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 Dexcom continuous glucose monitoring device and supplies. Researchers note that continuous glucose monitoring systems (CGMS) enable patients to effectively control and adjust their insulin therapy. The author further notes that while use of CGMS may not significantly reduce the number of severe hypoglycemic episodes, recent data indicate that they may reduce the time spent in hypoglycemia. In this case, a CGMS is medically indicated for this patient to improve her glycemic control and prevent diabetic complications. Therefore, Dexcom continuous glucose monitoring device and supplies are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Prolia. A study notes treatment is generally recommended in postmenopausal women who have a bone mineral density T-score of -2.5 or less, a history of spine or hip fracture, or indications of fracture risk. The U.S. Food and Drug Administration (FDA) indicates Prolia (denosumab) as appropriate for the treatment of postmenopausal women with osteoporosis at high risk of fracture. In this case, given the patients diagnosis of osteoporosis, T-scores of -2.6 and -2.9 in left and right hips, and probability of osteoporotic fracture of 11.3% within the next ten years, the requested medication is medically indicated. Therefore, Prolia 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 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 mesalamine suppositories. The American Gastroenterological Association (AGA) guidelines on the management of mild to moderate ulcerative colitis suggest a trend favoring rectal mesalamine over oral mesalamine for induction. For patients who opt for rectal therapy, the AGA recommends mesalamine suppositories, stating, Suppositories are generally well tolerated, with few treatment-related adverse effects and better retention than enemas. In reviewing cases of patients with ulcerative proctitis who were initially treated with oral 5-aminosalicylate (5-ASA), mesalamine suppository, or mesalamine enema, researchers noted that treatment escalation was common in patients initiated with oral 5-ASA treatment. Given that guidelines support rectal mesalamine for the treatment of ulcerative colitis, the requested medication is medically indicated. Therefore, mesalamine suppositories 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.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for contrast-enhanced computed tomography angiography (CTA) scan. This patients provider noted that the patient has a history of metastatic adenocarcinoma of the lung and cardiomyopathy. A computed tomography (CT) of the chest revealed stable perihilar right upper lobe mass-like consolidation, new irregular nodular opacity in the lingula, and stable appearance of thickening involving the septal apically segment of the left ventricle. The provider recommended a contrast-enhanced CTA to assess the patient for coronary artery disease as the cause of his cardiomyopathy. Current peer-reviewed medical literature has demonstrated that contrast-enhanced CTA has diagnostic utility and prognostic significance in this patient and is a standard of care approach. All told, the contrast-enhanced CTA scan was 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 contrast-enhanced CTA scan was 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 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 oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Hetlioz (tasimelteon) 20 mg. The U.S. Food and Drug Administration (FDA) approves the use of Hetlioz (tasimelteon) for the treatment of non-24. A study describes non-24 as a circadian rhythm disorder, occurring most commonly in blind individuals without light perception, characterized by a persistent cycle of nighttime insomnia and daytime sleepiness. The study notes clinical trials in healthy individuals confirmed the circadian phase-shifting potential of tasimelteon, and that safety assessments indicated that tasimelteon is well tolerated. In this case, the patient has a diagnosis of non-24 and has tried and failed several medications. The provider recommended continuing Hetlioz based on the patients clinical response during an initial trial of the medication. Given the patients diagnosis and the providers recommendation, the requested medication is medically indicated. Therefore, Hetlioz (tasimelteon) 20 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 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 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 Synvisc-One injection in the right ankle. Per the medical literature, although viscosupplementation may relieve ankle 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 relief from a prior injection and has tried and failed conservative treatments. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Synvisc-One injection in the right ankle is 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 Viberzi 75 mg tablets, 60 per 30 days. Findings:  The physician reviewer found that iberzi has been demonstrated to be safe and effective for the long-term treatment of irritable bowel syndrome, diarrhea-predominant in high-quality clinical trials. The records provided for review document that this patient has failed the standard alternatives recommended by American College of Gastroenterology (ACG) guidelines for the treatment of irritable bowel syndrome, including antispasmodics and tricyclic antidepressants (Ford, et al.). Moreover, no contraindication to Viberzi is documented. For these reasons, the requested Viberzi 75 mg tablets, 60 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 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 bilateral radiofrequency ablation (RFA) of the perforator veins. The documentation provided for review does not support the medical necessity of RFA of the bilateral perforator veins for this patient. It is not possible to attribute persistent symptoms to his perforator veins in the absence of an assessment of arterial perfusion, especially since the patient has a history of pelvic injury and is having persistent disabling symptoms despite ablation of all four major superficial veins. In addition, the records do not report that the patient continues to have lifestyle limiting symptoms despite bilateral greater saphenous vein (GSV) and small saphenous vein (SSV) ablations. Insufficient time has passed for the inflammation associated with four ablation procedures to resolve for such reevaluation. The duplex examination of the right leg on 9/21/20 indicate that the patients persistent symptoms are mild, and no other reflux was noted. RFA of the perforator veins is supported for patients with active or healed ulcer, which is not documented in this patients case. For these reasons, the requested bilateral RFA of the perforator veins 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 surgery with subspecialty certification in vascular 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 reimbursement and prospective authorization and coverage for Hizentra home infusions (13 grams administered by a nurse), (12 grams administered by a nurse), and (25 grams self-administered), and future for Hizentra 25 gram self-administered home infusions every 14 days for one year. Dysautonomia refers to any disorder associated with dysfunction of the autonomic nervous system. There are many different mechanisms by which dysautonomia may arise, but there has been increasing evidence and awareness that it may be immune-mediated in some patients. Autoimmune autonomic dysfunction may be peripheral due to an immune-mediated small fiber polyneuropathy (SFPN). Clinical manifestations of SFPN may include postural tachycardia syndrome, orthostatic intolerance or hypotension, inappropriate sinus tachycardia, gastrointestinal dysmotility, complex regional pain syndrome, or neurogenic bladder. Intravenous immunoglobulin (IVIG) is considered a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. In one study, 55 patients with confirmed SFPN attributed to autoimmunity received IVIG for more than three months. The authors concluded that their results provide Class IV evidence that IVIG is safe and effective for rigorously selected SFPN patients with apparent autoimmune causality. Subcutaneous immunoglobulin (SCIg) therapy has also been used successfully for patients with immune deficiency syndromes. One review showed that SCIg is more effective than IVIG in improving patient reported outcomes in autoimmune neuromuscular disease in terms of muscle strength maintenance, improvement overall strength and quality of life, as well as patient satisfaction. In this case, the patient has autoimmune autonomic SFPN. Based on the current medical literature, patients with autoimmune SFPN may improve clinically with immunoglobulin treatment administered subcutaneously or intravenously. Given this support, Hizentra home infusions (13 grams administered by a nurse), (12 grams administered by a nurse), and (25 grams self-administered), and future Hizentra 25 gram self-administered home infusions every 14 days for one year were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was and 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 Actemra. According to the American College of Rheumatology (ACR) and Arthritis Foundation guidelines, In patients with juvenile idiopathic arthritis and polyarthritis and moderate or high disease activity receiving DMARD monotherapy, adding a biologic is conditionally recommended over changing to triple DMARD therapy. In addition, the guidelines do not mandate that a tumor necrosis factor inhibitor (TNFi), such as Enbrel or Humira, must be the initial biologic drugs utilized in the treatment of juvenile idiopathic arthritis. The guideline states that, The class of initial biologic is not specified in the recommendations again due to lack of comparative data and the consideration that non-TNFi biologics may be preferred in certain scenarios based on patient-level factors. The guidelines indicate that alternate biologic drugs, such as Actemra, is an acceptable option as initial biologic therapy in the treatment of juvenile idiopathic arthritis. In this case, the patient is on disease modifying antirheumatic drug (DMARD) monotherapy with oral methotrexate 15 mg weekly with persistent inflammatory arthritis symptoms. According to the guidelines, the addition of biologic therapy is appropriate for this patient. These guidelines also indicate that Actemra is an acceptable and appropriate initial biologic drug of choice for the treatment of active juvenile idiopathic arthritis. For these reasons, the requested Actemra 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 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 Supartz injection series for both knees. Per the medical literature, although 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 benefit from prior viscosupplementation. She has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Supartz injection series for both 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture services two times a week. Findings:  The physician reviewer found that Acupuncture is effective for the treatment of chronic musculoskeletal, and osteoarthritis pain. Per the authors, Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. An initial trial of acupuncture, which may be indicated for chronic neck pain, generally consists of five to six appointments, with a re-evaluation after the trial is completed to assess the benefits obtained. In this case, the patient has received multiple sessions of acupuncture over several months, without documentation of significant, objective benefits. The documentation did not demonstrate significant symptom reduction, or improvement of activities of daily living functioning directly attributable to prior acupuncture. Given that measurable, progressive, significant, objective functional improvement has not been noted,  the requested services are  not medically indicated. Therefore, acupuncture services two times a week 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 a licensed acupuncturist, board certified in oriental 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continuous glucose monitor and disposable sensors. Salehi and colleagues note that hypoglycemia is a frequent complication occurring after bariatric and other forms of upper gastrointestinal surgery, posing severe health risks. The U.S. Food and Drug Administration (FDA) notes that CGM devices record blood sugar levels at repeated intervals throughout the day and night, detecting episodes of hyperglycemia and hypoglycemia, facilitating acute and long-term therapy adjustments. Given that the patient is status post gastric bypass surgery and is experiencing related hypoglycemia, the requested equipment is medically indicated. Therefore, CGM and disposable sensors are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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.