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

Findings:  The physician reviewer found that the patient has requested authorization and coverage for Tepezza (J3241). This patients records document a history of thyroid eye disease causing proptosis and eyelid retraction. The patients condition has failed to improve despite treatment with selenium, artificial tears, gel, and Restasis. The patients provider has recommended treatment with Tepezza. Thyroid eye disease is an autoimmune disorder that is associated with hyperthyroidism and can cause orbital disfigurement, double vision, and loss of vision. Management is guided by disease activity and severity status. Previously, treatment options were limited to the control of hyperthyroidism, local eye measures, glucocorticoids, selenium, orbital radiotherapy, and surgery (Kotwal and Stan). Newer targeted biologic therapies have shown promise, including Tepezza, which is an IGF-1 receptor antagonist. On review of the available clinical data, Tepezza has been demonstrated to substantially reduce proptosis associated with Graves ophthalmopathy (Kahaly, et al.). In addition, Tepezza has been shown to help reduce disease activity and the severity of Graves ophthalmopathy (Genere and Stan). For these reasons, the requested Tepezza (J3241) 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 subspecialty certification in diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for lymphovenous bypass or lymphaticovenous anastomosis (LVA).Findings: Two out of three physician reviewers found that a lymphovenous bypass or LVA is likely to be more beneficial for you than any available standard therapy.Rockson states that no medications have been shown to alleviate lymphedema. Instead, standard treatments involve various physiotherapeutic interventions, such as decongestive lymphatic therapy. Decongestive lymphatic therapy relies heavily on manual lymphatic drainage combined with compression bandaging. Garza and colleagues state, LVA or lymphovenous bypass is a surgical procedure where lymphatic vessels in a lymphedematous limb are connected to nearby small veins and venules using microsurgical and super-microsurgical techniquesNumerous studies have been published which show improved symptoms and as much as 61% reduction in volume difference of the affected limb after LVA at one year. Additionally, Pereira and colleagues report, LVA is an effective treatment option to reduce the volume [of cellulitis] in the affected limb and to improve symptoms involved. Garza and Chang state, Benefits of [lymphovenous bypass] are its effectiveness in treating early-stage lymphedema of either the upper or lower extremity and having low complication profile. The International Society of Lymphology states, LVAs are currently in use at multiple centers around the world. These procedures have undergone confirmation of long-term patency (in some cases more than 20 years) and some demonstration of improved lymphatic transport (by objective physiologic measurements of long-term efficacy). Multiple LVAs in a single surgical site with both the superficial and deep lymphatics, allow the creation of a positive pressure gradient (lymphatic-venous) and evade the phenomenon of gravitational reflux without interrupting the distal peripheral superficial lymphatic pathways. In this case, the patient has used multiple conservative measures for control of her lymphedema, but the lymphedema has progressed despite these measures. LVA or lymphovenous bypass is accepted therapy for the treatment of post-mastectomy lymphedema. Therefore, the requested lymphovenous bypass or lymphaticovenous anastomosis (LVA) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in plastic surgery. All reviewers 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:  An enrollee has requested authorization and coverage for regimen of Keytruda (pembrolizumab), Taxol (paclitaxel), and carboplatin.According the National Comprehensive Cancer Network (NCCN) guidelines, this patient should be treated as if he has a non-small cell lung cancer of adenocarcinoma subtype. Per the NCCN guidelines, based on staging, lack of driver mutations, and PD-L1 status, the treatment of choice would be carboplatin, pemetrexed, and pembrolizumab. Additionally, Gandhi and colleagues conclude, In patients with previously untreated metastatic non-squamous non-small-cell lung cancer without estimated glomerular filtration rate (EGFR) or anaplastic lymphoma kinase (ALK) mutations, the addition of pembrolizumab to standard chemotherapy of pemetrexed and a platinum-based drug resulted in significantly longer overall survival and progression-free survival than chemotherapy alone. In this case, this patient has an adenocarcinoma presumed of lung primary. Per the NCCN guidelines, the requested regimen is not indicated. Therefore, the requested regimen of Keytruda (pembrolizumab), Taxol (paclitaxel), and carboplatin is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested regimen 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 medical oncology 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:  An enrollee has requested authorization and coverage for right shoulder surgery (CPT codes 29827, 29826, 23929, and 29824).With regard to partial thickness rotator cuff tears with impingement, a review by Karjalainen and colleagues indicates that it is, uncertain whether rotator cuff repair surgery provides clinically meaningful benefits to people with symptomatic tears. Surgery may provide little or no clinically important benefits with respect to pain, function, overall quality of life when compared with non-operative treatment. For subacromial decompression, a similar non-surgical approach is recommended. The benefit of subcoracoid decompression is similarly uncertain. For lengthening of the clavicle at the midshaft with osteotomy and bone grafting, the advantage is mainly cosmetic. Wang and colleagues concluded, Distal clavicle resection in patients with rotator cuff tears did not result in better clinical outcome scores or shoulder range of motion and was not associated with a lower risk of reoperation. [It may also] cause acromioclavicular joint instability in patients with rotator cuff tears and concomitant asymptomatic acromioclavicular joint arthritis. Therefore, the requested right shoulder surgery (CPT codes 29827, 29826, 23929, and 29824) is not medically necessary for treatment of the patients medical condition.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 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 Stelara, prefilled syringe 90 mg/ml, every four weeks. Findings:  The physician reviewer found that mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, Kopylov and colleagues observed an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patient has symptoms consistent with active Crohns disease on Stelara 90 mg every eight weeks, with laboratory testing showing a low Stelara level of 2.6 ug/mL and lack of anti-Stelara antibodies. Continuation of dosing every eight weeks or a change to another medication may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Therefore, Stelara, prefilled syringe 90 mg/ml, every four weeks, is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment (DME) Dexcom G6 sensor. Findings:  The physician reviewer found that (FDA) has approved several continuous glucose monitor system (CGMS) devices that record blood sugar levels at repeated intervals throughout the day and night. The main advantage of a CGMS, is that the device can help identify fluctuations and trends that would otherwise go unnoticed, which helps to maintain tight glycemic control. The Dexcom CGMS has been shown to capture dangerously low overnight blood sugar levels, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, evaluate how diet and exercise affect blood sugars. CGMS has been shown to improve hemoglobin A1C levels of diabetic patients with high accuracy in glycemic values with a low complication rate. This patient has been unable to improve her glycemic control except with the Dexcom G6 CGMS. For these reasons, the requested DME Dexcom G6 sensor is 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 subspecialty certification in diabetes, endocrinology, 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 reimbursement for transcranial magnetic stimulation (TMS). Current medical literature supports the use of TMS for severe, recurrent major depressive disorder that is unresponsive to medication management and psychotherapy treatment. Researchers note that multiple randomized controlled trials and published literature have supported the safety and efficacy of TMS antidepressant therapy in the treatment of major depressive disorder. In this case, the patient has a diagnosis of major depressive disorder and has consistently been in cognitive behavioral therapy, along with trials of antidepressants, a mood stabilizer, and atypical antipsychotics without improvement in his symptoms and continued difficulty in functioning. The records document that following TMS therapy, the patient reported almost complete remission of his depressive symptoms, demonstrating the efficacy of TMS in this clinical setting. In this patients case, TMS was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, TMS was clinically appropriate in terms of type, frequency, extent, site, and duration. TMS was not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, TMS was medically necessary for the 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 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 Orthovisc injection series.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 good relief from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed steroid injections, with the alternative being total knee arthroplasty. Therefore, the requested Orthovisc injection series knee is medically necessary for treatment of the patients medical condition.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 Lupron injections. Lethaby and colleagues note that gonadotropin-hormone releasing analogues (GnRHa), such as Lupron, induce a state of hypo-oestrogenism that shrinks uterine fibroids, but have unacceptable side effects if used long-term.  Potential adverse effects in premenopausal women include cardiovascular effects due to androgen deprivation and decreased bone density. For this reason, GnRHa therapy is primarily used as transitional therapy to bridge patients from late perimenopause to menopause as in this case. While the submitted documentation noted FSH levels that were not in the postmenopausal range, the patient was reported to be postmenopausal. Given that heavy bleeding and fibroids resolve postmenopause, the requested services are not medically indicated. Therefore, Lupron injections are 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 obstetrics and gynecology 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 authorization and coverage for a computerized knee ankle foot orthosis (HCPCS L2006).Findings: Two out of three physician reviewers found that a computerized knee ankle foot orthosis (HCPCS L2006) is not likely to be more beneficial for you than any available standard therapy.Deems-Dluhy and colleagues concluded, The microprocessor swing and stance controlled knee-ankle-foot orthosis may contribute to improved quality of life and health status of patients with lower-extremity impairments by providing the ability to have better walking speed, endurance, and functional balance. Probsting and colleagues concluded, The microprocessor stance and swing control orthosis may facilitate an easier, more physiological, and safer execution of many activities of daily living compared to traditional leg orthosis technologies. The microprocessor stance and swing control orthosis offers new functions, including controlled knee flexion during weight bearing and dynamic swing control, resulting in significant improvements in perceived orthotic mobility and safety. However, there is limited literature that demonstrates that a computerized knee ankle foot orthosis would be of proven additional benefit over the standard knee ankle foot orthosis brace. Notwithstanding several studies that show the promise of the requested equipment, there is limited literature that demonstrates the safety and long-term effectiveness of computerized knee ankle foot orthoses.In this case, the patient notes that he can walk with a walker at home but does not walk in the community. Overall, there are well-documented clinical findings to support right lower extremity weakness as well as ambulation deficits. However, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. Therefore, the requested computerized knee ankle foot orthosis (HCPCS L2006) is not likely to be more beneficial than any other available standard therapy for patients medical condition.Final Result: The reviewers determined that the requested device is not likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in orthopedic surgery. All reviewers 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 brand name bupropion HCl tablet sustained release (SR) 24-hour 150 mg (Wellbutrin XL) twice daily. Findings:  The physician reviewer found that patient has a history of major depressive disorder that has failed to substantially improve despite treatment with amitriptyline, mirtazapine, temazepam, and trazodone. However, the records provided for review do not document that the patient has been treated with a selective serotonin reuptake inhibitor (SSRI) as first-line therapy. The patient is currently on Wellbutrin SR 150 mg twice daily and she has requested treatment with brand name Wellbutrin XL. A recent study from Kharasch and colleagues redemonstrated the bioequivalence and therapeutic equivalence of brand name Wellbutrin and its generic formulation bupropion. Given this patients sensitivity to medications and lack of remission in symptoms, augmenting Wellbutrin SR with a SSRI is consistent with current recommendations in the medical literature. The patients records lack evidence to support for treatment with brand name Wellbutrin XL. Moreover, the requested brand name Wellbutrin XL is not in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the requested brand name bupropion HCl tablet sustained release (SR) 24-hour 150 mg (Wellbutrin XL) twice daily is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested brand name 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 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.