch insulin pen is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: An enrollee has requested authorization and coverage for Repatha. The enrollee is a high risk patient and should be on maximal risk factor modification therapy including tight hypertension and diabetes control and aggressive lipid management. He is intolerant of multiple statins. Based on his medical condition, Repatha is reasonable and necessary for risk reduction use in this specific clinical situation, in accordance with published guidelines and with published data for improvement in clinical outcomes. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for microvascular decompression surgery or treatment of the enrollee who has a history of facial pain. Findings:  The physician reviewer found that patients facial pain is attributable to a well known condition called trigeminal neuralgia. In trigeminal neuralgia, there is irritation of the trigeminal nerve, which provides sensation to the face. Oftentimes, the irritation is caused by pulsations of an artery that is contact with the trigeminal nerve. Treatment may include microvascular decompression or separation of the artery from the nerve when patients have not responded to medical therapy. In this patients case, he is documented to have facial pain that has not responded to medical treatment. In summary, the large body of medical evidence as well as standard practice patterns indicate that the patients trigeminal neuralgia will likely benefit from the requested microvascular decompression. As such, the requested microvascular decompression surgery is likely to be more beneficial when compared to the standard options for treating this patients medical condition.Final Result: Two of the three reviewers determined the requested services are 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:  All three reviewers are board certified in neurological surgery 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block therapy and prospective authorization and coverage for continued occipital nerve block therapy. Findings:  Two of the three physician reviewers found that neuralgia is a type of neuropathic pain. Attacks can either be spontaneous or provoked by direct stimulation or palpation of other trigger point zones. Occipital neuralgia can specifically refer to pain or headache in the occipital region in the greater, lesser, or third occipital nerve areas which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. This patient has been diagnosed with occipital neuralgia on examination. Another key element to the diagnosis is response to occipital nerve blocks, which is also reported in the documentation provided. The treatment of choice for occipital neuralgia is a local occipital nerve block due to its ability to relieve pain and act as a diagnostic marker. There is sufficient support for the services at issue in this clinical setting. Therefore, the service at issue were and are likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were and are 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 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 parent of a male enrollee has requested authorization and coverage for a speech therapy assessment and continued speech therapy. Based on his current testing scores, this patient continues to require speech therapy for articulation, but no longer requires speech therapy for pragmatic language, expressive language or any other language areas. The testing does not indicate that an additional speech therapy assessment is needed at this time. Based on his current scores, he requires individual speech therapy once per week for one hour, but does not require group speech therapy. The research on articulation disorder indicates that individual speech therapy is helpful for this patients current speech and language deficits. His testing demonstrated typical and age appropriate speech skills for pragmatic language and all other areas. His ABA can provide therapy for social communication problems that involve pragmatic issues. Thus, the requested speech therapy assessment is not medically necessary while individual speech therapy once per week for articulation disorder is medically necessary. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg, two tablets daily. This patients records do not document an adequate treatment with topical steroids. Moreover, the patient has not tried and failed the Health Plans preferred formulary agents, Enbrel, Humira and Cosentyx. As there is no contraindication or documented history of adverse effects from treatment with the preferred agents which are U.S. Food and Drug Administration (FDA) approved for this patients medical condition, the requested Otezla is not medically necessary. 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 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.