Persius/hicric huggingface dataset:
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 cold therapy machine that uses ice or ice water. Findings:  The physician reviewer found that various treatment options for patient with chronic abdominal wall pain and found that treatment protocol included abdominal wall injections or a localized removal of terminal branches of intercostal nerves. The authors did not include a cold therapy machine as part of treatment protocol. Another review of conservative to more invasive treatment options for abdominal wall pain by Shian and Larson found that local injections with an anesthetic and a corticosteroid were effective treatments for anterior cutaneous nerve entrapment syndrome, with an overall response rate of 70% to 99%, while for refractory cases that required more than two injections, surgical neurectomy generally resolved the pain. The review did not mention a cold therapy machine as a studied or proven therapy for this condition. Given the current medical literature, a cold therapy machine is not medically indicated for treatment of chronic abdominal wall pain. Therefore, a cold therapy machine that uses ice or ice water 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 anesthesiology with sub-specialty certification in pain management 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 Otrexup (methotrexate) 25 mg/0.4 mL subcutaneous auto-injector pen. The medical literature supports the efficacy of methotrexate for the treatment of patients with chronic recurrent multifocal osteomyelitis (CRMO). In a retrospective study, Borzutzky and colleagues reported that 20% of patients treated with methotrexate demonstrated clinical remission. Zhao and colleagues demonstrated support for oral methotrexate or subcutaneous methotrexate injections for patients with CRMO refractory to treatment with non-steroidal anti-inflammatory drugs (NSAIDs). In this case, the patients records document that she was unable to tolerate first-line therapy with the celecoxib, which is an NSAID. The provider noted that celecoxib was contributing to exacerbation of the patients ulcerative colitis symptoms with rectal bleeding. The patient was then treated with injectable methotrexate in the form of the Otrexup 25 mg/0.4 mL auto-injector pen. Based on current medical literature and guidelines, methotrexate is an appropriate choice for CRMO as an alternative to NSAID therapy. However, according to the consensus treatment plan, treatment with methotrexate in this patients clinical scenario can be in oral or injectable formulations (Zhao, et al.). Thus, the use of oral methotrexate is appropriate and consistent with current recommendations. All told, the requested Otrexup (methotrexate) 25 mg/0.4 mL subcutaneous auto-injector pen 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 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

The patient has requested authorization and coverage for a transthoracic echocardiogram. Echocardiography is appropriate to evaluate cardiac structure and function when a patient presents with symptoms of suspected cardiac etiology including, but not limited to, chest pain, shortness of breath, or recent embolic event, or has palpitations with symptoms or signs of cardiovascular disease, for example, an abnormal physical examination or electrocardiogram. In this case, the patient has new onset of symptoms, including shortness of breath and palpitations in the past six months. A previous echocardiogram documented mild mitral insufficiency. Given this patients change in symptoms, abnormal prior imaging, and that the prior study is over a year old, repeat echocardiography is medically indicated. Therefore, a transthoracic echocardiogram is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for transcranial magnetic stimulation (CPT 90867, 90868, and 90869). While there is evidence that prefrontal transcranial magnetic stimulation (TMS) may be safe and effective in treating the acute phase of depression in patients who are treatment resistant or tolerant, current standard clinical practice is to trial psychotropic medications before proceeding with TMS. In this case, the documentation showed that the patient had tried and failed psychotherapy and only one drug, sertraline, to treat her depression. Although the provider reported the patient was nervous about trying other medications, further drug trials would be recommended prior to treatment with TMS. Therefore, transcranial magnetic stimulation (CPT 90867, 90868, and 90869)  was 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for osteochondral allograft transplant surgery. Findings:  The physician reviewer found that the patient presents with recurrent patellar dislocations and bilateral patellar chondral defects. The patients provider has recommended treatment with osteochondral allograft transplantation and tibial tubercle transfer. Osteochondral allograft transplantation is an option in the setting of osteochondral or large chondral defects after failure of other treatment options. The use of fresh allograft for patellar defects as recommended for this patient has been well documented in the current medical literature. Specifically, patient treated with osteochondral allograft transplantation for focal and diffuse chondral defects have experienced positive outcomes. Jungmann and colleagues found that patients undergoing cartilage resurfacing procedures showed less progression of degenerative magnetic resonance imaging (MRI) changes at six-year follow-up than patients with untreated patients with initially identical osteochondral defects. Patients with focal cartilage defects are good candidates for osteochondral allograft transplantation as it promotes healing of the articular defect and prevents progression to osteoarthritis of the knee. In this case, patellar chondral defects are documented based upon arthroscopic evaluation of both knees. This patients provider is planning an osteochondral allograft transplantation procedure in conjunction with tibial tubercle osteotomy for recurrent patellar dislocations and chronic pain. The records document that the patients pain interferes with his ability to perform activities of daily living. Moreover, the patient has reportedly failed conservative treatment with bracing, medications, injections, physical therapy, and arthroscopic chondroplasty. For these reasons, the requested osteochondral allograft transplant surgery 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for wearable cardioverter defibrillator (DME K0606) provided by Zoll LifeVest. This patient sustained a recent MI and underwent acute revascularization with coronary stenting. His subsequent ejection fraction was less than 35% and his medical management was being optimized. Chung and colleagues noted that the risk for sudden cardiac death appears to be highest in the first 30 days after MI in patients with left ventricular dysfunction or heart failure. This patients ejection fraction may have been transiently low and may have improved over time due to recovery of stunned myocardium from the MI, treatment with medications, or revascularization surgery. If the patient did achieve an ejection fraction greater than 35%, then he would not be a candidate for a permanent implantable defibrillator. A wearable LifeVest cardioverter defibrillator was appropriate to provide temporary protection from early sudden death due to arrhythmia during this interim period. In motivated patients who can manage the device, there is data that a wearable LifeVest cardioverter defibrillator can provide temporary protection from possible lethal ventricular arrhythmias in this patient population during this interim waiting period. All told, the wearable cardioverter defibrillator (DME K0606) provided by Zoll LifeVest was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the wearable cardioverter defibrillator (DME K0606) provided by Zoll LifeVest 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cabometyx tablet. Soft tissue sarcomas are a diverse group of cancers that comprise of over 50 different histologic subtypes. Alveolar soft part sarcoma is characterized by a pathognomonic translocation that can lead to the production of pro-angiogenic factors, which provides the basis for anti-angiogenic therapy. Sunitinib is a small molecule inhibitor of PDGFR, vascular endothelial growth factor (VEGF) among others. The records provided for review document that this patient progressed despite treatment with sunitinib. Given this progression, his provider has recommended treatment with Cabometyx, a multi-function tyrosine kinase inhibitor. Cabometyx has been FDA approved for progressive metastatic medullary thyroid cancer. In addition, at least two studies have shown activity of Cabometyx in the treatment of soft tissue sarcomas. Given this support, the requested Cabometyx tablet is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Cabometyx tablet is likely to be more beneficial for treatment of the patients medical condition than any available standard therapyFinal Result: The reviewers determined that the requested medication is 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 medical oncology 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 and 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for MRI of the left wrist and thumb. Plotkin and colleagues note that the tendons of the wrist are commonly symptomatic and can be torn, infected, or inflamed. The authors note that MRI and ultrasonography are useful tools for evaluating the wrist for possible pathologic conditions including de Quervain tenosynovitis, extensor carpi ulnaris tendinopathy, rheumatoid tenosynovitis, infectious synovitis, tendon tears, hydroxyapatite deposition disease, intersection syndrome, tenosynovial giant cell tumor, and fibroma of the tendon sheath. In this case, the patient has pain in his left wrist and thumb and has failed conservative treatment with wrapping, bracing, and medications. As such, an MRI scan is medically indicated to help provide a definite and accurate diagnosis and allow for appropriate treatment. Therefore, MRI of the left wrist and thumb is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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 patients parent has requested authorization and coverage for renal-bladder ultrasound on an Acuson imaging machine and annual renal-bladder ultrasound on the same Acuson imaging machine. This patient presents with bilateral hydronephrosis. The records indicate that the patients condition showed improvement in the right degree of dilatation on last imaging. The dilation is mild enough to be followed annually to monitor for changes that might be indicative of increasing obstruction. The patients renal-bladder ultrasound scans have been performed on an Acuson machine. The patients provider has recommended repeat imaging with use of the same machine and follow-up with the same provider, who has been treating the patient for the past six years. Based on the available medical literature, it is appropriate for this patient to receive an annual ultrasound on a machine of current resolution that utilizes similar technique in order to be comparable to prior scans. In addition, the patient requires continuous monitoring by a pediatric urologist for examinations to assure appropriate care. However, the records provided for review do not support an indication for repeat imaging with the same machine or provider to accurately monitor his hydronephrosis. Therefore, the requested renal-bladder ultrasound on an Acuson imaging machine and annual renal-bladder ultrasound on the same Acuson imaging machine are not medically necessary for 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 urology with subspecialty certification in pediatric urology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. While gene expression profile (GEP) testing has been shown to accurately identify risk of metastasis for patients with cutaneous melanoma, there is a lack of consensus on how this affects the treatment plan for patients. GEP testing is not considered routine standard of care and is not currently recommended under the National Comprehensive Cancer Network (NCCN) guidelines. There is a lack of medical literature supporting its use for the evaluation of patients with thin melanomas. In this case, the course of treatment for this patient would not change based on the results of the GEP testing. Therefore, DecisionDx-Melanoma genetic testing was not 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 requested DecisionDx-Melanoma genetic testing was not 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 requested services was not 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 upheld. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Skyrizi. The 2018 American College of Rheumatology/National Psoriasis Foundation guideline for the treatment of psoriatic arthritis (PsA) recommended treatment of PsA with tumor necrosis factor inhibitors (TNF1) over an interleukin-12/23 (IL-12/23) biologic. A study noted that an IL-12/23 may be considered if the patient has severe psoriasis, prefers less frequent drug administration, or has contraindications to TNF1 biologics. While the study noted some data supporting the use of selective inhibition of IL-23 to treat PsA, its use is fairly new. In this case, the patient has plaque psoriasis, and the provider noted that he has arthritis. Skyrizi is not the recommended therapeutic for a patient with psoriatic arthritis. In this patients case, the records do not support the use of Skyrizi. Therefore, Skyrizi 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 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.