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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for injections of dehydrated alcohol solution in the left foot. Sclerosing injections have not been demonstrated to be more beneficial for treatment of neuromas than presently available standard therapies. Studies show inconsistent results that do not demonstrate an improvement in outcomes over traditional therapies. One study evaluated injection with alcohol sclerosant for Mortons neuroma. The study concluded that although short-term results are encouraging, alcohol injection does not offer permanent resolution of symptoms for most patients and can be associated with considerable morbidity. Therefore, the requested injections of dehydrated alcohol solution in the left foot are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the requested injections of dehydrated alcohol solution in the left foot 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. Final Result: The reviewers determined that the requested injections of dehydrated alcohol solution in the left foot are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Credentials/Qualifications: Medical professional reviewers 1 and 2 are board certified in podiatry and are actively practicing. Medical professional reviewer 3 is board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for HP Acthar Gel. Findings:  Two out of three physician reviewers found that HP Acthar Gel is not likely to be more beneficial than any other available standard treatments for the patients medical condition. There are several studies reviewing the use of Acthar or repository corticotropin injection (RCI) for the treatment of rheumatological disease. One study performed a retrospective review and concluded that RCI may improve disease control and warrants further evaluation. Another study, involving four patients, found that their results were encouraging and suggested that randomized, controlled clinical trials applying RCI to dermatomyositis and polymyositis were warranted. Another recent retrospective case series showed improvement with Acthar in five patients with refractory dermatomyositis (DM) or polymyositis (PM). This study is small, however, and larger studies are needed. Although there is literature to show possible efficacy of Acthar in refractory myositis, these studies are small. There is no randomized controlled trial (RCT) demonstrating the efficacy of Acthar in the treatment of refractory myositis. The current literature supports the use of rituximab in cases of resistant myositis. In this case, the patient was diagnosed with statin induced myopathy mimicking PM. His statin was stopped with initial improvement in symptoms. There is no history of other more first line immunosuppressive agents reflected in the submitted documentation. The submitted records fail to demonstrate that the patient is resistant to more standard first line therapy. Under these circumstances, HP Acthar Gel 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 medication is not likely to be more beneficial than any other available standard treatments for this patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine and allergy and immunology, with subspecialty certification in rheumatology, and is actively practicing. Physician reviewer 2 is board certified in internal medicine and allergy and immunology, and is actively practicing. Physician reviewer 3 is board certified in internal medicine, with subspecialty certification in rheumatology, 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hematopoietic progenitor cell autologous transplantation. Multiple sclerosis is a progressive immune disease affecting the central nervous system, causing neurological dysfunction. The disease is characterized by multifocal inflammation of the central nervous system, which causes impaired nerve conduction. The most common form of multiple sclerosis is the relapsing and remitting subtype, which clinically refers to episodes of new or worsening functioning with magnetic resonance imaging (MRI) correlation and periods of clinical stability. As noted in the medical literature, there are several therapies available to manage the disease. While there is evidence to suggest stem cell transplantation is effective for patients with multiple sclerosis, there is a lack of well-designed randomized controlled trials and studies comparing stem cell transplant with the available therapies. Further, the studies lack data on the long-term safety of this therapy. He has tried and either had poor effectiveness or adverse effects with other medications. The records suggest that this patient has stable disease on MRI with Tysabri. Given these findings, the requested hematopoietic progenitor cell autologous transplantation is not 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 that the requested services are 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: Medical professional reviewers 1 and 3 are board certified in neurology and are actively practicing. Medical professional reviewer 2 is board certified in oncology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Grafix skin graft procedures. While placental allografts show promise for the treatment of diabetic foot ulcerations, there is a paucity of large prospective randomized controlled clinical trials demonstrating the significant effectiveness of Grafix application in the treatment of surgical incision dehiscence wounds. The current standard of care includes soft tissue and nonviable tissue debridement along with scrupulous cleansing of the wound, antibiotics if needed, and non-weight bearing and/or offloading of the ulcer site. In this patients case, Grafix allograft was used as a supplement to wound debridement for the patients left lower leg surgical incision dehiscence wound. The patient did not have additional risk factors that would have slowed the progression of the wound with standard wound care management. All told, the Grafix skin graft procedures were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three reviewers determined that the services at issue were 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.Final Result: The services at issue were 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:  One reviewer is board certified in podiatry and is actively practicing. One Reviewer is board certified in podiatry and is actively practicing.  One Reviewer is board certified in podiatry and is actively practicing.  All three 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 liposuction of the trunk (abdomen and flanks, outer thighs). The World Professional Association for Transgender Health (WPATH) Standards of Care discussed the complex nature of aesthetic versus reconstructive aspects of non-genital surgeries. The WPATH noted that some procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. In this case, the documentation provided by this patient and his treating providers establishes the diagnosis of gender dysphoria. The providers letters state that the patient has gender dysphoria related to his body and the shape of his trunk, which has feminine fat distribution and causes psychological distress. The provider noted that the patients treatment plan includes bilateral mastectomies and liposuction. The planned bilateral mastectomies will directly address the patients distress related to gender dysphoria and is consistent with the WPATH Standards of Care. A 2019 study suggests that body fat in transgender men is positively correlated with testosterone dose. A 2018 study indicates that the use of testosterone improves the gynecoid appearance of fat distribution. In this case, the patient is noted to continue to have gender dysphoria despite high dose testosterone therapy. Given this continued distress, it is reasonable to consider liposuction as adjunct management of the gynecoid fat distribution. Therefore, liposuction of the trunk (abdomen and flanks, outer thighs) 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 psychiatry with expertise in transgender 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 conditio
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan Orthovisc injections  of the left knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known 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. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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 when everything else has been tried and the options are limited. In this case, the patient has a history of excellent response to viscosupplementation in the past with documented pain relief and the ability to continue working. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. Under these circumstances, hyaluronan Orthovisc injections of the left knee are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara 90 mg every four weeks. Current medical literature supports the requested dose escalation of Stelara in this case. The patient has active disease symptoms. The mechanism of Stelara is different from anti- tumor necrosis factor (TNF) medications, which this patient has failed. A large randomized controlled trial demonstrated the safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-to-severe Crohns disease resistant to anti-TNF therapy. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. With regard to dosing, one study found that dosing at 90 mg every four weeks can 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. Further, the American Gastroenterological Association (AGA) guidelines for the management of Crohns disease state that when response to a biologic medication is lost in the setting of a low drug level and lack of anti-drug antibodies, the drug dosage should be increased. In this case, the patient has failed multiple conventional and biologic alternatives as well as Stelara dosed at every eight weeks. He did initially have a response to Stelara, but later lost response in the setting of a low Stelara level. Continuation of the current dose may result in complications. For these reasons, Stelara 90 mg every four weeks is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication dosage 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for admission into an alcohol detoxification facility. Based on the available documentation, this patient meets the American Society of Addiction Medicine (ASAM) criteria for admission into an alcohol detoxification facility. Overall, the patient is medically unstable. Overall, this patients presentation supports inpatient detoxification and related services. Given the severity of the patients illness and his history of relapses, admission into an alcohol detoxification facility is in accordance with generally accepted standards of medical practice and is therefore medically necessary. 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 psychiatry with expertise in addiction 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 Synvisc injections. The current evidence suggests that viscosupplementation for treatment of ankle osteoarthritis is a safe and effective treatment modality. Injections of hyaluronic acid into the ankle can be used to provide pain relief and to delay the need for major surgery in patients with osteoarthritis of the ankle. One study evaluated 50 consecutive patients undergoing a three-injection protocol of sodium hyaluronate viscosupplementation in the ankle. The study compared the patients pre- and post-treatment opinions about their ankle problems and found that intra-articular injection of sodium hyaluronate viscosupplementation is a beneficial conservative therapy for osteoarthritis of the ankle. In light of the foregoing, the requested Synvisc injections are medically necessary for treatment of this patients severe osteoarthritis of the right ankle.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 enrollee has requested authorization and coverage for transoral incisionless fundoplication (TIF) utilizing the EsophyX device. Appropriate patient selection is critical prior to performance of anti-reflux procedures. In prelude to surgical intervention for GERD, one study noted that, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. The study noted that it is important to document the presence of abnormal distal esophageal acid exposure, to outweigh the potential side effects of fundoplication. This patients records document that she has undergone some of the recommended preoperative evaluation for treatment of her diagnosis of GERD. However, the medical records document does not support that the patient is medically refractory to acid blocker medications nor support the presence of advanced GERD or endoscopic evidence of esophagitis. Moreover, TIF has not been evaluated for use in patients with complaints of dysphagia in the form of globus sensation as in this patients case. All told, the requested TIF utilizing the EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested TIF utilizing the EsophyX device 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 TIF utilizing the EsophyX device 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, 2 and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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: The patient has requested authorization and coverage for Actemra. On review of the medical documentation, this patient has evidence of biopsy-proven active chronic antibody mediated rejection (cAMR) with positive donor specific antibodies (DSAs). As cAMR is a major cause of graft loss, it is critical to treat the patients condition to prevent graft failure. As the patient is sensitized, and has a strong presence of DSAs, her chances of a second renal transplant are limited. Combination therapy with intravenous immunoglobulins and rituximab with or without plasma exchange is one treatment option. However, improved patient health outcomes have been shown with Actemra. Actemra is an IL-6 receptor monoclonal antibody that helps reduce DSAs in patients and preserve graft function. Actemra is an approach that has shown significant reductions in DSAs and stabilization of renal allograft function with few to no severe adverse events. Hence, Actemra is a preferred approach to stabilize the graft and improve survival rates for patients with cAMR. All told, Actemra is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three 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.Findings: The requested medication is likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  One reviewer is board certified in internal medicine with subspecialty certification in nephrology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in nephrology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in nephrology and is actively practicing.  All three 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.