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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for external mobile cardiac telemetry. This patients records document a history of near syncope and palpitations. Evaluation with an echocardiogram revealed normal biventricular wall thickness, chamber size, diastolic and systolic function, with an ejection fraction of 55-60%, and 24-hour Holter monitoring was negative. The patient underwent further evaluation with external mobile cardiac telemetry. However, there is a lack of support in the peer-reviewed medical literature for the use of external mobile cardiac telemetry for evaluation of this patients symptoms, especially given the results of the previous work-up. The available clinical trials do not report improved clinical outcomes associated with the use of external mobile cardiac telemetry in lieu of patient-activated, external loop monitors in the detection of infrequent cardiac arrhythmias. All told, the external mobile cardiac telemetry was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the external mobile cardiac telemetry was not likely to have been 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 not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in cardiology 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 internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology 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 Xifaxan tablet 550 mg three times a day, indefinitely. The records provided for review document that this patient has a history of constipation. The patients provider has recommended ongoing treatment with Xifaxan. Xifaxan has been demonstrated to be safe and effective for the treatment of patients with irritable bowel syndrome-diarrhea predominant (IBS-D). Additionally, Xifaxan has been found to be effective for the treatment of patients with small intestinal bacterial overgrowth (SIBO). However, there is concern for the development of resistance to Xifaxan with long-term use. In this case, there is a lack of submitted documentation of IBS-D or SIBO to support an indication for treatment with Xifaxan. Moreover, there is a paucity of data in the peer-reviewed medical literature or current guidelines to support to use Xifaxan for an indefinite duration. For these reasons, the requested Xifaxan tablet 550 mg three times a day, indefinitely, is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested Xifaxan tablet 550 mg three times a day, indefinitely, 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 medication 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 reviewer 1 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for monitored anesthesia care (MAC) services during colonoscopy. The current guidelines for sedation and anesthesia in gastrointestinal endoscopy do not recommend the use of MAC services for patients who do not have significant health conditions or airway concerns (Early, et al.). The guidelines indicate that there is high quality evidence to support the use of mild to moderate sedation in healthy patients for endoscopy procedures. A review by Wernli and colleagues concluded that, Use of anesthesia service was associated with a 13% increase in the risk of any complication within 30 days and was associated specifically with an increased risk of perforation, hemorrhage, abdominal pain, complications secondary to anesthesia, and stroke. In this case, the patient presents for a routine colonoscopy. The records provided for review do not document any significant heart, lung, kidney, or liver disease. There is a lack of report of a history of alcohol or substance abuse, or previous history of difficulties with anesthesia or sedation with past colonoscopies. Furthermore, the patient does not present with unstable coronary artery disease. The patients cardiac work-up included a stress echocardiogram, which was negative for ischemia. In addition, the patient reportedly exercises regularly and is asymptomatic. For these reasons, the requested MAC services during a colonoscopy are not medically necessary for this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for pharmacogenetic testing. Findings:  The physician reviewer found that International Society of Psychiatric Genetics states, Pharmacogenetic testing should be viewed as a decision-support tool to assist in thoughtful implementation of good clinical care. We recommend HLA-A and HLA-B testing prior to use of carbamazepine and oxcarbazepine, in alignment with regulatory agencies and expert groups. Evidence to support widespread use of other pharmacogenetic tests at this time is still inconclusive. Bousman and colleagues report that pharmacogenetic testing is unstandardized and conclude at present there are insufficient data to support the widespread use of combinatorial pharmacogenetics testing in clinical practice. In a table of pharmacogenetic associations, the U.S. Food and Drug Administration (FDA) explains, Specific information regarding therapeutic management is provided for some pharmacogenetic associations listed in the table, but most of the associations listed have not been evaluated in terms of the impact of genetic testing on clinical outcomes, such as improved therapeutic effectiveness or increased risk of specific adverse events. In addition, clinical studies, if available, may only have linked genetic variation to a drug's pharmacokinetics (such as the way in which the drug is metabolized), and differences in drug efficacy or safety across different genotype subgroups may not be known. If no statements related to efficacy or toxicity are provided, the scientific evidence the FDA reviewed was considered insufficient to support such associations. Given the lack of support in current medical literature for the routine use of pharmacogenetic testing for medication decision-making in psychiatry, the requested services are not medically indicated. In this patients case, pharmacogenetic testing is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, pharmacogenetic testing is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology with sub-specialty certification in neurodevelopmental disabilities 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 bilateral knee Euflexxa injections. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a documented history of lasting benefit from viscosupplementation with Euflexxa injections to both knees in the past. In addition, the patients provider has recommended repeat injections of Euflexxa into both knees. The patients remaining treatment option is bilateral total knee arthroplasties. For these reasons, the requested bilateral knee Euflexxa injections are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left total hip replacement surgery. The American College of Rheumatology (ACR) recommends total joint arthroplasty for patients with hip osteoarthritis following failure of adequate attempts at medical therapy (Hochberg, et al.). Conservative treatment options for the treatment of patients with hip osteoarthritis include exercise, weight loss for overweight patients, medication management, walking aids, and psychosocial interventions. Per Hochberg and colleagues, Pharmacologic modalities conditionally recommended for the initial management of patients with knee osteoarthritis included acetaminophen, oral and topical NSAIDs [non-steroidal anti-inflammatory drugs], tramadol, and intraarticular corticosteroid injections; intraarticular hyaluronate injections, duloxetine, and opioids were conditionally recommended in patients who had an inadequate response to initial therapy. The authors noted, Recommendations for hip osteoarthritis were similar to those for the management of knee osteoarthritis.This patient is being treated for left hip degenerative joint disease. Her provider has recommended left total hip replacement. The patient reports left hip pain occurring both at rest and at night, and her pain is rated 8/10. The records document that treatment with cortisone injections have not provided substantial relief of the patients symptoms. However, there is a lack of detailed documentation of trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures prior to consideration for surgical intervention. The records do not report failure of medication, physical therapy, or home exercises. Moreover, there is a lack of evidence of worsening symptoms or pain levels, and the objective findings did not demonstrate any worsening range of motion. For these reasons, the requested left total hip replacement is not medically necessary for 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 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 Norco. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, 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. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The Federation of State Medical Boards (FSMB) strongly recommends prescribers use, Opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has chronic low back pain, as a result of twisting his back, without signs or symptoms of neurological deficit or weakness. A follow up lumbar MRI detected an old stable compression fracture at L1 and evidence of ungraded facet joint disease at the other levels, without sign of high grade canal or foraminal stenosis at the other lumbar levels. Treatment included medication management with nonsteroidal anti-inflammatory drugs and non-pharmacological treatments such as exercise, physical therapy, and trigger point injections of the latissimus dorsi. The patient has been prescribed a short course of Norco 5-325 mg without follow up prescriptions or documentation that chronic opioid therapy was indicated. In this case, objective imaging did not find evidence of cord or nerve compression and physical examination did not reveal evidence of disability or impairment. The treating provider did not document that chronic opioid therapy is medically necessary to treat musculoskeletal pain thought to be from a pulled muscle. Given that clinical guidelines do not recommend opioid therapy for musculoskeletal pain as first line therapy and that nonpharmacological treatments are preferred, the requested medication is not medically indicated. Based on the available medical records for review and the national guidelines and literature reviews, the request for Norco is not medically necessary.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 Monovisc injection in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of lasting benefit from viscosupplementation with Orthovisc injections of both knees in February 2019 that has been well documented. Physical therapy and home exercises have not reportedly been effective. The patients remaining treatment options are limited, and she has obtained relief from prior viscosupplementation injections in the past. For these reasons, the requested Monovisc injection in both knees is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Prolia injection (denosumab) 1 mg 60 units every six months. Findings:  The physician reviewer found that The records provided for review document that this patient has a history of osteoporosis that has worsened over time. The patients provider has recommended treatment with Prolia. Over the past few years, the number of treatment options for the management of osteoporosis has grown significantly (Khosla and Hofbauer). Of the medications developed, the most potent antiresorptive agent is Prolia. In a large, randomized placebo-controlled trial of 7,868 postmenopausal female patients with osteoporosis, biannual 60 mg subcutaneous Prolia injections were able to increase bone mineral density (BMD) by 9.2% in the spine and 6.0% in the hip when compared to placebo (Lorentzon). Prolia is indicated as therapy for postmenopausal female patients with osteoporosis who are at high risk for fracture. In addition to this patients worsening osteoporosis, she has a history of spine problems which have required surgery. In this clinical setting, the medical literature supports treatment with Prolia for this patients osteoporosis and elevated fracture risk. All told, the requested Prolia injection (denosumab) 1 mg 60 units every six months 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 internal medicine with subspecialty certification in endocrinology, diabetes, 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for medical services rendered. In this case, the records documented that the patient was actively bleeding, as her initial hemoglobin level was over 8, then 7.2, then 6.6, and was to be transfused as needed for her low hemoglobin levels. Notes documented hypotension. In this patients case, the absence of immediate medical attention could have been reasonably expected to place the patients health in serious jeopardy. Therefore, the services at issue were emergency medical services.Final Result: The reviewer determined that the services at issue were emergency medical services, the absence of which could have been reasonably expected to place the patients health in serious jeopardy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in emergency 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 Skyrizi. Systemic treatment of psoriasis is indicated when topical treatments fail or do not achieve sufficient control of disease, particularly for psoriasis in the scalp or hands or other difficult to treat areas with topical medications. The U.S. Food and Drug Administration approves the use of several systemic options including methotrexate, cyclosporine, acitretin, cyclosporine,  apremilast, and biologics including tumor necrosis factor (TNF)-alpha inhibitors, interleukin (IL)-17 pathway inhibitors, IL-12/23 inhibitors, and IL-23 inhibitors, such as Skyrizi. Kridin and colleagues note that in a study of 3,151 patients with psoriasis who tested positive for COVID-19, the use of oral methotrexate was associated with increased hospitalization. Fagni and colleagues reported that the immune response to vaccination may be somewhat reduced in groups taking methotrexate. In this case, treatment with the immunosuppressives cyclosporine and methotrexate are not recommended due to the risk of increased COVID-19 morbidity. Given that this patient has failed topical therapies and light therapy and the current COVID-19 pandemic, treatment with a systemic biologic agent is medically indicated. Therefore, Skyrizi 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 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.