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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trikafta, 100/50/75 mg and 150 mg tablets (84 per 28 days). The U.S. Food and Drug Administration (FDA) has approved the use of Trikafta for the treatment of cystic fibrosis in patients aged 12 years and older with at least one F508del mutation in the CFTR gene or a gene that has been responsive based on in vitro data such as G551D. Medical literatures report that elexacaftor-tezacaftor-ivacaftor (Trikafta) was efficacious in patients with cystic fibrosis with Phe508del-minimal function genotypes, in whom previous CFTR modulator regimens were ineffective. Researchers reported, Elexacaftor-tezacaftor-ivacaftor was efficacious and safe in patients with Phe508del-gating or Phe508del-residual function genotypes and conferred additional benefit relative to previous CFTR modulators. In this case, given that the records document a diagnosis of cystic fibrosis CFTR genotype mutation G551D, the requested medication is medically indicated. Therefore, Trikafta, 100/50/75 mg and 150 mg tablets (84 per 28 days), is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary diseases 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 day treatment at the Centre for Neuro Skills, five hours per day, three days per week, for a duration of three months. In this case, the patient has a documented history of traumatic brain injury (TBI) with speech, cognitive, and physical disabilities. The records document that the patients diagnoses include post-traumatic headache, exertion intolerance, and insomnia. The provider charted that the patients symptoms include blurred vision, balance and coordination issues, blood pressure and heart rate disturbances, and problems with attention and word finding. The patients provider has recommended day treatment due to the patients continued cognitive difficulties. Based on the current peer-reviewed medical literature, rehabilitation is indicated for patients with varying degrees of TBI. Increasing severity of TBI is usually accompanied by greater severity and complexity of impairments of body structure and function, which contribute to activity limitations and participation restrictions. Marklund and colleagues noted that the extended time frames for the recovery process for patients with the most severe TBI may continue over months or even years. Turner-Stokes and colleagues reviewed the evidence for multidisciplinary rehabilitation for acquired brain injury (ABI) in adults. The authors concluded that, Patients discharged from inpatient rehabilitation benefit from access to outpatient or community-based services appropriate to their needs. Given this support, the requested day treatment at the Centre for Neuro Skills, five hours per day, three days per week, for a duration of three months is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX Reflux Management Procedure (CPT 43284).Findings: Two out of three physician reviewers found that the current medical evidence supports the requested service in this clinical setting. This patient has fulfilled eligibility criteria for the LINX Reflux Management Procedure since he has typical GERD symptoms, an abnormal pH study, intolerance to PPI therapy and absence of a large hiatal hernia. The requested service has been shown to be superior to twice-daily PPI therapy. Bell and colleagues compared the effectiveness of increased PPI dosing with laparoscopic magnetic sphincter augmentation in patients with moderate-to-severe regurgitation despite once-daily PPI therapy. The authors noted that the LINX Reflux Management Procedure normalized the total number of reflux episodes and acid exposure in 91 and 89 percent of patients, compared with 58 and 75 percent of those treated with twice-daily PPI therapy. The LINX Reflux Management Procedure has been compared with laparoscopic Nissen fundoplication in several meta-analyses. Clinical control of reflux was comparable after the two procedures. Aiolfi and colleagues noted that there was less gas bloat associated with the LINX Reflux Management Procedure than laparoscopic Nissen fundoplication. Ganz and colleagues evaluated the long-term safety and efficacy of the LINX prosthesis in a prospective single-group trial of 100 patients with long-standing GERD. The authors noted, Augmentation of the lower esophageal sphincter with a magnetic device provides significant and sustained control of reflux, with minimal side effects or complications. Therefore, the LINX Reflux Management Procedure (CPT 43284) is likely to be more beneficial than any other available standard therapy to treat the patients condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any other available standard therapy to treat the patient's condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in gastroenterology, 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: Urgent Care
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested reimbursement for services. The services provided to this patient are supported as emergent. In this case, the patient has a history of small bowel obstruction. The patient presented with abdominal pain similar in character to prior small bowel obstruction. Imaging on presentation to the emergency department revealed a partial small bowel obstruction, and laboratory testing showed leukocytosis. The patients symptoms responded to intravenous opioid analgesia and antibiotics. In this clinical setting, it was appropriate for the patient to seek immediate medical attention as these complications could have been present given the patients history and presenting symptoms (Paulson, et al.; Loftus, et al.; Azagury, et al.). A delay in diagnosis and treatment of this condition could have placed the patients health in serious jeopardy, impaired bodily functions, and resulted in serious organ dysfunction. Colonoscopy can be appropriate to rule out organic disease as a cause for abdominal pain but was not supported given resolution of the patients abdominal pain and lack of hematochezia, diarrhea, or other findings which would warrant colonoscopy (Early, et al.). Given these findings, the services, with the exception of the colonoscopy, were emergency services provided for the treatment of an emergent medical condition as defined by California law. Final Result: The reviewer determined that a portion of the services at issue were emergency services as defined by California law for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for power morcellation of uterine fibroids (laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas). Laparoscopic myomectomy is an option for the treatment of symptomatic fibroids recommended by the American College of Obstetricians and Gynecologists (ACOG). Researchers report that laparoscopy has supplanted laparotomy. While the U.S. Food and Drug Administration (FDA) discourages the use of uterine morcellation due to oncological risk, the authors note that this is controversial, and that the recommendation has been challenged by a part of the profession. The use of power morcellation has been used for some time to aid in the removal of the fibroids, and with the addition of precautions and patient education, continues to be an accepted and recommended course of treatment that has been well-studied and with well-known risks and benefits for symptomatic uterine fibroids. Therefore, power morcellation of uterine fibroids (laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas) 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 power morcellation of uterine fibroids (laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas) 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 reviewer 1 and 3 are board certified in obstetrics and gynecology and are actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and infertility 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 reimbursement for a Synvisc injection. 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 had tried and failed conservative treatments with ibuprofen, ice packs, and a corticosteroid injection, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the service at issue was medically indicated. Therefore, the Synvisc injection was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 pen injector. The records provided for review document that this patient has significant itching, redness, bleeding, and pain due to his severe atopic dermatitis, which affects their ability to perform activities of daily living. The patients provider noted that the patient has failed treatment with clobetasol and hydrocortisone. The provider has recommended treatment with Dupixent. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical therapies. A recent consensus article of atopic dermatitis by Boguniewicz and colleagues defined moderate-to-severe atopic dermatitis as more than 10% BSA involvement and/or involvement of highly visible areas or those important for function and significantly impaired quality of life. The severity of this patients symptoms meet the criteria for moderate-to-severe disease with more than 30% BSA involvement and symptoms in areas important for function. In addition, Dupixent has the highest-quality trial evidence for safety and efficacy in atopic dermatitis (Siegels, et al.). Systemic cyclosporine is not recommended for long-term use to due to toxicities. Methotrexate is an immunosuppressant that has been associated with increased hospitalizations when a patient is infected with COVID-19. For these reasons, the requested Dupixent 300 mg/2 mL pen injector 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: The patient has requested authorization and coverage for Dupixent (dupilumab) subcutaneous solution prefilled syringe 300 mg/2 mL. Current medical literature supports the use and efficacy of the requested medication in this clinical setting. Bachert and colleagues report that in patients with chronic rhinosinusitis with nasal polyps, dupilumab reduced polyp size, sinus opacification, and severity of symptoms and was well tolerated. In this case, given the patients phenotype of chronic asthma, eosinophilia, nasal polyposis, and pansinusitis, the requested medication is medically indicated. Therefore, Dupixent (dupilumab) subcutaneous solution prefilled syringe 300 mg/2 mL is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine and in allergy and immunology 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 implantation of peripheral nerve stimulator. This patient presents with a history of chronic low back pain. The provider noted that the patients pain is likely due to history of L1 pathologic fracture secondary to metastatic cortical adrenal carcinoma status post L1 transpedicular decompression and T10-L5 fusion. The patients pain is described as multifactorial in nature including reaction to hardware. The provider charted that the patient responded well to diagnostic erector spinae blocks and paravertebral nerve blocks with temporary relief. On review of the current peer-reviewed medical literature, there is a paucity of studies demonstrating the long-term safety and efficacy of peripheral nerve stimulation in the treatment of patients with low back pain. Specifically, there is a lack of studies showing that peripheral nerve stimulation yields superior patient health outcomes as compared to standard available therapies. Cohen and colleagues reported on nine patients who reported improvement with percutaneous peripheral nerve stimulation in function, as evidenced by clinically and statistically significant reductions in pain, disability, and pain interference. Gilmore and colleagues have reported similar preliminary findings. However, the data was not obtained in prospective randomized controlled trials to support the routine use of percutaneous peripheral nerve stimulation for treatment of this patients low back pain. All told, the requested implantation of peripheral nerve stimulator 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 implantation of peripheral nerve stimulator 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 anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for MRI of the thoracic and cervical spine. There is a lack of support for the requested services in this clinical setting. According to the American College of Radiology Appropriateness Criteria, new onset of cervical and thoracic spine pain should be assessed with radiographs. Additionally, computed tomography (CT) of cervical or thoracic spine may be appropriate. MRI should be used if there are new or worsening symptoms of radiculopathy or myelopathy. Per medical literatures, when patients exhibit myelopathy symptoms, such as rapidly developing muscle weakness or sensory deficit, MRI should be considered. Additionally, patients with suspected malignancy or infection involving the thoracic spine should be evaluated with a spinal MRI. In this case, the patient presented with no red flag symptoms to warrant an MRI. Therefore, MRI of the thoracic and cervical spine is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 a nuclear thyroid scan with vascular flow. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services. Iodine-131 (I-131) thyroid scan is an appropriate study for assessing thyroid malignancy, residual malignancy post-thyroidectomy, and recurrent or distant metastatic disease post-thyroid cancer treatment in appropriate patients. Post-thyroidectomy patients are assessed for recurrence or metastases by measuring serum thyroglobulin level. If thyroglobulin levels are within normal range, residual or recurrent thyroid malignant disease is unlikely. According to American College of Radiology, whole-body scintigraphy (I-131) is not utilized in low-risk patients without suspicion for recurrence and normal thyroid ultrasound. It has no role in low-risk patients who have had a lobectomy. This patient is status post thyroidectomy. She had normal serum thyroglobulin and a normal ultrasound of the neck. The patient is at low risk for recurrent or metastatic thyroid malignancy. Therefore, the requested nuclear thyroid scan with vascular flow is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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.