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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Dexcom G6 continuous glucose monitor (CGM) system (sensor, receiver, transmitter). Olczuk and Priefer note that self-monitoring of glucose allows patients with diabetes mellitus to take control of their disease and thus directly affect the outcomes related to it. The authors note that while finger-prick devices have commonly been used to monitor blood glucose, CGM systems have recently been refined and improved for home use. Zheng and colleagues note that CGM systems may be clinically valuable due to their accuracy and convenience and may promote glycemic and weight control, helping to reduce the risk of hypoglycemia and hyperglycemia. In this case, the patients glycemic control has been improving since they began using the Dexcom CGM. Given that current medical literature supports the use and accuracy of CGM systems, such as the Dexcom G6, for home monitoring of glucose levels, the requested equipment is medically indicated. Therefore, a Dexcom G6 CGM system (sensor, receiver, transmitter) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 endocrinology, diabetes and metabolism 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 a hydrogel spacer. Current medical literature supports the use of the requested service in this clinical setting to minimize the risk for high grade radiation induced urinary, bowel, and sexual morbidity. The National Comprehensive Cancer Network (NCCN) guidelines for the management of prostate cancer endorse the use of perirectal spacers to improve sparing of the adjacent rectum. Researchers report in a randomized prospective clinical trial, The randomised controlled trial in image-guided intensity-modulated radiotherapy demonstrated that SpaceOAR reduces rectal radiation dose and late gastrointestinal and genitourinary toxicities, with urinary, bowel and sexual quality-of-life improvement. These advantages were verified in observational studies in various radiotherapy types.` Therefore, a hydrogel spacer is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested hydrogel spacer is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for liver transplant (CPT 47135). This patient has a metastatic neuroendocrine tumor (NET) with involvement of numerous liver metastases, mass in the tail of the pancreas, ascites and possible lymph node involvement. Although this patient has a well-differentiated tumor, the patient also has several risk factors for recurrence or inferior survival including symptomatic tumor, a primary tumor in the pancreas, and greater than 50% involvement of the liver. The patient may have extrahepatic spread as noted by ascites and lymphadenopathy (Moris, et al.). Liver transplantation has been used in the past for patients with isolated metastases to the liver with mixed results. The proposal in this case is for living donor liver transplantation. Fan and colleagues performed a metanalysis of the literature of liver transplantation for patients with NET. The authors reported no difference in five-year survival of transplanted patients when compared to non-transplanted patients. However, there is a lack of clinical data demonstrating that living donor liver transplant is superior to deceased donor liver transplant. Given these findings, the requested liver transplant (CPT 47135) 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 liver transplant (CPT 47135) 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 reviewer 1 is board certified in surgery and is actively practicing. Physician reviewer 2 is board certified in surgery with expertise in kidney, pancreas and liver transplantation and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cimzia.Findings:  The physician reviewer found that guidelines for the treatment of rheumatoid arthritis recommends the addition of biologic disease-modifying antirheumatic drugs (DMARDs), such as   tumor necrosis factor (TNF) inhibitors like Cimzia, when escalating therapy to optimize rheumatoid arthritis disease control. The guidelines do not indicate a recommendation for a target synthetic DMARD over a biologic DMARD. Mariette and colleagues note that there is minimal to no placental transfer of certolizumab pegol (brand name Cimzia), an Fc-free anti-TNF drug, supporting continuation of treatment with certolizumab pegol during pregnancy when necessary. In this case, the records note that the patient has moderate-to-severe rheumatoid arthritis disease activity after poor response to methotrexate, Enbrel, and Humira. The patient reports that she is planning to get pregnant. In this clinical setting, the requested medication is medically indicated. Therefore, Cimzia 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 rheumatology 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

The patient has requested authorization and coverage for an Aimovig 70 mg/mL auto-injector. Aimovig (erenumab) is a calcitonin gene-related peptide receptor antagonist (CGRP) approved by the U.S. Food and Drug Administration (FDA) for the preventive treatment of migraine in adults.  Tepper and colleagues found that in patients with chronic migraines, erenumab 70 mg and 140 mg reduced the number of monthly migraine days with a safety profile similar to placebo. Pellesi and colleagues note that dual therapy with monoclonal antibodies and botulinum toxin type A holds promise in patients with treatment-resistant chronic migraine. In this case, the patient has tried and failed Nurtec, and reports improvement on a combination of Botox and Aimovig. Given that the concurrent use of CGRP and Botox as a management option for chronic migraines is not contraindicated in current medical literature, the requested medication is medically indicated. Therefore, an Aimovig 70 mg/mL auto-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 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 an Emgality 120 mg/mL injection pen. Findings:  The physician reviewer found that the American Headache Society (AHS) notes that treatment with monoclonal antibodies to calcitonin gene-related peptide (CGRP) may be indicated for patients with chronic migraines with an inability to tolerate topiramate (brand name Topamax). The AHS recommends that clinicians and patients reassess the benefits of CGRP monoclonal antibody therapy after three to six months and to continue treatment if benefits can be documented, such as a reduction in mean monthly headache days of 50% or more relative to the pretreatment baseline. The U.S. Food and Drug Administration approves the use of Emgality, a CGRP antagonist, for preventive treatment of migraine in adults. Robbins notes that in a trial of Emgality administered along with Botox, adverse interactions were not observed. In this case, the patient has a history of chronic migraines that have not responded to medication trials of Depakote, Topamax, amitriptyline and propranolol. She is currently managed on gabapentin and Cymbalta, is receiving Botox injections and trigger point injections, and has reported some improvement with a trial of Emgality. The provider has recommended continued management with Emgality along with Botox. In this clinical setting, CGRP monoclonal antibody therapy is medically indicated. Therefore, an Emgality 120 mg/mL injection pen 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for   advanced lipoprotein testing (CPT 83704, 82172, and 83695). Based on current American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, the target of lipid lowering is low density lipoprotein (LDL) cholesterol levels (Grundy, et al.). Currently, testing for lipoprotein fractions are not considered to be within the standard of care. Decisions regarding statin therapy are based on LDL levels and atherosclerotic cardiovascular disease risk. In this case, the patients cardiovascular risk factors were minimal, based on the documentation provided for review, and her LDL cholesterol level is not significantly elevated, at 79 mg/dL. Lipoprotein subfraction measurement is not more beneficial than standard lipid measurements in this case. Therefore, the advanced lipoprotein testing (CPT 83704, 82172, and 83695) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the advanced lipoprotein testing (CPT 83704, 82172, and 83695) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 reviewer 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for the requested Tymlos.Fractures are the most dangerous aspect of osteoporosis, which can lead to acute and chronic pain. Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates. Newer treatment agents have become available over the past few years, including Tymlos (abaloparatide), a synthetic analog of parathyroid hormone-related peptide. Liu and colleagues state, Anabolic agents, [such as Tymlos], have been shown to improve bone mass and decrease fracture risk in osteoporosis patients by directly stimulating osteoblasts to produce new bone. There is sufficient support for the requested medication in this clinical setting. Therefore, the requested medication Tymlos is medically necessary for treatment of the patients medical condition.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 endocrinology, diabetes, and metabolism 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 triamcinolone acetonide injection (Zilretta).Findings:  The physician reviewer found that (FDA) approves the use of triamcinolone acetonide extended-release (brand name Zilretta), a synthetic corticosteroid, for intra-articular use for the management of osteoarthritis pain of the knee. Langworthy and colleagues noted in a study of 170 participants that triamcinolone acetonide extended-release provided five to six months of pain relief, suggesting that it may be an effective non-opioid treatment option. The authors further noted that in a phase 3 randomized controlled trial, injections of an extended-release formulation of triamcinolone acetonide in participants with unilateral or bilateral knee osteoarthritis demonstrated substantial improvement in pain and symptoms. Triamcinolone acetonide extended-release is formulated in poly lactic-co-glycolic acid (PLGA) microspheres that slowly release triamcinolone acetonide in the synovium, providing long acting efficacy along with a decrease in systemic absorption and lessening of systemic side effects, such as blood glucose elevations. Given that triamcinolone acetonide extended-release is safe, effective, and does not accelerate the progression of osteoarthritis in these patients while delaying the need for a total knee arthroplasty, the requested service is medically indicated. Therefore, triamcinolone acetonide injection (Zilretta) 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 parent of an enrollee has requested authorization and coverage for Xeljanz 5 mg tablets.Xeljanz (tofacitinib) is well-tolerated in the studies to date and is effective in patients who are refractory or no longer respond to other therapies. In an article by Strazzulla and colleagues, an algorithm was published that recommended immunotherapy or Janus kinase (JAK) inhibitors with or without intralesional Kenalog for scalp involvement greater than 50%. In this case, the patient presents with hair loss. At the time of initial presentation, the patient had one patch that progressed to involve 80% of his scalp hair. The patients prior treatments include intralesional Kenalog and minoxidil. After a course of prednisone, the patients scalp hair grew back. By April 2021, the patient had lost about 40-50% of scalp hair again. Given the recurrence was about 50% involvement, the patients disease is refractory to traditional treatments. The requested medication is effective in patients who are not responding to traditional therapies. Thus, Xeljanz 5 mg tablets are medically necessary for treatment of the patients medical condition.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation (RFA) of the nerves innervating the sacroiliac (SI) joint with image guidance. The records provided for review document that this patient has a history of chronic low back pain secondary to right-sided sacroiliitis. Treatment has included a successful SI joint injection followed SI joint RFA with improvement in pain from 8/10 to 2/10. The patients provider has recommended repeat RFA of the SI joint. As noted in the medical literature, RFA of the sacral lateral branches affects the nerves that supply the posterior SI ligaments and posterior portion of the SI joint, also referred to as the posterior SI joint complex. Yang and colleagues evaluated the use of the local anesthetic blocks for the diagnosis of posterior SI joint complex pain and the efficacy of RFA on the sacral lateral branches. The authors concluded that RFA is effective in relieving pain that originates from the posterior SI joint complex. Chen and colleagues reported that patients who received RFA had a significantly greater improvement in Oswestry disability scores compared with patients who received sham treatment. The records document that this patient has responded well to the SI block and previous RFA that lasted eight months. The records also support that the patients pain generator is the right SI joint. Given these findings, the requested RFA of the nerves innervating the SI joint with image guidance is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested RFA of the nerves innervating the SI joint with image guidance 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician 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 patient has requested authorization and coverage for Qbrexza. Hyperhidrosis can consist of severe sweating in the axilla, palms of the hands, and soles of the feet. McConaghy and Fosselman noted that the typical progression of treatment includes topical therapies with over-the-counter antiperspirants, Drysol, iontophoresis, oral anticholinergics, and Botox injections. The records provided for review document that this patient has a history of eczema. The patients provider noted that the patients history of eczema precludes him from using Drysol. The medical literature supports treatment with short contact time application of Drysol, application of petroleum jelly, and over-the-counter antiperspirants or oral anticholinergics. The patients history of eczema should not preclude treatment with Drysol since eczema should not be considered a contraindication. All told, the requested Qbrexza 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 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.