Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tibsovo (ivosidenib) 500 mg once daily. In the medical literature, Researchers reported on an open-label, phase I, dose escalation and expansion study of Tibsovo in patients with solid tumors with IDH1 mutations. The authors found that Tibsovo dosed at 500 mg once per day in 66 patients was associated with a favorable safety profile, which is promising. However, there is a paucity of prospective large controlled trials and major compendia supporting an indication for Tibsovo in the treatment of oligodendroglioma. In addition, the U.S. Food and Drug Administration (FDA) has not approved Tibsovo for the treatment of oligodendroglioma. Currently, there is greater evidence for a dual mutant-IDH1/2 inhibitor, vorasidenib, which has entered phase III testing in patients with grade II non-enhancing IDH-mutant glioma. Moreover, the patients records do not report that he has failed treatment with standard therapeutic regimens such as procarbazine, lomustine, and vincristine (PCV), and temozolomide. Given these findings, the requested Tibsovo (ivosidenib) 500 mg once 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 HP Acthar Gel 80 units. The submitted documentation supports the medical necessity of the requested medication. The U.S. Food and Drug Administration approved the use of Acthar Gel for exacerbations of multiple sclerosis. Standard therapy for acute exacerbations of multiple sclerosis include high-dose corticosteroid therapy, plasmapheresis, and intravenous immunoglobulin (IVIG). Researchers note that Acthar Gel may be considered as an alternative treatment option and that its efficacy and treatment outcomes may be comparable to those seen with corticosteroids. Reasons for treatment with Acthar Gel may include a lack of benefit established with corticosteroids, inability to tolerate corticosteroids or adverse effects, and poor access to intravenous treatment. In this case, the patient has multiple sclerosis with exacerbations despite disease modifying therapy with Ocrevus. She has experienced relief without side effects using Acthar Gel in the past. Based on current medical literature showing Acthar Gels efficacy and the patients past successful outcomes, Acthar Gel is medically indicated for this patient. Therefore, HP Acthar Gel 80 units are 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for chiropractic manipulative treatment services (CPT 98942), two sessions per month for three months. The requested chiropractic manipulative treatment services (CPT 98942) are for an adjustment of five different spinal regions. In this case, the patient has a diagnosis of right arm pain. There is no anatomical relationship between the lumbar spine, occiput, or coccyx to any nerves related to the arm. For chiropractic treatment, the spinal level must bear a direct causal relationship and symptoms should be related to the level of anatomic region that has been diagnosed. There is insufficient research on the effectiveness of chiropractic treatment on upper limb conditions. In this case, the patient does not have any spinal complaints. Given this patients diagnosis, chiropractic manipulation of five spinal regions is not medically indicated. Therefore, chiropractic manipulative treatment services (CPT 98942), two sessions per month for three months are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested 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 chiropractic 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Synthroid. The goals of treatment of hypothyroidism include alleviation of symptoms and normalization of serum thyroid-stimulating hormone (TSH) levels. Once initiated, the TSH should be monitored and levels rechecked in four to six weeks with each dose change until the patients TSH levels have normalized with alleviation of symptoms. Treatment of hypothyroidism is straightforward with thyroid replacement therapy consisting of tablets, gel, and liquid agents. With tablets, there are brand name and generic formulations. Based on current medical literature and guidelines, generic formulations may be bioequivalent to branded formulations, but they may not be therapeutically equivalent. Therefore, it is important to titrate any dose of medication whether branded or generic. This patient has a history of Hashimotos thyroiditis with resultant hypothyroidism. Her treatment with initiated with brand name Synthroid with good response and alleviation of her symptoms. When she was switched to the generic formulation, levothyroxine, at the same dose, her symptoms reportedly recurred. However, no follow-up laboratory testing was performed to determine her TSH levels. Moreover, there were no reported trials of titrating her dose based on laboratory testing of TSH levels. The patients symptoms are likely to improve on generic levothyroxine with readjustment and titration of dosage. The records support an increase of the patients generic levothyroxine dose based on TSH levels to help alleviate her symptoms, but there is a lack of support for brand name Synthroid. Accordingly, the requested brand name Synthroid is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested brand name 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 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 (1) surgery to repair a fractured fifth metacarpal in his right hand and (2) surgery to repair a fractured fifth metacarpal in his right hand within the next two weeks. Researchers found that treatment for a fifth metacarpal fracture varied based on whether the fracture is open or closed, characteristics of the fracture including the degree of angulation, shortening, and rotation, and other concomitant injuries. Immobilization with an ulnar gutter splint may be the definitive treatment for closed, non-displaced fractures without angulation or rotation, while open fractures, significantly angulated or malrotated fractures or those involving injury to neurovascular structures may require operative fixation. In this case, the patient has a moderately displaced fracture of the base of the fifth metacarpal. An examination of the right small finger demonstrated shortening of the fifth metacarpal, minimal extensor lag on active extension, and slight rotational deformity without scissoring on composite fist formation. Initial treatments included splinting, sling, and restricted activities. Given the displacement and rotation documented, operative fixation is medically indicated. The documentation also supports the urgency of the request. Without surgical treatment within the next two weeks, the fracture would have a marked increased probability of malunion, requiring procedures of greater magnitude, such as surgical osteotomy and fixation. Undue delay would further increase the potential for adverse outcomes, along with overall prolonged and ongoing morbidity from bony and soft tissue pain and swelling. Therefore, (1) surgery to repair a fractured fifth metacarpal in the patients right hand and (2) surgery to repair a fractured fifth metacarpal in the patients right hand within the next two weeks 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for OxyContin ER 15 mg tablets every 12 hours. The Centers for Disease Control and Prevention (CDC) guidelines state that, non-pharmacologic therapy and non-opioid 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 non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. The Federation of State Medical Boards (FSMB) recommends 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 and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. This patients records document chronic pain related to cervical radiculopathy, cervicalgia, and migraines. She has attempted several forms of conservative non-opioid therapy including epidural steroid injections, trigger point injections and physical therapy with marginal results. Her urine toxicology screens and CURES reports have been consistent with her therapeutic regimen. The provider documented that the patients pain control has been satisfactory with OxyContin and that there is no evidence of adverse drug reactions or aberrant behavior identified. Given these findings, the requested OxyContin ER 15 mg tablets every 12 hours is medically necessary for 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma injection to the right elbow. Platelet-rich plasma injection therapy is a technique using a concentrated portion of autologous blood in an attempt to augment and accelerate healing of various tissues. Review studies and national guidelines have not reported substantial improvement in patient health outcomes with use of platelet-rich plasma for the treatment of musculoskeletal disorders. Currently, data suggest that the use of platelet-rich plasma for most musculoskeletal soft tissue injuries should occur within the context of a well-designed clinical trial. There is a paucity of studies demonstrating the safety and efficacy of platelet-rich plasma for the treatment of chronic pain. There are studies supporting the utility of platelet-rich plasma injections as second-line treatment of lateral epicondylitis. This patient has a history of chronic right elbow pain and a 20-year history of chronic widespread musculoskeletal pain. She has failed treatment with surgery, physical therapy, acupuncture, and corticosteroids. On review, the medical records do not support a diagnosis for her right elbow pain, nor are there imaging study reports of the right elbow demonstrating an objective pathology that might benefit from a platelet-rich plasma injection. Therefore, the requested platelet-rich plasma injection to the right elbow 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 the requested platelet-rich plasma injection to the right elbow 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 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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 parent of the patient has requested authorization and coverage for Absorica 25 mg tablet, once a day. A high-fat meal is needed for optimal absorption of isotretinoin. Absorica, isotretinoin-Lidose, is a specialized formulation of isotretinoin that enhances absorption of isotretinoin in the absence of dietary fat and may be used with patients who are unable to take medication with food. Vegetarianism in and of itself is not a medical indication for the use of Absorica, as there are non-meat alternatives with high fat content, including nuts and oils. In this case, the use of isotretinoin-Lidose is not medically indicated over the use of isotretinoin. Therefore, Absorica 25 mg tablet, once a day is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Repatha SureClick pen injector. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor therapy may be used for LDL cholesterol lowering in the management of patients at risk for cardiovascular disease. In this case, the patient had hyperlipidemia, type 2 diabetes, and a strong family history of early cardiovascular disease. She was on a moderate dose statin, atorvastatin 40 mg, with side effects, but could not tolerate ezetimibe. Due to her family history and intolerance of high dose cholesterol lowering agents, the patient was at elevated risk for development of cardiovascular disease. She had undertaken successful lifestyle changes, including weight loss, diet and exercise, but these did not have a marked effect on her lipids, and her LDL and non-HDL cholesterol levels were elevated. Based on current medical literature and this patients elevated risk for cardiovascular disease, Repatha SureClick pen injector is medically indicated for the treatment of this patients persistent and refractory hyperlipidemia. Therefore, the requested Repatha SureClick pen injector 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 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 authorization and coverage for Tecfidera 240 mg twice daily. Tecfidera (dimethyl fumarate) is indicated for the treatment of patients with relapsing forms of multiple sclerosis (MS) at a starting dose of 120 mg twice daily for one week, followed by maintenance dosage of 240 mg twice daily. The American Academy of Neurology practice guideline recommendations for disease-modifying therapies (DMTs) for adults with MS include respecting and evaluating patient preferences to improve acceptance of and adherence to DMT. Patient preferences may include the safety, route of administration, lifestyle, efficacy, common adverse effects, and tolerability in the choice of DMT. Dimethyl fumarate (BG-12) (Tecfidera) as an oral treatment has been shown to significantly reduce relapse rates, the development of new brain lesions on MRI, and rates of disability progression in patients with active MS. Scientists found that patients experienced improved effectiveness of treatment with dimethyl fumarate over first-line agents such as interferons, glatiramer acetate, and teriflunomide, and similar effectiveness to treatment with fingolimod. Researchers concluded that fingolimod had more safety issues than the other two agents. For this reason, it should be strictly monitored for risks of infections, cancers, and certain transitory effects such as irregular cardiac function, decreased lymphocyte count, and a higher level of liver enzymes. The authors noted, The main risks marked with dimethyl fumarate were flushing and gastrointestinal events. In this case, the patient has a diagnosis of relapsing remitting MS. The provider presented and weighed options for DMT and determined Tecfidera as most effective, considering the route of administration, efficacy and safety for the patient, and the patients preference to avoid injectables. Based on the current medical literature, Tecfidera has an efficacy superior to or comparable with the other approved DMTs such as Extavia, Glatopa, and Gilenya, and its safety profile is potentially less harmful than Gilenya, the other oral alternative. Therefore, Tecfidera 240 mg twice daily is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections in the right knee (J7324). 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 advanced osteoarthritis of the right knee and recurrent pain. The records show that the patient has a history of excellent response with viscosupplementation, with relief lasting as long as nine months. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injections in the right knee (J7324) 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.