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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Humira pen injection 40 mg/0.4 mL every seven days. Findings:  The physician reviewer found that Anti-tumor necrosis factor (TNF) medications such as Humira are recommended by current guidelines and the peer-reviewed medical literature for the treatment of patients with moderate-to-severe Crohns disease. The use of Humira 40 mg more frequently than every 14 days has been demonstrated to be effective to prevent complications related to Crohns disease. The American College of Gastroenterology (ACG) guidelines state that patients with continued symptoms should have their medication dose adjusted in order to attempt to optimize therapy (Lichtenstein, et al.). According to the American Gastroenterological Association (AGA) guidelines, dosage increase is recommended when Humira levels are low and anti-Humira antibody levels are undetectable. In this case, the patient has severe Crohns disease with an extensive surgical history. The patient has active disease with perianal abscess and fistula. She has been corticosteroid dependent while on Humira 40 mg every 14 days with azathioprine, in the setting of low Humira level. The continued use of Humira 40 mg every 14 days, or a discontinuation of Humira and treatment with another medication, could result in complications of disease activity. In this patients clinical setting, the requested increase in dosage consisting of Humira pen injection 40 mg/0.4 mL every seven days is appropriate and consistent with current recommendations and guidelines. For these reasons, the requested Humira pen injection 40 mg/0.4 mL every seven days 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the neck. According to the American College of Radiology (ACR), MRI of the cervical spine is usually appropriate for the evaluation of patients with new or increasing nontraumatic cervical radiculopathy, or in the setting of known malignancy. In addition, MRI is the optimal examination for the evaluation of intervertebral discs, facet arthropathy, foraminal stenosis, nerve root compression, and spinal stenosis. In this case, the patient underwent evaluation with prior radiographs of the cervical spine, which demonstrated spondylosis at multiple levels. The patient also has a personal history of breast cancer and there is concern for metastatic disease given her nontraumatic neck pain. The results of the MRI could change clinical management including surgical or medical interventions. MRI is currently the preferred modality to evaluate the cervical spine in the setting of this patients nerve root impingement. Given these findings, the requested MRI of the neck is 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 patient has requested authorization and coverage for cervical nerve ablation with sedation. Medical literatures report, The use of dual blocks may increase the radiofrequency ablation success rate. However, this will invariably result in false-negative blocks and deny some patients the benefit of radiofrequency ablation. There are also patient inconveniences and increased costs and risk exposure to consider. Nonetheless, for clinical trials that aim to show efficacy, the benefits of a higher percentage of true positives (enriched population) may outweigh the cons and should be considered in trial design. The authors further recommend 50% pain relief as the cut-off threshold for selecting patients for radiofrequency ablation. In a systematic review on the effectiveness of cervical medial branch thermal radiofrequency neurotomy, researchers report, Outcome data showed a greater degree of pain relief more often when patients were selected by triple placebo-controlled medial branch blocks or dual comparative medial branch blocks, producing 100% relief of the index pain. The degree of pain relief was similar when triple or dual comparative blocks were used. The authors further concluded, Higher degrees of relief from cervical medial branch thermal radiofrequency neurotomy are more often achieved, to a statistically significant extent, if patients are selected on the basis of complete relief of index pain following comparative diagnostic blocks. If selected based on lesser degrees of relief, patients are less likely to obtain complete relief. In this case, the patient reports neck pain radiating into the upper extremity consistent with a diagnosis of cervical radiculopathy. The records documented limited benefit from a cervical epidural steroid injection (CESI), with 20% pain relief reported. Given that current medical literature does not support the efficacy of cervical medial branch blocks and nerve ablation procedures for treating cervical radiculopathy, and as the records do not document diagnostic blocks with at least 50% pain relief, the requested service is not medically indicated. Therefore, cervical nerve ablation with sedation is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a cochlear implant in the left ear. Cochlear implantation improves communication ability in patients with profound hearing impairment. The American Academy of Otolaryngology  Head and Neck Surgery (AAOHNS) considers unilateral and bilateral cochlear implantation as appropriate treatment for adults and children over nine months of age with moderate to profound hearing loss who have failed a trial with appropriately fit hearing aids. In this case, the patient has moderate hearing loss in the right ear and profound hearing loss in the left ear. She has benefited from hearing aid use in the right ear. An otologic examination was normal. Her otologic examination was normal, and magnetic resonance imaging (MRI) showed bilateral enlarged vestibular aqueducts, and cochlea that were otherwise normal. In this case, even though the patient has bilateral hearing loss, the patient has responded well to hearing aid therapy in the right ear and thus has not failed a trial of hearing aids in both ears. This would not meet AAOHNS guidance for cochlear implants. Likewise, a recent systematic review by researchers concluded that there remains no high-level evidence strongly supporting cochlear implants in asymmetric hearing loss. Accordingly, the requested device is not medically indicated. Therefore, a left ear cochlear implant is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 otolaryngology  head and neck 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 an upper endoscopy with monitored anesthesia care. The submitted documentation supports the medical necessity of the requested upper endoscopy. Clinical guidelines recommend an endoscopy for investigation of upper gastrointestinal symptoms (such as heartburn or dyspepsia) when those symptoms are refractory to proton pump inhibitor therapy taken properly for four to eight weeks without response. American Society for Gastrointestinal Endoscopy (ASGE) guidelines state that endoscopy is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful. American College of Gastroenterology guidelines for gastroesophageal reflux disease recommend endoscopy if eight weeks of proton pump inhibitor therapy are ineffective. In this case, there is documentation of heartburn symptoms despite longstanding proton pump inhibitor therapy. Therefore, the requested upper endoscopy is medically necessary for the evaluation of this patient. The submitted documentation fails to demonstrate the medical necessity of the requested monitored anesthesia care. The provided records do not document reasons for the use of monitored anesthesia care supported in the medical literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater than 70, pregnancy, increased aspiration risk, American Society of Anesthesiologist (ASA) class III or higher, or morbid obesity. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy, during endoscopic procedures (unlike surgery) consciousness during the procedure is acceptable and is the goal during most procedures (which are performed with moderate sedation), and monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic variant. The submitted records do not support the medical necessity of monitored anesthesia care over conscious sedation in this case. Therefore, the requested monitored anesthesia care is not medically necessary for the treatment of this patient. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cequa 0.09% eye solution. Findings: In a randomized, double-masked, placebo-controlled trial of patients with an eye dryness score (EDS) of at least 40, a study concluded that lifitegrast, the active ingredient in Xiidra, significantly improved symptoms of eye dryness versus placebo, as measured by EDS. In a multicenter, randomized, double-masked, vehicle controlled study, it was found that 20.5% of study participants receiving Cequa 0.09% achieved a greater than or equal to ten mm increase in their Schirmers tear score, compared to 11.3% of study participants receiving vehicle, and that Cequa 0.09% significantly improved total conjunctival staining over vehicle at week 12. However, these results have so far not been replicated and independently verified by other studies. In a meta-analysis of thirty randomized-controlled trials to evaluate the effectiveness of cyclosporine A (CsA) eye drops in the treatment of dry eye disease, another study concluded that, despite its widespread use, there was inconsistent evidence on the efficacy of CsA on ocular discomfort and on ocular surface and tear-film parameters such as corneal fluorescein staining, Schirmers test, and tear break-up time. Given that the patient is being appropriately treated with Xiidra, and the lack of high-level evidence in current medical literature supporting the efficacy of Cequa in this clinical setting, the requested medication is not medically indicated. Therefore, Cequa 0.09% eye solution 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 ophthalmology 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 Cosentyx Sensoready 300 mg solution autoinjector. Systemic treatment of patients with psoriasis is indicated when topical treatments fail or do not achieve  sufficient control of disease. There are several U.S. Food and Drug Administration (FDA) approved systemic options for patients with moderate-to-severe psoriasis. The FDA treatment options include non-biologics and biologics. Armstrong and colleagues found that the non-biologics have worse efficacy than the biologics. This patient has been treated with tried Otezla with initial relief, but it has lost its efficacy. The patients provider has recommended treatment with Cosentyx. However, the records do not document adequate treatment or a contraindication to medications recommended for the treatment of patients with moderate-to-severe psoriasis. Lockshin and colleagues noted that ixekizumab has the greatest prolonged drug survival of tumor necrosis factor (TNF) inhibitors. On review of the available documentation and current medical literature, the patient is a candidate for treatment with an interleukin-17 (IL-17) or IL-23 biologic. Moreover, there is a lack of data reporting superior health outcomes with one IL-17 or IL-23 agent over another. The clinic notes dated 5/31/22 mention the patients concern about malignancy risk for Tremfya, which has been reported to be low (Blauvelt, et al.). All told, the requested Cosentyx Sensoready 300 mg solution autoinjector is not medically necessary for 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a continuous glucose monitor. The current medical evidence supports the requested device in this clinical setting. A continuous glucose monitoring system (CGMS) is one of several United States Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. Over the last decade, continuous glucose monitoring systems have been demonstrated to be clinically valuable due to its accuracy, convenience, and improvement of software. CGMS can promote glycemic and weight control, help reduce the risk of hypoglycemia and hyperglycemia, and improve relevant lifestyle behaviors. It has become a useful tool for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. CGMS has been confirmed to be a safe method for diabetes management, with high accuracy in glycemic values and a low complication rate. Therefore, the requested continuous glucose monitor is medically necessary for treatment of this patientFinal 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. Credentials/Qualifications: The reviewer is board certified in internal medicine with a 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: The patient has requested authorization and coverage for Wegovy (J3490). Findings:  The physician reviewer found that current medical evidence supports the requested medication in this clinical setting. 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 multiple pharmacologic therapies which are available for weight management. Wegovy (semaglutide) is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs. These medications improve glycemic control, reduce body weight, and decrease cardiovascular risk. Multiple studies have demonstrated this medications ability to promote weight loss, via reduced appetite and energy intake, and delayed gastric emptying. Additionally, the likelihood of health risks associated with this medication has been noted to be low. Therefore, the requested medication Wegovy (J3490) 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  The physician reviewer found that The patients initial history and pathology shows mismatch repair was intact in his tumor. However, his family history showed a maternal aunt with breast cancer, another maternal aunt with lung cancer, maternal grandfather with pancreatic cancer, maternal grandmother with stomach cancer, and paternal uncle with testicular cancer. The patient underwent genetic testing as recommended by his provider with the CancerNext Expanded testing. According to the National Comprehensive Cancer Network (NCCN) guidelines, testing by a multi-gene panel is appropriate when no single disease syndrome can explain the patients family history. A comprehensive genetic testing panel that analyzes for germline mutations in genes that predispose to cancer is best used in instances where the familial predisposition syndrome is not well characterized based on the history, like in instances where both BRCA and Lynch syndrome genes may be implicated. Comprehensive gene lists for testing are supported by the current medical evidence. Given this support, a comprehensive panel such as the CancerNext-Expanded was medically appropriate in this patients clinical setting. Accordingly, the genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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.