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

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for sublingual immunotherapy and/or food tolerance induction. The records provided for review document that this patient has a history of food allergies for which his provider has recommended oral immunotherapy. However, there is a lack of published peer-reviewed literature, scientific evidence, or professional standard guidelines supporting the safety and efficacy of food allergy oral immunotherapy. The newly available, U.S. Food and Drug Administration (FDA) approved oral immunotherapy treatment Palforzia, was not included in the treatment plan for this patient, who has a diagnosis of allergy to peanut. With the exception of Palforzia, there are no other FDA-approved oral immunotherapy/desensitization treatments available. Current standard food allergy guidelines and recommendations for food allergy still include avoidance and the availability of an epinephrine autoinjector. Per the American Academy of Allergy, Asthma, and Immunology (AAAAI), oral immunotherapy (OIT) is not a curative therapy and patients who undergo treatment with OIT need to continue to carry epinephrine and avoid allergens. Per the AAAAI, it is not expected that OIT will lead to ingestion of the allergen without limitation. The current standard of care for treatment of food allergy is avoidance of the allergen and treatment of anaphylaxis with auto-injectable epinephrine. For these reasons, the requested sublingual immunotherapy and/or food tolerance induction is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested sublingual immunotherapy and/or food tolerance induction is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be 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 reviewer 1 is board certified in internal medicine with subspecialty certification in allergy and  immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and  immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and  immunology with subspecialty certification in pediatrics 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 patients parent has requested reimbursement for residential treatment facility (RTC) services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to a history of self-harm, two past suicide attempts, and prior suicidal ideation. In terms of functional status, the records support a score of 3. The documentation noted the patient was able to focus in school and complete her work. With regard to comorbidity, the records support a score of 4. The patient had significant comorbidity, due to the presence of hypothyroidism.In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to the patients concerns about parental expectations.With regard to level of support of the recovery environment, the records support a score of 1 due to parental engagement in family therapy. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment as previous outpatient treatment did not ameliorate anxiety, depressive symptoms and suicidal ideation. The patient continued to struggle with cognitive rigidity and emotional lability. With regard to treatment acceptance and engagement, the records support a score of 2. The patient was able to engage in treatment and demonstrated continued growth in challenging herself to be authentic. Thus, the patient has a total score of 20 which is consistent with Level 4 services. However, the score of 4 for risk of harm and comorbidity support a higher level of care which is Level 5- medically monitored residential care. Therefore, RTC services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for re-admission to an outpatient neurological rehabilitation day program (3 hours/day; 5 days/week). Researchers describe progressive multifocal leukoencephalopathy (PML) as a rare opportunistic infection that occurs in patients whose immune system is compromised either because of an underlying illness or an immunosuppressive medication. The authors note that John Cunningham (JV) virus, prevalent in 60% or more of the adult population as a latent or persistent infection, is responsible for the syndrome of PML. Clinical symptoms may involve multiple domains, including cognition, vision, speech, behavior, sensation, motor function and gait. Motor dysfunction related to PML often manifests as hemiparesis. Treatment in cases of an allogeneic organ transplantation may include an adjustment of the immune suppressive therapy, and otherwise includes symptomatic and supportive care, including the treatment of complications such as seizures and psychiatric symptoms. In this case, the patient underwent a liver transplantation, which was complicated postoperatively by PML. The provider noted improvements following adjustments in the patients immunosuppressive regimen. Despite extensive rehabilitation, the patients gains have been modest overall and the patient continues to require extensive assistance for basic and instrumental ADLs due to multiple, severe, and persistent deficits related to his underlying, multifocal, degenerative brain disease. While records reflect that the patient recently sustained a left hip fracture which was surgically repaired, there is no indications that he requires or would be expected to marginally benefit from intensive outpatient multidisciplinary rehabilitation over usual rehabilitative services for hip fracture convalescence, if needed. Given that the patients primary deficits are due to a severe, progressive infectious condition, and that his clinical outcomes are not expected to be a function of the intensity of the rehabilitation services he receives, the requested services are not medically indicated. Therefore, re-admission to an outpatient neurological rehabilitation day program (3 hours/day; 5 days/week) is 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 physical medicine and rehabilitation 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 Hymovis injections in both knees. Findings: Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the guidelines do not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients remaining treatment options are limited, and they have failed conservative treatment consisting of physical therapy with and strengthening exercises and NSAIDs. Given these findings, the requested Hymovis injections in both knees are 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit with viscosupplementation. This patient presents with a history of osteoarthritis of the knee. The patient is unable to tolerate NSAIDs, but did respond well to viscosupplementation in the past. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. Given the patients positive response with prior viscosupplementation and the limited treatment options, the requested Synvisc One injection 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for foot orthotics.Plantar fasciitis is one of the most common causes of heel pain seen by foot and ankle surgeons. Approximately 10% to 16% of the population suffer from plantar fasciitis. Plantar fasciitis can be caused by numerous conditions, but most common is a biomechanical change in the subtalar joint placing excessive pressure to the medial column and the plantar fascia. This condition may cause inflammatory or degenerative changes of the fascia and periostitis of the medial calcaneal tubercle.Custom orthotics have been long considered a standard of care for plantar fasciitis. Orthotics are utilized to control the abnormal biomechanics of the foot. The use of custom foot orthotics has been shown to improve short and long-term pain in patients suffering from plantar heel pain. In this case, the patient has been diagnosed with plantar fasciitis which is painful when weight-bearing on the right side. The patients current orthotics do not appear to be sufficient to control the patients abnormal calcaneal eversion. Thus, the provider recommended that the patient receive a new pair of foot orthotics to control the foot and help alleviate the painful plantar fasciitis. The new orthotics would control the abnormal resting calcaneal stance position, alleviating pressure from the plantar fascia. Under these circumstances, the requested foot orthotics are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medical equipment is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in podiatry 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 Gamunex-C infusions every four weeks at an outpatient hospital infusion center. This patient has clinical findings consistent with common variable immune disease (CVID) and requires immunoglobulin replacement therapy to reduce her risk of infections. Per her provider, she has a history of frequent adverse reactions to previous infusions for her diagnosis of rheumatoid arthritis. Moreover, the patient has experienced issues with her providers obtaining peripheral access and she has required use of ultrasound guidance. During her first infusion of Gamunex-C, she reported pain at the infusion site as well as significant headaches. Given the patients response to her first infusion of Gamunex-C, it is appropriate to administer her IVIG at an outpatient infusion center where she can be closely monitored and evaluated throughout the infusion process. All told, the requested Gamunex-C infusions every four weeks at an outpatient hospital infusion center are 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 internal medicine with subspecialty certification in allergy and immunology 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 Nelarabine infusions. Dunsmore and colleagues reported that the addition of nelarabine to an augmented Berlin-Frankfurt-Muenster regimen improved disease-free survival rates for children and young adults with newly diagnosed T-cell acute lymphoblastic leukemia without increased toxicity. Abaza and colleagues concluded that a hyper-CVAD chemotherapy regimen plus nelarabine was well tolerated and in the frontline treatment of adult patients with T-cell acute lymphoblastic leukemia. In this case, the patient has a history of T-cell lymphoblastic lymphoma. Given current medical literature, the requested service is standard of care and medically indicated. Therefore, Nelarabine infusions 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 internal medicine with sub-specialty certifications in medical oncology and hematology 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 Simponi (golimumab) 50 mg/0.5 mL injection once monthly. Researchers noted, In adults with active ankylosing spondylitis despite treatment with nonsteroidal anti-inflammatory drugs, we strongly recommend treatment with tumor necrosis factor inhibitors (TNFi) over no treatment with TNFi. The authors did not recommend any particular TNFi as the preferred choice, and further stated, In adults with active ankylosing spondylitis despite treatment with the first TNFi used, we conditionally recommend treatment with a different TNFi over treatment with a non-TNFi biologic in patients with secondary nonresponse to TNFi. In this case, the patient has a diagnosis of ankylosing spondylitis. She is unable to tolerate NSAIDs and was unable to tolerate treatment with her first TNFi, Humira. Given current medical literature, treatment with a different TNFi, such as golimumab, is standard of care and medically indicated. Therefore, Simponi (golimumab) 50 mg/0.5 mL injection once monthly 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: An enrollee has requested authorization and coverage for an Orthovisc injection series of the right knee. Findings:  The physician reviewer found that Viscosupplementation or injection of exogenous hyaluronic acid into the knee joint has been studied and found to have limited short-term efficacy in the treatment of osteoarthritic knee pain. There is no scientific evidence indicating hyaluronic acid injection is effective in the treatment of chronic posttraumatic knee pain or improves outcomes following the treatment of multi ligamentous knee injury. As a consequence, no evidence based treatment algorithms recommend hyaluronic acid injection in the clinical scenario of a young patient who has sustained a multi ligamentous knee injury for which surgical ligament reconstruction was performed. In this case, the patient has chronic knee pain following posterior cruciate ligament and posterolateral corner allograft reconstruction. Current medical literature does not support that hyaluronic acid injection would be more effective than standard treatment under these circumstances. Accordingly, the requested Orthovisc injection series of the right knee is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Findings: Two out of three physician reviewers found that the requested Orthovisc injection series of the right knee is not likely to be more beneficial than any other available standard treatments for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that, Anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine. In this case, the patient underwent a routine colonoscopy for suspected cecal mass. He did not have any significant heart, lung, kidney, or liver disease. There was no documentation of a history of alcohol or substance abuse. There was no detailed description of a history of difficulties with anesthesia or sedation in the submitted records. The patient had an ASA classification score of 1 and there was no evidence that he presented with a difficult airway. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy, uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the service at issue was not medically indicated. Therefore, monitored anesthesia care was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at 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 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.