Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for tongue and palate radiofrequency ablation (RFA). The records provided for review document that this patient has obstructive sleep apnea (OSA) with a body mass index (BMI) of 26 kg/m2. The patients primary sites of obstruction are the base of tongue and palate. Physical examination revealed that the patient has a long uvula and a short mandibular height. RFA of the palate and tongue base in a patient with normal BMI who cannot tolerate treatment with positive airway pressure (PAP), or an oral appliance is the treatment of choice. A study found that, Because of the wide variety of physiologic and anatomic causes of this disorder it is important to tailor the treatment to offer the patient the best possible outcome. Genioglossus, hyoid, and tongue base procedures should be considered among these treatment options. Overall, data suggest that RFA in this patients clinical setting was likely to have been of benefit as demonstrated in a randomized clinical trial and other clinical studies. Given this support, the tongue and palate RFA procedure was 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 treatment 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 certification in sleep medicine and is actively practicing. Physician reviewer 2 is board certified in otolaryngology with subspecialty certification in neurotology and is actively practicing. Physician reviewer 3 is board certified in otolaryngology 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 patient has requested authorization and coverage for Humira 40 mg/mL inject (every seven days per 28 days). Anti-tumor necrosis factor (TNF) medications such as Humira are recommended by current guidelines for the treatment of Crohns disease in patients with moderate-to-severe disease. One study reported that the remission rate with weekly dosing was 46.9% versus 22.5% when dosing every other week (Sandborn, et al.). In addition, even higher doses have proven safe and effective when necessary (Ma, et al.). The American College of Gastroenterology (ACG) guidelines for the treatment of Crohns disease state that patients with ongoing symptoms should have their medication dose adjusted in order to attempt to optimize therapy (Lichtenstein, et al.). Current data support that Humira 40 mg dosed more frequently than every 14 days can be safe and effective to prevent disease complications. In this case, the patient had active disease requiring treatment with corticosteroids while on Humira 40 mg every 14 days. Therefore, continuation of Humira 40 mg every 14 days, or a discontinuation of Humira and change to another medication, could result in complications of disease. For these reasons, the requested Humira 40 mg/mL inject (every seven days per 28 days) is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication dosage 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for authorization and coverage for injection, immune globulin, Gammagard liquid, non-lyophilized, (e.g., liquid, 500 mg) (CPT J1569). Findings:  The physician reviewer found that there is debate regarding the use of intravenous immunoglobulins (IVIG) in refractory uveitis and a limited number of clinical studies available on its efficacy. Saadoun and colleagues report that biotherapies used in clinical practice for the treatment of ophthalmologic manifestations of systemic diseases include interferons (IFN), IVIG, and monoclonal antibodies (anti-TNF, anakinra, tocilizumab and rituximab). The authors note that tolerance of IVIG is good but their efficacy is transient. Given the lack of randomized, prospective studies available in current medical literature regarding the use of IVIG in refractory/autoimmune uveitis, the requested service is not medically indicated. Therefore, injection, immune globulin, Gammagard liquid, non-lyophilized, (e.g., liquid, 500 mg) (CPT J1569), 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 internal medicine with sub-specialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Taltz. The submitted documentation supports the medical necessity of the requested medication. Taltz has excellent safety and efficacy profiles. According to the American Academy of Dermatology and the National Psoriasis Foundation, Taltz receives an A recommendation for the treatment of moderate to severe plaque psoriasis in adults. Multiple recent publications have compared Taltz to other psoriasis treatments and reported that Taltz is more efficacious and has better adherence than other biologic medications that are commonly prescribed for psoriasis. There is sufficient support for the requested medication in this clinical setting. Therefore, Taltz 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 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 patients parent has requested authorization and coverage for Xeljanz 5 mg tablet (60 tablets per 30 days). The records provided for review document that this patient presents with alopecia areata. The patient has reportedly responded well to treatment with Xeljanz. The provider has recommended continued treatment with Xeljanz. As noted in the medical literature, the current treatment options for alopecia areata limited, especially for patients with multifocal involvement. Oftentimes, therapies such as topical steroids, intralesional Kenalog, contact immunotherapy and conventional immunosuppressants are inadequate to control symptoms and can be associated with side effects. There is substantial clinical evidence to support the use of oral Janus kinase (JAK) inhibitors such as Xeljanz for the management of patients with alopecia areata (Guo, et al.; de Oliviera, et al.). In one open label pilot study, eight of 12 patients demonstrated approximately 50% hair regrowth as measured by Severity in Alopecia Tool scoring (SALT) (Jabbari, et al.). Given this support, the requested Xeljanz 5 mg tablet (60 tablets per 30 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 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: Overturned Decision of Health Plan

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the use of ENDURAgen (CPT 15275 51), provided to the left eye. In this clinical setting, based on the patients disease, the symptoms, and the results of published clinical trials, the use of ENDURAgen graft was superior to autografting with respect to indirectly lowering morbidity and risk by avoiding extended operating time and multiple operating sites for this patient. Enduragen is likely more beneficial than alternative methods for reconstruction involving autografting from other tissues, such as retro-auricular cartilage and hard palate. Other possible grafting materials include bovine extracellular matrix and human cadaveric material.  Cole and colleagues note the Enduragen material is either equivalent or superior to AlloDerm, DermaMatrix, and DuraMatrix with respect to direct surgical outcomes. Therefore, the use of ENDURAgen (CPT 15275 51), provided to the left eye, was likely to have been more beneficial for treatment of the pateint's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the ENDURAgen (CPT 15275 51), provided to the left eye, 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. There is a lack of robust controlled data to support a role for genetic testing in the evaluation and treatment of patients with various behavioral health issues. Researchers reported on a systematic literature review, focusing on studies published from 2013 to 2018, to assess whether obtaining CYP2D6 and CYP2C19 pharmacogenetic testing predicted antidepressant response or adverse drug reactions. The authors concluded that the literature reviewed had mixed findings, suggesting that CYP2D6 and CYP2C19 testing may predict response in certain individuals but it remains unclear. Researchers found that, pharmacogenomic testing is widely available, but its utility has not yet been clearly established. Given these findings, the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 psychiatry and is actively practicing. Physician reviewer 2 is board certified in psychiatry and is actively practicing. Physician reviewer 3 is board certified in psychiatry 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Prolia injections (60 mg every six months for two doses). While pharmacological treatment of patients with prevalent osteoporotic fractures is universally accepted, the treatment of patients at increased risk of fracture due to low bone mass is more controversial. Eriksen noted, According to the World Health Organization criteria for assessment of dual-energy x-ray absorptiometry measurements, patients are considered to have low bone mass (osteopenic), when their bone mineral density T-score of the spine or hip lies between 1 and 2.5. Although fracture risk increases with decreases in bone mineral density, the vast majority of osteoporotic fractures occur in osteopenic patients. This is because even though the risk of fracture is lower in the osteopenia than in osteoporosis, the number of subjects at risk is much higher in the osteopenic range due to the Gaussian distribution of bone mineral density values in the population. Prolia (denosumab) is a bone anti-resorptive drug used for the treatment of osteoporosis and other bone-related disorders. It is indicated as therapy for postmenopausal women with osteoporosis at a high-risk for fracture. Although this patient does not yet have osteoporosis, but does have hypercalciuria and hyperparathyroidism in conjunction with osteopenia. Both of these conditions can lead to worsening of bone mineral density. The patients upcoming dental surgery increases the risk of osteonecrosis of the jaw if the patient undergoes therapy with zoledronic acid. Studies show that the mean maximal serum concentration of Prolia is reached at 10 days, and the mean half-life is 25.4 days, and declines over a period of four to five months. There is no accumulation or change in the pharmacokinetics of denosumab over time in those who take it every six months. Bisphosphonates, on the other hand, have a long in vivo half-life following cessation and may be associated with delayed dental healing and the complication of osteonecrosis of the jaw. Some studies have shown that bisphosphonates have a half-life in bone of up to 11 years. Therefore, Prolia injections (60 mg every six months for two doses) are 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.
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 Tobii Dynavox I-110 with Snap + Core First speech-generating device (SGD). The American Speech-Language-Hearing Association (ASHA) notes that communication services and supports should be based on individual communication needs, and should be evaluated, planned, and provided by an interdisciplinary team with expertise in communication and language form, content, and function, as well as in augmentative and alternative communication (AAC). Brady and colleagues report that individuals with disabilities should be able to access functioning AAC and other AT (assistive technology) services and devices at all times. Current medical literature supports the provision of an AAC device for individuals with disabilities who have been evaluated and found capable of using such a device. Morin and colleagues report that the use of high-tech AAC to teach social-communication skills to individuals with autism spectrum disorder or intellectual disabilities and complex communication needs can be considered an evidence-based practice. Virbalas and colleagues describe the reduced receptive vocabulary and profound deficit in expressive language in children with Cri-du-Chat syndrome, noting that speech and language therapy, including augmentative communication devices, may enhance effective communication and improve the quality of life of these patients. In this case, the records note that the patient has undergone a thorough evaluation by a speech therapist skilled in the evaluation of children for their suitability for AAC devices. Other, less technologically complex devices have been considered and found to be inadequate for this patient's communication needs. She is not expected to develop oral language  and is exhibiting significant behavioral issues which are probably largely a result of frustration due to her inability to communicate. The patient has adequately demonstrated an ability to use the device, and ongoing speech therapy using the device is planned. Given that current medical literature supports the use of AAC is this clinical setting, and as the requested device enables the patient to communicate her wants and needs, the requested device is medically indicated. Therefore, a Tobii Dynavox I-110 with Snap + Core First SGD is medically necessary for the treatment of this patient.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.Credentials/Qualifications: The reviewer is board certified in neurology with special qualifications in child 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 patients parent has requested authorization and coverage for Dupixent. Findings: The records document that this patient has atopic dermatitis with involvement of over 10% of her body surface area (BSA). The provider charted that since starting treatment with Dupixent in August 2021, the patient has experienced improvement. The provider has recommended continued treatment with Dupixent. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of children and adults with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. The data supporting the use of Dupixent in the treatment of patients with moderate-to-severe atopic dermatitis is substantial and studies have reported a favorable side effect profile in comparison to other systemic agents for use in this clinical setting. A study concluded that, In two phase 3 trials of identical design involving patients with atopic dermatitis, dupilumab improved the signs and symptoms of atopic dermatitis, including pruritus, symptoms of anxiety and depression, and quality of life, as compared with placebo. Based on all of the information provided, this patient is a good candidate for treatment with Dupixent. Therefore, the requested Dupixent 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 dermatology with subspecialty certification in dermatopathology 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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for adaptive car seat. The records provided for review do not document that this patient has poor head, neck, or trunk control to support an indication an extra restraint to help the child sit in proper position and stay in place (Wilkes; Will, et al.). Specifically, the patient does not have a feeding tube, an arm or leg cast, or joint deformity that requires the accommodations of an adaptive car seat. The patient may benefit from ongoing occupational therapy training for the child's impairments. However, based on the patients current level of function, an adaptive car seat is not medically necessary to address any concern for disease prevention or issues with safety during transportation. There is a paucity of research that supports use of an adaptive car seat for sensory, activities of daily living, or fine motor deficits in this patients clinical setting. On review of the records, an adaptive car seat is not being requested to prevent disease, disability, and other health conditions or their progression, prolong life, promote physical and mental health and efficiency or correct or ameliorate any physical or behavioral conditions. Given these findings, the requested adaptive car seat is not medically necessary for 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.