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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Onabotulinumtoxin (Botox) (Codes 64615 and J0585) for chronic migraines. The medical record shows a patient with a history of chronic intractable migraines. She has had Botox injections in the past that relieved her pain. The note stated that the patient had mild headache all the time but had severe headaches twice per week.  She states Botox was beneficial.  Examination showed no distress, upper back muscle tightness, and was otherwise normal.  Diagnoses were migraine, and neck tightness.  The medication list included Sumatriptan, Percocet, Maxalt, and Nadolol.  The patient was referred for Botox injection because she had less frequency of headache when she was treated with Botox.  The medical literature supports benefit in lessening migraine headaches with Botox. For migraine, various classes of preventives can be used including botulinum toxin, with the choice of therapy tailored to the patient's risk factors and symptoms. In studies, injections of a specified dose were generally well tolerated and effective in producing significant and clinically meaningful improvements in headache symptoms, acute headache pain, medication usage, headache impact and health-related quality of life in adults with chronic migraine. More recently, the efficacy and tolerability of onabotA (Botox) over a period of 1 year has been substantiated and extended by the results of a long-term phase IV study. In conclusion, the totality of evidence from clinical trials and real-world studies indicate that onabotA (Botox) is an effective and generally well tolerated option for the prevention of chronic migraine for patients who have previously failed to respond to or are intolerant of commonly prescribed oral preventive medications. Botox was noted to provide more relief for this patient than other medications tried, including Sumatriptan, Percocet, Maxalt, and Nadolol.     Final Result: Two of the three reviewers determined that the requested service was likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is overturned.Credentials/Qualifications: Three reviewers are board certified in Neurology and are actively practicing.  All three 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:  The enrollee requested coverage for Prometheus testing for Crohns Disease. A review of the records indicates the patient has a history of Crohns Disease and is on immunosuppressant therapy. The patient had two perianal fistulas and originally was on budesonide without improvement.  She began Remicade every 8 weeks. However, two years later she had antibodies present with low levels and medication was reduced to every 5 weeks.  She had a follow-up colonoscopy and additional inflammatory markers.  The laboratory studies revealed mildly elevated inflammatory markers and the colonoscopy showed two small ulcers.  Infliximab was increased. Later, it appeared the patient was in clinical remission. It was recommended that she have her infliximab levels checked to maintain the current regimen. Her gastroenterologist indicated the blood test from Prometheus Laboratories is necessary to check for Remicade levels and antibody formation, and that this is the only way to determine if the patient has adequate levels of Remicade in her blood.  One reviewer did find that the literature supported the measurement of antibodies and infliximab concentration impacts management and is clinically useful.  However, two reviewers indicated the medical literature found that after dose optimization continued concentration-based dosing was not superior to clinically based dosing for achieving remission after 1 year. This patient was stable, had two previous tests which have shown an elevated level of Remicade and no antibiodies. Nothing had changed with her treatment and there is nothing to support performing this test again.Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.Credentials/Qualifications: Three reviewers are board certified in Internal Medicine and Gastroenterology and are actively practicing.  All three 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

An enrollees parent has requested authorization and coverage for Nutropin AQ Nuspin. The current medical evidence supports growth hormone therapy for patients with idiopathic short stature. This patient has a pre-treatment height that was a few standard deviations below the mean and a diagnosis of idiopathic short stature. The records document suboptimal growth for her pubertal development. She has a history of anorexia nervosa, which can affect linear growth. Of note, even when her weight has improved, her height remained a few standard deviations below the mean, which indicates abnormal linear growth. This patient had a normal work-up to exclude other cause of short stature. Therefore, Nutropin AQ Nuspin 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 pediatrics with sub-specialty certification in pediatric 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for coenzyme Q10 testing, leptin, cytokine panel, interleukin-6, prothrombin fragment, and matrix metallopeptidase 9 (MMP-9) testing. Findings:  Three physician reviewers found that the current guidelines do not support the services at issue in this patients case. Per the patients provider, these tests were performed to assess nutritional status and make individual lifestyle recommendations. Data gathered largely from observational studies suggest that certain dietary factors may modify breast cancer risk. Of note, methodologic issues regarding the measurement of nutritional intake and the contribution of other factors complicate these analyses and the interpretation of studies. Coenzyme Q10 has been widely promoted for patients undergoing treatment for cancer, based upon the suggestion that it might improve tolerance for chemotherapy. Lesser and colleagues performed a double-blind, placebo-controlled trial in patients with newly diagnosed breast cancer. The authors noted that there was no benefit from the use of coenzyme Q in self-reported cancer treatment-related fatigue. To date, there are no standard testing recommendations or nutritional supplementation that have been shown to decrease the risk of breast cancer. Therefore, coenzyme Q10 testing, leptin, cytokine panel, interleukin-6, prothrombin fragment, and matrix metallopeptidase 9 (MMP-9) testing were not likely to have been superior over other methods of evaluating this patient. 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Synvisc One injection in the left knee. In the medical literature, researchers concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 patients. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. In addition, the American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. However, researchers noted that evidence from eight systematic reviews and six randomized controlled trials suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients, but questions remain about the most effective formulations and which populations are likely to benefit. This patient presents with persistent left medial knee pain and recurrent effusion. He is status post left knee arthroscopy, partial medial and lateral meniscectomy, chondroplasty, and debridement on 8/16/18. He has been diagnosed with moderate medial compartment osteoarthritis. Detailed evidence of a recent comprehensive non-operative treatment protocol trial, including two aspirations and corticosteroid injections, activity modification, ice, medications, and physical therapy, and failure has been submitted. Evidence-based medical peer-reviewed literature and guidelines supports the use of viscosupplementation injections as an option for the treatment of pain in patients with osteoarthritis of the knee in this clinical setting. Given this patients presentation, proceeding with the requested Synvisc One injection for the left knee is supported as medically necessary.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 hydrogel (perirectal spacers). Hydrogel perirectal spacers (SpaceOAR) are considered the standard of care in this patients clinical setting. As noted in the current medical literature, SpaceOAR is supported by randomized prospective studies as improving bowel, urinary, and sexual side effects for prostate radiotherapy patients, as compared with patients not receiving the perirectal spacers. Further, SpaceOAR is supported by the National Comprehensive Cancer Network (NCCN) and American Society for Radiation Oncology (ASTRO) guidelines for management of prostate cancer. Moreover, SpaceOAR hydrogel perirectal spacers have been associated with high quality radiation delivery. Thus, the requested hydrogel (perirectal spacers) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the requested hydrogel (perirectal spacers) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that requested hydrogel (perirectal spacers) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. For these reasons, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology 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 a pneumatic compression device. The principal therapies for confirmed cases of lymphedema include skin care, compression garments, intensive bandaging, and lymphatic massage. Complete decongestive physiotherapy is an effective treatment for both primary and secondary lymphedemas. The management of lymphedema includes three phases: an initial treatment that aims to reduce volume of the lymphedema; a maintenance phase to maintain the result; and a withdrawal phase. These therapies approach a 70% reduction in edema burden and in compliant patients and success is maintained in greater than 80%n of patients treated. One specific contraindication to compressive therapy is the presence of arterial disease. This patient was found to have arterial and venous insufficiency. Thus, treatment should include weight loss and interventions to improve arterial and venous disease. All told, the available documentation does not support the requested pneumatic compression device as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device 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 surgery with subspecialty certification in general vascular 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for HP Acthar.Findings:  Three physician reviewers found that there is a lack of support for the requested medication in this clinical setting. The available medical records do not adequately document trial and failure of standard psoriatic arthritis treatments, including disease-modifying antirheumatic drugs and biologic agents. Although the records noted that the patient has failed multiple medications, there is a lack of documentation regarding the dosages of medications used or duration of trial of medications. Objective documentation supporting failure of medication trials is lacking. Therefore, HP Acthar is not likely to be superior over other treatment options. 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in rheumatology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for corneal collagen cross-linking.Findings:  Three physician reviewers found that the medical evidence supports the services at issue in this clinical setting. Based on the patients vision loss and progression, corneal collagen cross-linking was the most effective treatment available. Corneal collagen cross-linking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant.  Corneal collagen cross-linking for corneal ectasias fulfills an unmet need, as there is a lack of other treatment options available to slow or halt disease progression. Therefore, corneal collagen cross-linking was likely to have been more efficacious than other treatment options.Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2 and 3 are board certified in ophthalmology 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 enrollee has requested coverage for Claravis 30 mg capsules which was denied by the health plan as not medically necessary. The records indicate the enrollee has had acne for many years. Provider notes indicate treatment has included oral and topical antibiotics as well as Retin A. It is noted the patient was on two different oral antibiotics for nine months. According to current literature, the utilization of isotretinoin (Claravis) is typically recommended for severe recalcitrant nodular acne.  Severe by definition, is proven by many as opposed to fewer or several nodules.  Nodules are typically defined as inflammatory lesions with a diameter of 5 mm or greater.  The submitted documentation does not include clinical notes detailing the above.  The documentation does not detail the enrollee has evidence of severe recalcitrant nodular acne.  Although the provider notes the enrollee had taken nine months of antibiotics, which failed, the notes have no information about the date range the patient took those antibiotics. Final Result: The reviewer determined that the requested service is not medically necessary for thetreatment of the enrollees medical condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested coverage for Vitamin D 25-Hydroxyvitamin D Testing on one date and going forward, which was denied by the health plan as not medically necessary. A review of the records indicates the enrollee was seen for a routine 6-month medical follow-up appointment on an unspecified date.  His active problems include vitamin D deficiency.  His medications included vitamin D3 1000 units daily.  The patient was to check his vitamin D level prior to his follow-up visit. At the follow-up appointment, the patients laboratory results were reviewed. His vitamin D level was slightly low and continuation of vitamin D supplementation was recommended at an increased dose. The patient was to repeat the vitamin D 25-hydroxyvitamin laboratory test on a designated date. According to the medical literature,  vitamin D deficiency is defined as a serum vitamin D level of less than 20 ng/mL for which a plan to replenish serum 25-hydroxyvitamin D levels is prescribed. The optimal time for re-checking the serum levels after repletion has not been clearly defined, but the goal is to achieve a minimum level of 30 ng/mL. Serum 25-hydroxyvitamin D levels are to be measured again after completion of therapy, and if values have not reached or exceeded the minimum level, a second course of treatment would be prescribed.  After vitamin D levels are replete, maintenance dosages would be prescribed. Review of the records indicates laboratory results showing a vitamin D level that was low at which time vitamin D2 capsules were prescribed. Subsequent testing revealed a vitamin D level that was normal.  Therefore, maintenance dosing was appropriate with no further Serum 25-hydroxyvitamin D laboratory testing.  The submitted documentation does not include laboratory evidence of persistent vitamin D deficiency despite supplementation to justify the testing on one date and going forward as medically necessary.  Final Result: The reviewer determined that the requested service is not medically necessary for thetreatment of the enrollees medical condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician 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 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 radiofrequency ablation (RFA). In this case, the patient has cervical spine magnetic resonance imaging (MRI) findings of degenerative joint disease at the C5-6 and C6-7 levels, which correlates with her current complaint of neck pain radiating to the shoulder blades, but not into the forearms or hands. Her physical examination findings are positive for tenderness over the right cervical facet joints of C4-6. Her provider reports the patient has undergone multiple RFA treatments to the cervical spine, which have all provided excellent relief. The current evidence-based medical guidelines advise that repeat diagnostic blocks are not required in patients who have already received previous RFA procedures if a repeat procedure is being planned to a segment of the spine that has already successfully been treated. In this case, the patient has had this procedure before with excellent results and is requesting a repeat of the procedure. Therefore, the requested RFA is medically necessary for treatment of this patients neck pain.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 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.