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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lymphovenous bypass surgery. Findings:  The physician reviewer found that eview of the available medical records, this patient presents with significant worsening of her right lower extremity lymphedema despite treatment with conservative management. The patient is noted to have a history of significant weakness and pain in the right lower extremity, due to extensive surgical treatment for cancer with residual lymphedema. The patients provider has recommended treatment with lymphovenous bypass surgery. Although there are limited randomized controlled clinical trials addressing the long-term outcomes for microsurgery of patients with primary or secondary lymphedema, there are adequate reports demonstrating improvements in quality of life and limb reduction. In addition, Drobot and colleagues found that lymphaticovenular anastomosis surgery is a safe and effective method of reducing lymphedema severity, especially in upper extremity lymphedema at an earlier disease stage. Similarly, Chang and colleagues indicated that lymphovenous bypass is effective in reducing the severity in lymphedema in patients with early-stage upper extremity lymphedema. This patients attempts at conservative management have failed to alleviate her symptoms. Therefore, the requested lymphovenous bypass surgery is 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 services are 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 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 vascular surgery with subspecialty certification in general surgery and is actively practicing. Physician reviewer 2 is board certified in vascular surgery with subspecialty certification in general surgery and is actively practicing. Physician reviewer 3 is board certified in vascular surgery with subspecialty certification in general 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for IVIG Gammaked 120 grams IV over five days every month x six cycles.  Findings:  The physician reviewer found that Churg-Strauss syndrome is a rare systemic and pulmonary vasculitis associated with asthma and eosinophilia. Treatment consists of corticosteroid therapy and immunosuppressive drugs such as cyclophosphamide and azathioprine. While there is a lack of large study data due to the rarity of the disease, current medical literature includes several case studies that report improvement in disease control in refractory patients to treatments such as glucocorticoids or cyclophosphamide.  A combination of pulse corticosteroids, pulse cyclophosphamide, and high-dose IVIG may be effective for the treatment of severe Churg-Strauss syndrome. Ikeda and colleagues report that an earlier add-on administration of adjunct mepolizumab and IVIG led to significant improvement in symptoms and prevention of flare-up of the disease. In a multicenter, double-blind, randomized clinical trial of 23 patients with Churg-Strauss syndrome, Koike and colleagues evaluated the effect of IVIG on residual peripheral neuropathy and reported that IVIG was found to improve neurological function via control inflammation in the peripheral nervous system. In this clinical setting, the potential clinical advantage with IVIG outweigh the risks of treatment and is likely to be more beneficial than the many systemic immunosuppressants that this patient has already tried and failed. Therefore, IVIG Gammaked 120 grams IV over five days every month x six cycles is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the IVIG Gammaked 120 grams IV over five days every month x six cycles 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 allergy and immunology and is actively practicing. Physician reviewers 2 and 3 are board certified in dermatology 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laparoscopic gastric restrictive procedure with gastric bypass with Roux-en-Y gastroenterostomy. Findings:  The physician reviewer found that records document a history of prior laparoscopic sleeve gastrectomy with current complaints of gastroesophageal reflux disease (GERD) despite treatment with a proton pump inhibitor (PPI). However, the records do not demonstrate that the patient has undergone an adequate PPI trial length, or that the patients dietary and lifestyle factors are not contributing to her GERD symptoms. The patients current BMI is 29 kg/m2. The esophagogastroduodenoscopy (EGD) report was from a few years ago, prior to the patients sleeve gastrectomy. An upper gastrointestinal series revealed normal sleeve anatomy and a tiny sliding hiatal hernia without mention of GERD. The records do not include a recent dietary or behavioral evaluation. Furthermore, there is a lack of recent EGD or 24-hour pH study documenting GERD. Overall, there is insufficient evidence to support the medical necessity of the requested conversion to gastric bypass procedure. All told, the requested laparoscopic gastric restrictive procedure with gastric bypass with Roux-en-Y gastroenterostomy 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 general surgery with expertise in advanced minimally invasive surgery and bariatric 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 TriVisc hyaluronan injections. Findings:  The physician reviewer found that 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 significant relief from viscosupplementation in the left knee in 2019 and the right knee in 2020. In addition, other conservative treatments have not been substantially effective. Thus, treatment with TriVisc injections to both knees is appropriate and consistent with the current AAOS recommendations. Accordingly, the requested TriVisc hyaluronan 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 patients parent has requested authorization and coverage for cochlear device implantation, with or without mastoidectomy. Findings:  The physician reviewer found that Current medical literature supports the use of cochlear implantation for single sided deafness as safe and effective. The U.S. Food and Drug Administration (FDA) notes a minimum age criterion of five years of age based on a lack of large clinical trials in young children with single sided deafness and cochlear implantation. In this case, the patient has a history of right-sided profound hearing loss. An MRI showed that the right vestibulocochlear nerve is diminutive, and the records noted a very small internal auditory canal. Given that this patient is below the FDA approved age for cochlear implantation secondary to unilateral hearing loss, and as the results of a cochlear implant may be poor due to the patients diminutive cochlear nerve and narrow internal auditory canal, the requested service is not medically indicated. Therefore, cochlear device implantation, with or without mastoidectomy, 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 otolaryngology  head and neck surgery with sub-specialty certification in neurotology 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 left knee injections. Findings:  The physician reviewer found that 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 reports persistent pain despite a history of three surgical procedures and physical therapy. There is MRI evidence of osteoarthritis of the lateral compartment. The provider has recommended viscosupplementation along with other conservative treatment including icing, splinting, taking Tylenol, and restricting activities, with the objective of delaying total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Monovisc left knee injections 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for special cold therapy cryoablation. Findings:  The physician reviewer found that This patients records document that she is being treated for neoplasm of bone. The provider noted that the patient presented with a right talus bone lesion. X-rays of the right ankle showed a bone lesion in her right talus. The patients physical examination revealed right ankle with medial swelling, tenderness to palpation at the medial ankle, and limited range of motion due to stiffness and pain. The patients provider has recommended treatment with cryoablation. In this case, this patient has undergone a thorough evaluation with multiple imaging studies corroborating a non-enhancing sclerotic lesion along the medial aspect of the talus with significant surrounding soft tissue and bone marrow edema, which most likely represents an osteoblastoma. A review of the peer-reviewed medical literature suggests that the requested special cold therapy cryoablation is likely to be more beneficial treatment in this patients clinical scenario than standard alternatives. Cazzato and colleagues concluded that percutaneous image-guided cryoablation represents an effective therapeutic option for patients affected by painful osteoblastomas. Scandiffio and colleagues reported that percutaneous cryotherapy can be considered a safe and effective technique in the treatment of benign and malignant musculoskeletal tumors. El-Hussein and colleagues found that intralesional extended curettage with bone grafting and cryotherapy is a successful and safe treatment for patients with benign tumors of the talus. For these reasons, the requested special cold therapy cryoablation is 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 services are 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 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 orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dosage escalation to Humira 40 mg/0.4 mL pens two units every 20 days. Findings:  The physician reviewer found that On review of the current medical literature and the patients records, requested  dose increase of Humira 40 mg two units every 20 days, or one dose every 10 days, is supported as medically necessary for treatment of this patients Crohns disease. Anti-tumor necrosis factor (TNF) medications such as Humira are recommended by the current guidelines for Crohns disease in patients with moderate to severe disease .Treatment with Humira 40 mg more frequently than every 14 days can be supported to prevent disease complications. The remission rate with Humira weekly dosing has been reported at 46.9% versus 22.5% when dosing every other week .In addition, the American College of Gastroenterology (ACG) guidelines state that patients with continued symptoms should have their medication dose adjusted in order to attempt to optimize therapy .In this case, the patient was found to have elevated fecal calprotectin, which is indicative of active disease, as well as a low Humira level, while on Humira 40 mg dosed at every other week.The patients condition stabilized while on his current dose of Humira 40 mg every 10 days. Thus, a decrease in the Humira dose, or a discontinuation of Humira and change to another medication, could result in severe complications of disease activity. Given these findings, the requested dosage escalation to Humira 40 mg/0.4 mL pens two units every 20 days is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested dose escalation 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 patient has requested authorization and coverage for hip and knee replacement. Findings:  The physician reviewer found that records document that this patient is being treated for right hip arthritis and bilateral knee arthritis. The patient reports hip and knee pain with walking and standing. The patient endorses use of a walker or cane for ambulation. The patients physical examination revealed right hip crepitus, decreased range of motion and right knee tenderness, as well as an antalgic gait. The patients records also state that recently she presented with alcohol intoxication and subsequent withdrawal, which required a hospital admission. The treating provider charted that the patient should be sober for six months prior to undergoing arthroplasty surgery. The records do not suggest that the patient has participated in a recent physical therapy program or undergone cortisone injections since February 2022. The medical literature and guidelines recommend adequate treatment with conservative modalities prior to consideration for arthroplasty procedures. Riddle and colleagues reported that the risk-to-benefit ratio for total knee arthroplasty favors patients who have intense or severe symptoms of knee osteoarthritis, are at least 55-years-old, have limited mobility, and have a body mass index (BMI) less than 40 kg/m2. Van Zaanen and colleagues noted that the guidelines for managing hip and knee osteoarthritis advise extensive non-surgical treatment prior to surgery. The authors evaluated hip and knee osteoarthritis patients who received non-surgical treatment prior to arthroplasty and assessed patient satisfaction regarding alleviation of symptoms and performance of activities. The authors concluded that hip and knee osteoarthritis patients were mostly satisfied with non-steroidal anti-inflammatory drugs (NSAIDs) followed by exercise-based therapy. Overall, there is a paucity of large-scale prospective studies showing the long-term safety and efficacy of hip or knee arthroplasty in this patients clinical setting. For these reasons, the requested knee replacement surgery and hip replacement surgery are 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 Rexulti 1 mg daily.Findings:  The physician reviewer found that records provided for review document that this patient presents with a history of moderate major depressive disorder and generalized anxiety disorder. The records indicate that the patients conditions have been non-responsive to multiple therapies including selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitor (SNRIs), and norepinephrine and dopamine reuptake inhibitors (NDRIs). Per the provider, the patients mood improved substantially with Rexulti. The provider has recommended continued treatment with Rexulti. However, the available documentation does not support that this patient has undergone an adequate trial of a first-line augmenting atypical antipsychotic. Data yielded from double blind randomized placebo controlled trials reported that patients who added Rexulti to their current antidepressant experienced a greater improvement in their symptoms of depression than the patients who continued taking only their antidepressant (Zhou, et al.; Cantu, et al.). Based on the clinical trial data, the U.S. Food and Drug Administration (FDA) approved Rexulti for augmentation therapy for the treatment of patients with major depressive disorder. Several atypical antipsychotic augmentation strategies exist for the treatment of patients with major depressive disorder including aripiprazole, quetiapine extended release, and Rexulti. A systematic review by Zhou and colleagues found that all standard dose atypical antipsychotics for the adjunctive treatment of patients with resistant depression are efficacious in reducing depressive symptoms. However, there is a lack of data demonstrating that Rexulti is more effective than other atypical antipsychotics in treating patients with major depressive disorder. Moreover, the requested Rexulti 1 mg daily is not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. Given these findings, the requested Rexulti 1 mg daily is not medically necessary for 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 psychiatry with subspecialty certification in preventive 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.