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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Otezla Starter Pack followed by 30 mg twice a day.Findings: Otezla (apremilast) is a phosphodiesterase 4 inhibitor, which decreases PDE4 activity, which in turn reduces the inflammatory process thought to be associated with psoriasis. Researchers noted that Otezla is also indicated for psoriatic arthritis. According to guidelines of care for the management of psoriasis, `Overall, apremilast as monotherapy is beneficial to treat psoriasis and psoriatic arthritis. These benefits include oral administration and the lack of a requirement for laboratory monitoring. For patients who would prefer to avoid frequent injections as well as laboratory monitoring and are willing to accept a slower onset of skin clearance and lower likelihood of clearing, apremilast is an appropriate choice.`In this case, the patient has been having psoriasis vulgaris symptoms for several years. On their initial visit, the patient reported the use of numerous topical steroids of varying strengths with mild improvement. They were found to have psoriasis affecting about 10% of the body surface area. They also complained of joint pain and had needle phobia. Medications included Concerta and Zyrtec. They were started on Otezla, which did improve the skin disease at the three-month follow-up. Additionally, the patient has a needle phobia which makes most biologics not appropriate. Alternative treatments such as acitretin, methotrexate and cyclosporine all require frequent lab monitoring and have more potential for side effects. Otezla is a reasonable choice for the patient given it will require fewer needle sticks in the long-term for lab monitoring. Under these circumstances, the requested medication, Otezla Starter Pack followed by 30 mg twice a day, is medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for biopsy, oocyte polar body or embryo blastomere, microtechnique less than or equal to 5 embryos (CPT 89290). Findings:  The physician reviewer found that records provided for review document that this patient and her spouse are carriers of cystic fibrosis. The likelihood of the patient having a child afflicted with cystic fibrosis is estimated at 25%. In order to prevent the birth of a child affected with cystic fibrosis, the patients provider recommended in vitro fertilization (IVF) with preimplantation genetic diagnosis (PGD) procedures. Cystic fibrosis is inherited in an autosomal recessive manner. When both parents are carriers, the chances of an offspring having the disease is 25%. PGD procedures are supported by the medical literature to eliminate the risk of cystic fibrosis in children of affected couples. Since the advent of PGD and with the development of sensitive techniques, IVF with PGD has become the standard of care for patients in this clinical setting. After the embryo is biopsied, a sample is submitted for microarray testing to determine whether an embryo is free of cystic fibrosis. Nonaffected embryos are then transferred into the patient with IVF. Based on current data, IVF with PGD was appropriate for this patient given her likelihood of having a child with cystic fibrosis without these services. Therefore, the biopsy, oocyte polar body or embryo blastomere, microtechnique less than or equal to 5 embryos (CPT 89290) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewer determined that the services at issue were 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 obstetrics and gynecology with subspecialty certification in reproductive endocrinology 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 bariatric surgery. The records provided for review document that this patient is morbidly obese and may benefit from bariatric surgery. However, a dietary evaluation that includes education and understanding of nutritional and dietary changes and appropriateness for candidacy for bariatric surgery has not been documented. The dietary evaluations provided for review are for weight management and do not detail any understanding of post-bariatric diet and follow-up, or the need for micronutrient supplements. In the absence of this nutritional evaluation as part of a multidisciplinary evaluation to determine candidacy for bariatric surgery, the records do not support an indication for the requested surgical intervention. Accordingly, the requested bariatric surgery is not medically necessary for 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 surgery with subspecialty certification in minimally invasive 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: An enrollee has requested authorization and coverage for Laparoscopic Sleeve Gastrectomy.Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity (Mechanick, J., et al.). Mechanick and associates have developed updated clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues. These guidelines recommend that all patients should undergo a psychosocial-behavioral evaluation as well as an appropriate nutritional evaluation before any bariatric surgical procedure. In this case, the patient has been documented to have both severe obesity with a BMI of 35 kg/m2 and the co-morbid condition of hypertension. The patient is noted to have been obese and struggling with weight since childhood, and she has a long-term history of prior weight loss efforts that have not been successful in maintaining any significant weight loss. Records document that the patient has also successfully completed a standard multidisciplinary evaluation. Under these circumstances, the requested Laparoscopic Sleeve Gastrectomy is medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for this patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: An enrollee has requested authorization and coverage for one level lumbar fusion surgery.Degenerative disc and facet joint disease of the lumbar spine is common in the aging population, and is one of the most frequent causes of disability. Lumbar spondylosis may result in mechanical back pain, radicular and claudicant symptoms, reduced mobility and poor quality of life. Surgical interbody fusion of degenerative levels is an effective treatment option to stabilize the painful motion segment, and may provide indirect decompression of the neural elements, restore lordosis and correct deformity (Mobbs, R., et al.).In this case, the patient has advanced degenerative disc disease at L5-S1, mild neuroforaminal stenosis on the left at that level, and clinical and electromyography (EMG) evidence of moderate left L5 and S1 radiculopathy on the left and L5 radiculopathy on the right. The patients clinical and EMG findings corroborate magnetic resonance imaging (MRI) findings. Conservative treatment has been tried and failed, including over three months of medications, physical therapy, and an epidural steroid injection that was diagnostic. Under these circumstances, the requested one level lumbar fusion surgery is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's 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 right sacroiliac joint injection with sedation (CPT 27096). Schmidt  and colleagues note that sacroiliac joint-based pain can be difficult to diagnose definitively through physical examination and conventional radiography, and that a fluoroscopically guided injection into the sacroiliac joint can be both diagnostic and therapeutic. The authors further note that the initial phase of treatment involves nonsurgical treatment such as activity modification, use of a sacroiliac belt, nonsteroidal anti-inflammatory drugs, and physical therapy. In this case, the patient has tried and failed conservative therapy. There is a history of one sacroiliac joint injection providing all day relief, and another injection that did not provide relief. Physical examination supports sacroiliac pathology with three positive tests. In this clinical setting, the requested service is medically indicated. Therefore, right sacroiliac joint injection with sedation (CPT 27096) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 Dupixent 300 mg/2 mL. Dupixent is U.S. Food and Drug Administration (FDA) approved for patients with moderate to severe eczema. The records provided for review document that this patients condition has been persistent for at least four years. Treatment has included mometasone, triamcinolone, and clobetasol, as well as several courses of prednisone and an antihistamine to control itching. Work-up revealed that the patient also has a component of allergic contact dermatitis, as demonstrated by positive patch testing and biopsy. Her disease has recently worsened with new involvement of the face and 10% of her overall body surface area. The provider charted that the patients symptoms have been affecting her quality of life and ability to work. The patient experienced a positive response to Dupixent, which waned upon stopping the medication. Dupixent has been shown to be effective in the treatment the atopic dermatitis and its associated itching component. Drucker and colleagues reported that Dupixent and cyclosporine are the most effective treatments after 16 weeks of therapy, while Dupixent has a more favorable risk profile than cyclosporine. Given this support, the requested Dupixent 300 mg/2 mL 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 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: An enrollee has requested authorization and coverage for Tyvaso Inhalation Solution (Starter Kit followed by Refill Kit for maintenance).The submitted documentation supports that the requested medication is medically necessary. The development and approval of 14 medications over the last several decades have led to a rapidly evolving approach to therapy for pulmonary arterial hypertension. Tyvaso Inhalation Solution is FDA-approved for the treatment of Group 1 pulmonary arterial hypertension in patients with NYHA Class III symptoms to improve exercise ability. In this case, the patient has Group 1 pulmonary arterial hypertension that was confirmed on right heart catheterization. The patient also has borderline NYHA Class III symptoms given his limitation in physical activity, such as being unable to complete a 6-minute walk test. Under these circumstances, the requested medication, Tyvaso Inhalation Solution (Starter Kit followed by Refill Kit for maintenance), is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in pulmonary 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fetal chromosomal microdeletions provided. There is a lack of evidence in peer-reviewed literature from large, randomized trials or high-quality prospective observational trials supporting the clinical utility and impact on patient management of nucleic acid sequencing-based testing of maternal plasma for microdeletions. Researchers note that cell-free fetal DNA non-invasive prenatal testing (NIPT) performance is affected by the condition under investigation. The sensitivity and specificity of screening tests for microdeletion syndromes, which may occur sporadically or due to other genetic mechanisms, has not been validated in clinical studies. Therefore, the provided maternal blood testing for fetal chromosomal microdeletions was not likely to have been more beneficial for the evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the maternal blood testing for fetal chromosomal microdeletions at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and infertility and is actively practicing, Physician reviewers 2, and 3 are board certified in obstetrics and gynecology 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 anastrozole tablets. Findings: Testosterone replacement therapy can lead to high levels of estradiol and symptoms such as breast tenderness and enlargement. These symptoms can be treated with estrogen antagonists such as anastrozole. Aromatase inhibitors can also lead to increased testosterone levels. In the medical literature, a study noted that the long-term efficacy and safety of aromatase inhibitors has not yet been established in malesand their routine use is therefore not yet recommended. Similarly, another study concluded that aromatase inhibitors are not recommended as treatment for functional hypogonadism because of insufficiency as well as a decrease in bone mineral density. The records provided for review document that this patient does not have reported side effects from testosterone replacement therapy. The provider charted that the patient has obtained adequate testosterone levels with their current treatment testosterone cypionate injections. However, the addition of an estrogen antagonist for hypogonadism and low testosterone treatment is not supported in the peer-reviewed medical literature. For these reasons, the requested anastrozole tablets are 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 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 patient has requested authorization and coverage for Euflexxa injection series 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 injections. 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, Euflexxa injection series in the right knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 a custom-fitted mandibular advancement oral device. Researchers note that the mandibular advancement oral appliance is frequently an option for the treatment of mild obstructive sleep apnea (OSA), modifying the upper airway and improving the airway patency. In this case, the patient has mild OSA. While she reports clenching and grinding her teeth, this is not a contraindication to oral appliance therapy. Given that an oral appliance device is standard of care in treating mild OSA and recommended by the provider, the requested device is medically indicated. Therefore, a custom-fitted mandibular advancement oral device is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 otolaryngology  head and neck 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.