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

An enrollee has requested authorization and coverage for matrix-induced autologous chondrocyte implant (MACI) knee implant. Autologous chondrocyte implantation, including MACI, has been evaluated for the treatment of patients with articular cartilage defects. Early evidence suggests that MACI can be effective in the treatment of isolated cartilage defects in the knee. However, MACI is not indicated and has not been shown to be effective for the treatment of severe osteoarthrosis with widespread cartilage loss in the knee and areas of full-thickness cartilage loss. Per the U.S. Food and Drug Administration (FDA), MACI is contraindicated in patients with severe osteoarthritis of the knee (Kellgren-Lawrence grade 3 or 4). Thus, MACI is contraindicated for this patient with severe osteoarthritic cartilage loss on both sides of the patellofemoral articulation. All told, the requested MACI knee implant is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Taltz 80 mg/mL auto-injector. In recent years, biologic medications such as Taltz, have shown to control disease safely for the majority of patients with chronic plaque psoriasis. The U.S. Food and Drug Administration (FDA) approved Taltz for the treatment of patients with chronic plaque psoriasis. According to the American Academy of Dermatology (AAD) and the National Psoriasis Foundation (NPF), Taltz is recommended as a monotherapy treatment option for use in adult patients with moderate-to-severe plaque psoriasis (Menter, et al.). As noted in the medical literature, additional data in the medical literature has reported significantly improved patient satisfaction with Taltz when compared to Enbrel for patients with moderate-to-severe disease. This patient presents with chronic plaque psoriasis that has failed to improve despite treatment with clobetasol and Epiduo Forte. Given these findings, the Taltz 80 mg/mL auto-injectors were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was and 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a replacement power wheelchair. Findings:  The physician reviewer found that Mukherjee and Pasulka state that pressure injuries frequently complicate the care of patients with spina bifida, particularly patients who use wheelchairs. Pressure injuries can occur due to many etiological factors, including cognitive/behavioral impairment (e.g., inability to comply with a pressure relieving schedule), sensory loss, nutritional deficits and hygiene issues (e.g., sweating or chronic urinary incontinence). Pressure injuries can occur no matter what type of power wheelchair or seating/cushioning system is used if an appropriate pressure relieving schedule is not in implementation and if the other underlying etiological causes of the pressure injuries are not identified and addressed. In this case, the patient has a history of multiple conditions, including hydrocephalus, developmental delay, spina bifida and spinal deformities. She has impairments and mobility deficits that are well-associated with these conditions. The patient has been using a power wheelchair to address her mobility issues but has developed pressure injuries. Given that the patient in this case has persistently sustained pressure injuries despite modifications to her current power wheelchair, it is not evident that the patient is performing appropriate pressure relieving maneuvers. A replacement of her wheelchair would not be expected to result in any change in her risk for pressure injuries. Therefore, the replacement power wheelchair is not medically necessary for treatment for the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testingFindings:  The physician reviewer found that based on current American Heart Association (AHA) and American College of Cardiology (ACC) prevention guidelines, this patient is not classified as a candidate for statin therapy to reduce his cardiovascular risk given his scoring (Arnett, et al.). However, his scoring supports use of additional risk enhancing factors to further define cardiovascular risk and the need for statin therapy. Advanced lipoprotein testing was indicated for this patient to further define cardiovascular risk and to help determine whether to start statin therapy. In this patients work-up, use of advanced lipoprotein testing was consistent with the current AHA and ACC guideline recommendations and published data. Accordingly, the advanced lipoprotein testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the advanced lipoprotein testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in cardiovascular disease with subspecialty certification in interventional cardiology 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 (1) Adderall and (2) Ativan. The U.S. Food and Drug Administration (FDA) approves the use of Adderall for the treatment of attention deficit hyperactivity disorder (ADHD). The FDA notes that contraindications to Adderall include agitated states. In this case, while the patient reports problems with attention and concentration that they attributes to ADHD, these issues may be caused by a variety of mental health disorders, including major depressive disorder, bipolar disorder, generalized anxiety disorder, obsessive compulsive disorder, learning disorder(s), and various substance use disorders, or may be caused by general medical conditions, including hypothyroidism, hypoglycemia, sleep disorders, hearing and vision impairment, and seizure disorders. Further, comorbidities such as depression, PTSD, various anxiety disorders, and personality disorders may complicate an ADHD evaluation. Given that the patient has been seen by several providers and has undergone psychological screening without a diagnosis of ADHD, the requested (1) Adderall is not medically indicated. Lorazepam (brand name Ativan) is a medication in the benzodiazepine family. Kennedy and ORiordan note that while benzodiazepines have effective anti-anxiety properties, best practice guidelines generally recommend short-term use, for two to four weeks, at the lowest possible dose due to issues of tolerance and dependence. The authors further note that benzodiazepines should only be prescribed in the lowest effective dose for the short-term relief of severe anxiety or panic disorder, usually in an acute crisis situation. In this case, the patient was prescribed lorazepam upon presenting to the urgent care. While the urgent care providers prescription of lorazepam may have been medically necessary for the acute treatment of this patients anxiety at that time, given that current medical literature does not support the prescribing of benzodiazepines beyond the short-term use, the requested (2) Ativan is not medically indicated. Therefore, (1) Adderall and (2) Ativan are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 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 (1) Adderall and (2) Ativan. The U.S. Food and Drug Administration (FDA) approves the use of Adderall for the treatment of attention deficit hyperactivity disorder (ADHD). The FDA notes that contraindications to Adderall include agitated states. In this case, while the patient reports problems with attention and concentration that they attribute to ADHD, these issues may be caused by a variety of mental health disorders, including major depressive disorder, bipolar disorder, generalized anxiety disorder, obsessive compulsive disorder, learning disorder(s), and various substance use disorders, or may be caused by general medical conditions, including hypothyroidism, hypoglycemia, anemia, sleep disorders, hearing and vision impairment, and seizure disorders. Further, comorbidities such as depression, PTSD, various anxiety disorders, and personality disorders may complicate an ADHD evaluation. Given that the patient has been seen by several providers and undergone psychological screening without a diagnosis of ADHD, the requested (1) Adderall is not medically indicated. Lorazepam (brand name Ativan) is a medication in the benzodiazepine family. Kennedy and ORiordan note that while benzodiazepines have effective anti-anxiety properties, best practice guidelines generally recommend short-term use, for two to four weeks, at the lowest possible dose due to issues of tolerance and dependence. The authors further note that benzodiazepines should only be prescribed in the lowest effective dose for the short-term relief of severe anxiety or panic disorder, usually in an acute crisis situation. In this case, the patient was prescribed lorazepam upon presenting to the urgent care. While the urgent care providers prescription of lorazepam may have been medically necessary for the acute treatment of this patients anxiety at that time, given that current medical literature does not support the prescribing of benzodiazepines beyond the short-term use, the requested (2) Ativan is not medically indicated. In this patients case, (1) Adderall and (2) Ativan are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medications are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, (1) Adderall and (2) Ativan are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 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 urine tests (albumin to creatinine ratio (ACR) and glomerular filtration rate (GFR)).McTaggart and colleagues state that albuminuria is an important sign of chronic kidney disease and is detected routinely by measurement of urinary ACR. Additionally, Ranch states that proteinuria in certain conditions can signify renal disease and worse outcomes. Given the patients VSD, thalassemia, and potential hepatorenal issues, evaluation of renal function is essential for subtle defects that require early medical intervention. Urinalysis results and serum creatinine are not adequate for detection of minor defects early in a disease process. Therefore, formal GFR and ACR are needed to assure proper care, particularly when a history of abdominal pain of unknown etiology exists. Therefore, the requested urine tests (ACR and GFR) are medically necessary for the evaluation 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 urology with sub-specialty certification in pediatric urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for consultation with a cardiac electrophysiologist, magnetic resonance imaging (MRI) of the heart, electrocardiogram, and/or blood tests (thyroid stimulating hormone (TSH), T3, T4, TSH-thyroid stimulating immunoglobulin, N-terminal pro-B-type natriuretic peptide (Nt-proBNP), troponin T, and plasma ceramides). Based on the available documentation, the requested consultation with a cardiac electrophysiologist is indicated for further evaluation of this patients medical conditions. The patients clinical picture may be clearer with additional information about her brothers condition. If the patients brother sustained an episode of syncope or aborted sudden cardiac death, this could support one of several possible genetic disorders such as polymorphic ventricular tachycardia (VT), Brugada syndrome, Wolff Parkinson White (WPW) syndrome or other supraventricular tachycardias, early depolarization syndrome, and short QT syndrome. A family history of sudden cardiac death (SCD) in the absence of apparent structural heart disease is associated with an increased risk for primary SCD. It is reasonable for this patient to undergo an evaluation by a cardiac electrophysiologist to assess for these possibilities. Overall, the records do not support an indication for MRI of the heart, electrocardiogram, or the blood tests requested by the patients caregiver. Advanced imaging and laboratory testing performed as part of a patients work-up is based on the clinical judgment of the patients providers. The requested consultation will allow the provider to determine whether additional imaging and/or specific laboratory testing would be beneficial. In the absence of a current indication for the requested MRI of the heart, electrocardiogram, and blood tests, these services are not medically necessary for this patient. Given these findings, the requested consultation with a cardiac electrophysiologist is medically necessary for evaluation of this patient while the requested MRI of the heart, electrocardiogram, and blood tests (TSH, T3, T4, TSH-thyroid stimulating immunoglobulin, Nt-proBNP, troponin T, and plasma ceramides) are not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology 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 OxyContin 15 mg ER tablets, once every 12 hours. The Centers for Disease Control and Prevention (CDC) guidelines state that, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. Similarly, the Federation of State Medical Boards guidelines noted that, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. In this case, the patient has chronic pain involving the lower back, and neck with involvement of the left side of her body, which the provider attributes to Lyme disease as demonstrated on antibody testing. The patients pain is rated as 10/10 and there is documentation of at least 30% pain relief with her current opioid regimen. The providers notes state that the patient has not demonstrated any aberrant or drug seeking behavior, and that the medications are managing the pain and allowing for the performance of activities of daily living. There is no documentation of any irregularities in the CURES report or inconsistent urine drug screens. The patient has tried and failed several different classes of medications including both opioid and non-opioid classes. The provider noted that the patients current regiment including OxyContin 15 mg every 12 hours is effective. Given these findings, the requested OxyContin 15 mg ER tablets, once every 12 hours is 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Entresto 24-26mg. Findings:  The physician reviewer found that The use of sacubitril-valsartan (Entresto) is usually reserved for patients who already take spironolactone and who require additional medication for blood pressure control, and particularly patients with a left ventricular ejection fraction (LVEF) less than 55 percent. Also, in this case, the severity of heart failure symptoms and New York Heart Association (NYHA) class is not clear. It is not clear if his symptoms were improving or worsening with therapy prior to starting Entresto. Additionally, a recent trial by Solomon and colleagues showed no difference in outcomes in patients treated with valsartan alone or sacubitril-valsartan. Solomon and colleagues concluded that, Sacubitril-valsartan did not result in a significantly lower rate of total hospitalizations for heart failure and death from cardiovascular causes among patients with heart failure and an ejection fraction of 45% or higher. The adverse effects, such as hypotension, compared with other antihypertensive agents seem to outweigh the potential small benefits of sacubitril-valsartan. Thus, Entresto 24-26mg is not medically necessary for the treatment of the patients medical condition.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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Durolane injection received 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 a history of relief from prior Orthovisc injections. Given the patients limited options and based on the current medical literature, the service at issue was medically indicated. Therefore, the Durolane injection received in the right knee was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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.