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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for percutaneous transcatheter patent foramen ovale (PFO) closure. Current peer-reviewed medical literature has demonstrated that transcatheter PFO closure is more effective for preventing recurrent ischemic stroke than antiplatelet therapy alone for well selected patients who have an embolic-appearing cryptogenic ischemic stroke and a PFO. For patients with a cryptogenic embolic-appearing ischemic stroke who have a PFO and no other evident source of stroke despite a comprehensive evaluation, data supports transcatheter PFO closure in addition to antiplatelet therapy, rather than antiplatelet therapy alone. The studies report a greater benefit of closure in patients with a large right-to-left shunt or an associated atrial septal aneurysm. This recommendation applies to patients who place a higher value on the moderate absolute stroke risk reduction of PFO closure and a lower value on the burdens and harms associated with device placement. Based on the available records, this patient has an atrial septal aneurysm and a right-to-left shunt. Thus, the requested percutaneous transcatheter closure of PFO 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 percutaneous transcatheter closure of PFO 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 percutaneous transcatheter closure of PFO 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 internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 3 is board certified in cardiovascular disease with subspecialty certification in interventional cardiology 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

The patient has requested authorization and coverage for Norco 10/325 mg, quantity 150, every 30 days. This patient has a history of spinal cord tumor status post resection. The patients pain has been managed with Norco. For cancer related pain, opiate pain medications such as Norco have a supported role for pain control.  However, Norco 10/325 mg, quantity 300, every 30 days, exceeds the dosing as recommended in the medical literature. Patients can build up tolerance from overexposure for a long period of time with one opiate pain medication. Norco 10/325 mg can still be beneficial for this patient, but should be combined with another medication. The patients treatment plan should include consideration of addition of a long-acting pain medicine, such as a Butrans patch, Nucynta ER or tramadol ER. Given these findings, Norco 10/325 mg, quantity 150, every 30 days is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The patient has requested coverage for Repatha SureClick autoinjector. Findings: The physician reviewer found that the patient had a history of coronary vascular risk factors including coronary artery disease, status post stent, diabetes mellitus, hypertension and elevated cholesterol.  The diagnoses included sclerotic heart disease of native coronary artery with a known history of coronary artery disease, status post prior percutaneous transluminal coronary angioplasty (PTCA). The American College of Cardiology and the American Heart Association support consideration of the addition of a non-statin cholesterol lowering therapy, such as Repatha in high risk patients, those with diabetes, those between the age of 40-75 who have a less than anticipated response to statins or are statin intolerant. Medications, such as Repatha, have demonstrated a decrease LDL levels. This patient had tried first line treatments and had significant risk factors that support the use of Repatha.Final Result: The reviewer determined that the service at issue was medically necessary for treatment of the patients condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in Cardiovascular Disease and Interventional Cardiology and is actively practicing.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether a sacroiliac joint injection procedure (CPT code 27096) is likely to be more beneficial for treatment of the patients condition than any available standard therapy. The patient presented to her provider with complaints of ongoing low back pain associated with intermittent radiation to the lower extremities.Findings:  Two out of three physician reviewers found that researchers determined that there is no single physical examination or historical feature that can reliably identify a painful SI joint; however, studies suggest that a battery of three or more provocation tests can predict response to diagnostic blocks. In this case, the records do not document sacroiliac joint tenderness or other provocative tests that would suggest SI joint dysfunction as a cause of pain. SI joint injections are unlikely to provide additional therapeutic relief in this patients case. In this clinical scenario, the requested sacroiliac joint injection procedure (CPT code 27096) is not likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested sacroiliac joint injection procedure is 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 anesthesiology with sub-specialty certification in pain management, 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 is diagnosed with Dupuytrens contractures. In October 2018, finger contractures were noted, and the patient had difficulty making a fist. In a current letter, the provider noted the patient has been taking Potaba for years. The provider states that the patient should continue taking Potaba as discontinuation could cause complications. At issue in this case is whether Potaba 500mg capsules are medically necessary for the treatment of the patients medical condition. Dupuytrens disease may require treatment with intralesional glucocorticoid injections, collagenase injections, open fasciectomy, percutaneous or open fasciotomy, and needle aponeurotomy. The U.S. Food and Drug Administration (FDA) has classified Potaba as possibly effective for the treatment of scleroderma, dermatomyositis, morphea, linear scleroderma, pemphigus, and Peyronies disease. In this case, the patient was diagnosed with Dupuytrens contractures. Currently, there is a lack of evidence to support the use of Potaba for this medical condition. Therefore, Potaba 500mg capsules are not medically necessary for the 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 family practice 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: A request was made for reimbursement and prospective authorization and coverage for cognitive behavioral therapy (CBT) utilizing a stress lab (exposure therapy program). The Health Plan has denied the services at issue as not medically necessary.Researchers noted the American Academy of Pediatrics (AAP) clinical practice guideline for patients 6 to 11 years of age recommend prescribing U.S. Food and Drug Administration (FDA) approved medications for ADHD with or without behavior therapy. Researchers reviewed 54 studies that compared nonpharmacologic treatment strategies with placebo, pharmacologic, or another nonpharmacologic treatment. The researchers concluded that despite wide use, there are significant gaps in knowledge regarding the effectiveness of ADHD nonpharmacologic treatments.The medical record indicates that the patient has primary problems due to his ADHD symptoms. He was noted to be impulsive, fidgety, and had difficulty staying organized. These symptoms are typical of ADHD disorder. Evidence-based treatment of ADHD includes pharmacology with psychotropic medications as well as therapy. CBT can be used for young patients with ADHD to improve coping skills as well as organizational skills. A short period of CBT was appropriate for the patient. However, there is no indication that ongoing CBT is clinically indicated due to the lack of specific symptoms that need to be treated in the progress notes. CBT is typically a short-term therapy and is not administered on an ongoing or indefinite basis. Final Result: The reviewer determined that some of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry, 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: An enrollee has requested authorization and coverage for continued skilled nursing facility services. This patient was hospitalized with various complaints suggestive of possible central nervous system pathology. A full work-up was precluded by body habitus. His symptoms and function improved. When he was subsequently seen by neurology, there were no clear indications of central nervous system pathology or indications for imaging. He was at the set up to supervision level for most basic mobility and self-care.  He was requiring maximum assistance for toileting hygiene, which was not improving and would not be expected to improve significantly with further time. He was otherwise functionally improved enough to return to the community, but this was precluded by a lack of housing. He was able to leave the facility with his girlfriend or family for several hours at a time. Therefore, continued skilled nursing facility services were not and are not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation 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 Spinraza dosing schedule of first dose on day 1, second dose on day 15, third dose on day 30, fourth dose on day 60, and then maintenance doses every four (4) months. Findings:  The physician reviewer found that the medical literature, Hoy noted that SMA is an autosomal recessive neuromuscular disorder characterized by degeneration of spinal motor neurons and poses significant adverse outcome in affected population. The author reports that SMA is most commonly caused by insufficient levels of survival motor neuron (SMN) protein (which is critical for motor neuron maintenance) secondary to deletions or mutations in the SMN1 gene. Spinraza is a U.S. Food and Drug Administration (FDA) approved medication for the treatment of SMA. As discussed by Finkel and colleagues, major evidence demonstrating the efficacy of Spinraza came from the ENDEAR, sham controlled phase 3 clinical study. The authors reported that the study was stopped early based on significantly favorable results in interim analysis. The study transitioned all patients to receive Spinraza in an ongoing open-label, phase 3 study, SHINE, which will evaluate the long-term efficacy, safety and tolerability of the drug. This patient has a diagnosis of SMA status post wound washout for fecal contaminated superficial infection of lumbosacral wound, after laminotomy for intrathecal access. The current medical literature supports Spinraza in this clinical setting, and the dosing schedule proposed by the provider is reasonable given the patients medical history. Accordingly, the requested Spinraza dosing schedule of first dose on day 1, second dose on day 15, third dose on day 30, fourth dose on day 60, and then maintenance doses every four (4) months, is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

An enrollee has requested authorization and coverage for bilateral Euflexxa injections. This patient has been diagnosed with osteoarthritis of both knees. Her provider has recommended weight reduction prior to proceeding with total knee arthroplasties. Intra-articular corticosteroid injections were tried, but she only obtained temporary relief for one month. The provider has deemed her to be an appropriate candidate for viscosupplementation while trying to postpone the total knee arthroplasties. An exhaustive review of the current medical literature pertaining to the viscosupplementation reveals mixed results. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited. 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 the options are limited. In this case, the options are limited, with need for temporary pain relief while weight reduction is being attempted prior to the total knee arthroplasties. The medical evidence supports the requested services in this setting. Therefore, the requested bilateral Euflexxa 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcatheter mitral valve repair. This patients records document an indication for mitral valve repair or replacement. The standard approach would be for the patient to undergo open surgery to repair or replace the mitral valve. Medical literature recommend considering transcatheter mitral valve treatment in symptomatic patients who are at high surgical risk or are inoperable. Percutaneous edge-to-edge repair is generally safe and can improve symptoms and improve left ventricular function over time. However, the rate of residual mitral regurgitation with the transcatheter approach is reportedly higher than with open surgical repair. Therefore, it has not been established that the transcatheter repair is safer or more effective than an open surgical repair. This patient does not have any documented prohibitive risk for an open surgical repair. Thus, the requested transcatheter mitral valve repair is not supported as medically necessary for treatment of this patients symptoms. 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 internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology 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 Neulasta. In the medical literature, Smith and colleagues noted that prophylactic use of colony stimulating factor (CSF) agents is recommended for the prevention of febrile neutropenia in patients who are at high risk on the basis of age, medical history, disease characteristics, and myelotoxicity of the chemotherapy regimen. However, the National Comprehensive Cancer Network (NCCN) guidelines and American Society of Clinical Oncology (ASCO) do not support the use of one CSF over another for growth factor support in this clinical setting. In addition, updated guidelines from ASCO suggest that all preparations of CSF, including biosimilar agents, can be used for the prevention of treatment-related febrile neutropenia (Smith, et al). This patients provider has recommended treatment with Neulasta. While Neulasta may be more convenient due to less frequent dosing, Neulasta has not been demonstrated to be more effective than Neupogen, which has been approved by the Health Plan. All told, the requested Neulasta 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

A request for two hours per week of speech therapy services was submitted by the enrollees parent. The Health Plan denied the request as not medically necessary.Autism spectrum disorder is a neurodevelopmental disorder defined by deficits in social communication and the presence of restricted and repetitive behaviors and interests. Treatment involves intensive behavioral therapy and educational programming along with speech and language, occupational, and physical therapies. Psychopharmacologic treatments are also used to target certain symptoms and comorbid conditions. Colleagues concluded that behavioral-based interventions were evidence-based to introduce speech to non-verbal patients with developmental disabilities. A recent study published by colleagues described that systematic instruction teaching multistep social-communication skills to children with autism spectrum disorder using an iPad is effective in developing advanced social-communication skills. In this case, the patient has made slow progress with speech therapy. His scores on the Receptive and Expressive One Word Picture Vocabulary Tests indicate that he has not reached a plateau and is making gradual progress. As such, the continuation of speech therapy services for one hour per week is medically necessary. The additional hour of speech therapy services per week is not medically necessary.Final Result: The reviewer determined that some of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology with special qualification in child 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.