Persius/hicric huggingface dataset:
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
A 28-year-old female insured has requested authorization and coverage for intravenous (IV) 
Gammagard. The Health Insurer has denied this request indicating that the requested treatment is 
considered investigational for the treatment of the insured's refractory relapsing polychondritis. 
The physician reviewer found that there is limited medical literature studying IVIG as a treatment 
option for patients with relapsing polychondritis. Relapsing polychondritis is a rare autoimmune 
disorder, and official guidelines to utilize certain therapies are not likely to be available in the near 
future. However, for patients who have tried and failed treatment with multiple therapies from 
several classes of medications, IVIG is appropriate as the next-line treatment option. This is 
particularly applicable when its efficacy has been established for a particular patient in keeping 
the disease stable or in remission. According to one study by Lekpa and Chevalier, IVIG has been 
shown to be effective in some patients with relapsing polychondritis. In this case, the patient 
presents with relapsing polychondritis. The records provided for review indicate that the patient 
has tried and failed treatment with multiple therapies from several classes of medications. The 
provider has recommended a continuation of IVIG therapy which has already been shown to be 
the most effective treatment option for this patient. All told, the requested IV Gammagard is likely 
to be more beneficial for the treatment of the patients condition than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 49-year-old female with a diagnosis of alopecia areata, totalis type, present for the 
past three years. The patient has requested authorization and coverage for Xeljanz [tofacitinib 
tablets; oral solution, 10 mg (60 per 30 days)]. The Health Insurer has denied this request and 
reported that the requested medication is not medically necessary for the treatment of this patient. 
This denial is the subject of this appeal and determination. The physician reviewer found that the 
submitted documentation supports the medical necessity of the requested medication. While the 
U.S. Food and Drug Administration (FDA) does not approve the use of Xeljanz, an oral Janus 
kinase (JAK) inhibitor, for the treatment of severe alopecia areata, it does approve the use of 
Olumiant (generic name baricitinib), another oral JAK inhibitor, for the treatment of adult patients 
with severe alopecia areata. Current medical literature supports the use of Xeljanz in this clinical 
setting. Ibrahim and colleagues report that oral tofacitinib is a successful treatment for alopecia 
areata. Given that the patient in this case has been treated with Xeljanz with improvement and 
without  side  effects  since  January  2021,  the  requested  medication  is  medically  indicated. 
Therefore, Xeljanz [tofacitinib tablets; oral solution, 10 mg (60 per 30 days)] is medically 
necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Synvisc injections of knees. Findings:  The physician reviewer found that viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. 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 a history of significant relief from prior injections. The patient has tried and failed other conservative treatments including cortisone injections. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, bilateral Synvisc injections of knees are medically necessary for the 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 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: The patient has requested authorization and coverage for epidural corticosteroid injection of the lumbar spine. Findings:  The physician reviewer found that At issue is whether the requested epidural corticosteroid injection of the lumbar spine is medically necessary for treatment of this patient. The American Society of Interventional Pain Physicians (ASIPP) have published guidelines on the use of epidural interventions for treatment of patients with chronic spinal pain .The authors noted that, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness. A systematic review from Fang and colleagues evaluated the clinical efficacy of epidural injections with or without steroids in the treatment of patients with pain due to degenerative disc disease. The authors found that the addition of steroids to local anesthetic was associated with superior Numeric Rating Scale (NRS-11) and Oswestry Disability Index (ODI) scores when compared to treatment with local anesthetic alone within one year in patients with degenerative disc disease. In this case, the patient has chronic low back pain with radiation into the right lower extremity since at least 2018 with recurrent episode. The patients lumbar magnetic resonance imaging (MRI) confirmed the presence of neuroforaminal stenosis at L4-5 and L5-S1 consistent with this presentation. The provider reported that the patients condition has been refractory to medication management despite treatment from a variety of different drug classes. The provider recommended an epidural steroid injection to provide relief of the patients radicular symptoms. Overall, the medical literature and current guidelines support the requested epidural corticosteroid injection of the lumbar spine to treat this patients lumbar radiculopathy due to degenerative disc and joint disease. Therefore, the requested epidural corticosteroid injection of the lumbar spine 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for computed tomography (CT) of the heart with calcium scoring. Findings:  The physician reviewer found that American Heart Association (AHA) and American College of Cardiology (ACC) have established guidelines for the management of blood cholesterol including evaluation with use of CT of the heart with calcium scoring .The AHA/ACC guidelines note that, Multiple studies indicate the utility of coronary artery calcium measurement in identifying the absence of atherosclerotic pathophysiology in older adults. Per the AHA/ACC guidelines, patients with a low 10-year arteriosclerotic cardiovascular disease risk, defined as 5% or less, should be managed with lifestyle modification. This patient presented with a 10-year arteriosclerotic cardiovascular disease risk of less than 5%. The patients family history is significant for early cardiovascular disease in his father. The patients records do not document any personal history of clinical arteriosclerotic cardiovascular disease, hypertension, or diabetes mellitus. The patient is a non-smoker and is not treated with a statin medication. Overall, a CT of the heart with calcium scoring is recommended when a patients risk is borderline or intermediate. This patient was found to have a low 10-year arteriosclerotic cardiovascular disease risk. For these reasons, the CT of the heart with calcium scoring was not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with expertise 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for major synovectomy of the right knee. Findings:  The physician reviewer found that available records document multiple diagnoses including plica syndrome, chondromalacia patella, and infrapatellar fat pad calcification. The providers notes referencing surgical intervention referred to a medial plica not identified on initial radiology review of the right knee magnetic resonance imaging (MRI) but was subsequently noted in an addendum to the radiology report. Plicae are small folds or shelves of synovial tissue that can rub or pop and contribute to pain and mechanical symptoms in the knee. Surgical treatment includes resection of the synovial prominence which corresponds to a synovectomy. In this case, the requested procedure is a major synovectomy, which would include two or more compartments. A major synovectomy may be appropriate for patients with synovial disease such as synovitis in the setting of inflammatory arthritis. However, evaluation and imaging of this patient does not indicate widespread synovitis throughout the right knee to support an indication for the requested major synovectomy . On review of the available documentation, the requested major right knee synovectomy of two or more compartments is not medically necessary and appropriate for this patient with knee pain attributed to a medial patellar plica. All told, the requested major synovectomy of the right knee 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for trigger point injections. . Findings:  The physician reviewer found that a review of treatments and management of myofascial pain, Urits and colleagues noted that studies that compared trigger point injection effectiveness against a control with some therapeutic value, such as dry needling or saline trigger point injection, all found that local anesthetic trigger point injection was not a significantly better treatment even if it did result in patient improvement from baseline pain. The authors further noted that studies suggest that while both topical and trigger point injection treatments may be effective in treating patient pain from myofascial pain syndrome, the less invasive nature and lower risk of adverse effects of topical treatment make it a better initial therapeutic route than local anesthetic trigger point injection. Weller and colleagues note that stretching and physical therapy are the mainstays of myofascial pain syndrome management, and that pharmacologic management of myofascial pain is generally indicated as the first-line therapy for patients in whom physical therapy and other noninvasive techniques are either  contraindicated or have failed. The authors further noted that a recent systematic review and meta-analysis found dry needling to be superior to sham or no treatment both immediately and for four weeks postintervention but did not demonstrate a significant difference compared with alternative interventions for myofascial trigger point derived myofascial pain syndrome. In this case, the patient reports upper back pain localized to the midline between the scapula.  There is no indication of recent attempts to treat suspected myofascial pain with physical therapy or a stretching program. Given that the evidence in current medical literature supporting trigger point injections is limited by studies with small sample sizes that are underpowered and a  lack of longitudinal data to demonstrating superiority over noninvasive treatment methods, the requested services are not medically indicated. Therefore, trigger point injections are not medically necessary for the 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a myPath melanoma assay.Findings:  The physician reviewer found that The myPath melanoma assay is a gene expression profiling (GEP) test used to classify melanoma pathology specimens by risk of recurrence. As a prognostic test for cutaneous melanoma, it is considered investigative. However, it may be beneficial when used to classify atypical spitz or spitzoid tumors, helping to differentiate benign nevi from cutaneous melanoma, including atypical Spitz tumors. Swetter and colleagues state, Diagnostic molecular techniques are still largely investigative and may be appropriate as ancillary tests in equivocal melanocytic neoplasms, but they are not recommended for routine diagnostic use in cutaneous melanoma. These include comparative genomic hybridization, fluorescence in situ hybridization GEP, and (potentially) next-generation sequencing. These tests may help to differentiate benign nevi from cutaneous melanoma, including atypical Spitz tumors. Therefore, the myPath melanoma assay was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the myPath melanoma assay at issue was likely to have been 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 likely to have been 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 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 computed tomography (CT) scan of the lower extremity without contrast material and/or magnetic resonance imaging (MRI) of any joint of lower extremity. Findings:  The physician reviewer found that The records provided for review document that this patient sustained a right talus fracture in a fall from a ladder. The patients provider has recommended treatment with surgery. As part of the patients preoperative evaluation, the provider has recommended right lower extremity imaging with MRI and CT scans. Barnett and colleagues noted that talus fractures can have devastating consequences. The authors reported that, The blood supply to the talus is tenuous and injuries are associated with a higher incidence of avascular necrosis and malunion. The talus involves multirotational movement, and in this patients case, involves multiple small fragments. As noted by the patients provider, the ultimate treatment often involves a joint fusion. As part of the patients preoperative work-up, the requested CT and MRI of the lower extremity are medically necessary. The current status of the patients condition including location of multiple fragments, which may have partially healed or moved, need to be assessed with a current CT scan prior to surgery. The patients previous CT scan was performed about nine months ago. Dale and colleagues determined that additional fracture information on talus fractures was not demonstrated on initial x-rays in 93% of cases. Further complicating the patients condition is the likelihood of injury to the ligaments and tendons. The requested lower extremity MRI is the best modality to evaluate these soft tissue injuries. MRI scanning is not routinely used in the early stage but is recommended when patients continue to complain of symptoms four to six weeks following injury in the presence of normal radiographs. Avascular necrosis, in particular, is a significant abnormality effectively diagnosed with an MRI scan. Given these findings, the requested CT scan of the lower extremity without contrast material and MRI of any joint of lower extremity are medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are 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: The patients parent has requested reimbursement for cranial remolding orthosis.Findings:  The physician reviewer found that Positional plagiocephaly and deformational brachycephaly are terms used to encompass abnormal head shape due to a wide variety of etiologies and can range from mild to severe. Patients with mild and moderate plagiocephaly or brachycephaly may respond to mechanical adjustments and exercises. However, some patients present with severe and refractory to repositioning. The current treatment for patients with mild head shape abnormalities includes repositioning, physical therapy, and increased time in the prone position. Most providers currently recommend cranial orthoses for infant patients with moderate to severe skull deformities. The American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) stated that, Helmet therapy is recommended for infants with persistent moderate to severe plagiocephaly after a course of conservative treatment (repositioning and/or physical therapy) (Tamber, et al.). This patient presented with mild plagiocephaly with a cranial vault asymmetry (CVA) of 9.0 mm and cephalic index (CI) of 82.8. The patients cranial asymmetry was 1.8 standard deviations from the mean. The patients physical presentation supports a diagnosis of mild plagiocephaly. The records indicate that treatment included repositioning attempts for 0.75 months prior to treatment with the cranial remolding orthosis. In the absence of severe plagiocephaly or brachycephaly, and documentation of limited attempts at conservative treatments, the use of a cranial orthosis is not recommended. Thus, the cranial remolding orthosis was not medically necessary to treat this patient.   Final Result: The reviewer determined that the device issue was 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 subspecialty certification in pediatric critical care 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.