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 Motegrity 2 mg tablets. The records provided for review document that this patient presents with chronic constipation. The patients symptoms have failed to substantially improve despite treatment with osmotic and stimulant laxatives, as well as Amitiza. The patients provider has recommended treatment with Motegrity. Per the American Gastroenterological Association (AGA) guidelines, newer agents such as Motegrity should be considered for use in patients with constipation when non-pharmaceutical laxatives are ineffective (Bharucha, et al.). On review of current available published data on the treatment of chronic constipation, Hong reported that Motegrity is an effective and safe option based on all the studies currently conducted. In addition, Motegrity has been shown to be beneficial in the management of constipation and associated symptoms including bloating and abdominal pain (Tack, et al.; Jadav, et al.; Camilleri, et al.). For these reasons, the requested Motegrity 2 mg tablets are 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 patients parent has requested authorization and coverage for additional physical therapy. Current medical literature does not support the use of physical therapy modalities to correct pes-planus or intoeing resulting from internal rotation of the hip. Researchers explain that to understand variational pathologies of the lower limb, it is important to be familiar with the normal growth and development of childrens lower extremities, noting that neonates are born with about 40 degrees of femoral anteversion or forward rotation of the femoral neck, and that this increased internal rotation of the hip decreases over time. The mainstay of management is observation and researchers state that parental education and reassurance is an important part of the treatment and must be re-emphasized. The authors further note that shoe inserts, orthoses and physical therapy are not to be encouraged as they provide no benefit, and that in the majority of cases, the natural history is one of spontaneous resolution of the deformity. In this case, the patient does not have a skeletal deformity, is independent with mobility, and does not have neurological deficit, and does not report pain. The records document mild limitations with recreational and competitive sports. The patient has functional range of motion in all joints of lower extremities. His gait pattern consists of benign intoning that does not interfere with function. In this clinical setting, additional physical therapy is not medically indicated. Therefore, additional physical therapy 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 with sub-specialty certification in pediatric rehabilitation 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 Aimovig 70 mg/mL autoinjector. Calcitonin gene-related peptide receptor antagonists (CGRP) are biologic agents with demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine that do not require dose titration, may achieve rapid treatment effects, and are effective in patients who have failed prior preventive treatment and in patients on concurrent oral preventive treatments. Aimovig (erenumab) is a CGRP approved by the U.S. Food and Drug Administration (FDA) for the preventive treatment of migraine in adults.  The American Headache Society (AHS) notes that treatment with monoclonal antibodies to CGRP may be indicated for patients with chronic migraines with an inadequate response to topiramate, beta-blockers, and nortriptyline. Researchers found that in patients with chronic migraines, erenumab 70 mg and 140 mg reduced the number of monthly migraine days with a safety profile similar to placebo. In this case, the patient has a history of chronic headaches and is unable to tolerate oral preventative medications. The records noted that topiramate and beta-blockers were contraindicated. Given that the patient fits AHS criteria for treatment with CGRP monoclonal antibody therapy, the requested medication is medically indicated. Therefore, Aimovig 70 mg/mL autoinjector 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for Ferrlecit infusions to be given every 30 days for a minimum of six months. Kaneva and colleagues report that intravenous iron is an alternative for children with severe iron deficiency anemia who have difficulty in adhering to or absorbing oral iron. The authors further note that the use of intravenous iron sucrose in pediatric patients with severe iron deficiency anemia is safe and leads to a moderate increase in hemoglobin and substantial improvement in iron studies. The records note that the patient presented to the emergency room with iron deficiency anemia leading to a syncopal episode. Laboratory testing showed a mean corpuscular volume (MCV) on the lower end at 77 fL, low iron levels of 22 mcg/dL, low iron saturation of 5%, and abnormal total iron binding capacity (TIBC) of 461 mcg/dL. The patients hemoglobin had dropped from 10.7 gm/dL to 9.4 gm/dL. In a referral form, the provider reported that the patient had very heavy and prolonged menstrual bleeding, and that she had failed oral iron supplements, which had worsened constipation and caused extreme abdominal discomfort. In this clinical setting, the administration of Ferrlecit intravenous infusions of iron is likely to be more beneficial than other forms of iron, including oral iron. Therefore, Ferrlecit infusions to be given every 30 days for a minimum of six months is likely to be more beneficial for treatment of the patients condition than any available standard therapyFindings:  Two of the three physician reviewers found the requested Ferrlecit infusions to be given every 30 days for a minimum of six months is 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 service 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 pediatrics with sub-specialty certification in pediatric hematology-oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certifications in medical oncology and 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 a Supartz injection series in the right knee. 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 tried and failed arthroscopic surgery, along with turmeric, Aleve, physical therapy, and rest. Given the patients limited options, with the alternative being a total knee arthroplasty, and based on the current medical literature, the requested service is medically indicated. Therefore, a Supartz injection series in the right knee 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for gene panel testing (CPT 81405), (CPT 81479), (CPT81404), (CPT 81323), (CPT 81402), (CPT 81321), and (CPT 81406). Findings:  The physician reviewer found that routine genetic screening is not recommended for all inflammatory bowel disease (IBD) patients, although it should be considered depending on the age of onset and further criteria such as family history, relevant comorbidities, and extraintestinal manifestations. Genomic testing may be especially useful in children with very early-onset (VEO) IBD diagnosed under the age of two. The older the age of disease onset, the less likely a monogenic disorder is to be identified. Other factors which might lead one to test for monogenic disorder include relevant comorbidities suggestive of more generalized immunologic dysfunction, such as frequent or unusual infections. In this case, notes report that the patient was diagnosed with ileocolonic inflammatory Crohns disease. The records noted that the patients brother had a diagnosis of VEO-IBD. The records did not include documentation of specific concerns for an immunologic disorder, or if the patients brother has undergone genomic testing, and if so, any findings. At this point, the requested service appears unlikely to be helpful in providing a more precise diagnosis or targeted management of this patients early-onset IBD. Therefore, gene panel testing (CPT 81405), (CPT 81479), (CPT81404), (CPT 81323), (CPT 81402), (CPT 81321), and (CPT 81406) is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested gene panel testing (CPT 81405), (CPT 81479), (CPT81404), (CPT 81323), (CPT 81402), (CPT 81321), and (CPT 81406) 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 service is 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 reviewers 1 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. Physician reviewer 2 is board certified in pediatrics with sub-specialty certification in pediatric gastroenterology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for high intensity focused ultrasound (HIFU). Findings: HIFU therapy for low-grade, low-stage multifocal lesions, such as those present in this enrollee, necessitate treatment of the hemi-gland. Current literature recognizes the complexity of treatment decisions in the setting of prostate cancer. Some lesions that are Gleason 3+3 may harbor micro-foci of higher grade cancer, and treatment is warranted in young patients as active surveillance and associated repeat biopsy are not acceptable management. Treatment with radiation and prostatectomy is also not standard with a 3+3 tumor. A study reports that short-term results of hemi-gland HIFU indicate safety, excellent potency and continence preservation, and adequate short-term prostate cancer control. Long-term efficacy was not a primary endpoint of this study. In addition, another study reports that early evidence from their meta-analysis suggests that HIFU may result in some improved outcomes over prostatectomy. However, the authors note that at the time of their study, there have been no prospective randomized-controlled trials actually comparing the outcomes of radical prostatectomy, radiation therapy, and HIFU and that these trials are needed to investigate the benefits of HIFU for prostate cancer. Given the lack of evidence in current medical literature on the long-term efficacy of HIFU, the requested service is not medically indicated. Therefore, HIFU is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections for the left knee. 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. 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 patients options are limited. He has tried and failed cortisone injections, platelet-rich plasma injections, and physical therapy. There is sufficient support for the requested services in this clinical setting. Therefore, the requested Euflexxa injections for the left knee 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 lidocaine patches 5%. Findings:  The physician reviewer found that  U.S. Food and Drug Administration (FDAs) official drug website states that the lidocaine patch is only approved for use in treating post-herpetic neuralgia. McColgan and colleagues stated that there has been no evidence to support the use of lidocaine patches for musculoskeletal pain.  A systematic review by Santana and colleagues evaluated the medical evidence supporting the use of lidocaine patches for chronic low back pain. The authors concluded, We found no randomized controlled trials with substantial evidence to support the use of 5% lidocaine patch in chronic low back pain.In this case, the patient has chronic low back pain due to lumbar radiculitis and facet joint arthropathy. Her records do not show any history of post-herpetic neuralgia or any complaints related to this condition. The records show that the patient has been prescribed lidocaine patches to treat musculoskeletal back pain. Currently, the FDA has not approved the patches for this use, and the recent reviews on this subject reinforce the lack of evidence for use of the lidocaine patches in musculoskeletal related chronic pain. Therefore, the requested lidocaine patches 5% 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 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.
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 (ustekinumab), 90 mg subcutaneously (SQ) every four weeks. The submitted documentation supports the medical necessity of the requested medication regime. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. 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, researchers 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 had symptoms consistent with active  disease on Stelara 90 mg every eight weeks. While a Stelara level of at least 4.5 ug/mL is associated with effective disease control, laboratory results dated reported a low Stelara level of 0.3 ug/mL, and the patient was placed on a dosing regimen of every four weeks. Discontinuation of dosing every four 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 (ustekinumab), 90 mg SQ every four weeks, 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 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.