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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve block therapy. A review performed by Barmherzig and Kingston evaluated the current evidence and recommendations for the diagnosis and management of patients with occipital neuralgia. The authors concluded that, Anesthetic block of the greater and/or lesser occipital nerves are often used both diagnostically and therapeutically. However, evidence is limited as most studies are noncontrolled. In this case, the patient presents with a history of chronic migraine headaches and occipital neuralgia for which they are being treated with abortive agents and prophylactic agents including Botox, Vyepti and Emgality. The most recent peer-reviewed literature does not support that occipital nerve blocks are superior to standard therapy for the treatment of this patients migraines and occipital neuralgia. Based on these findings, the requested occipital nerve block therapy 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 management and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management 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: An enrollee has requested authorization and coverage for Vascepa.Findings: Approved indications for the use of Vascepa based on randomized published data from a trial, and U.S. Food and Drug Administration (FDA) indications include severely elevated triglycerides greater than 500 mg/dL or triglycerides greater than 150 mg/dL in patients on maximally tolerated statin therapy with either established symptomatic coronary artery disease or diabetes and two other risk factors for coronary artery disease. In this case, the patient has mild elevation of triglycerides, but is not on statin therapy. There is no clinical documentation of established coronary artery disease or diabetes. Based on published randomized trial data and FDA approved indications, the patient does not meet the current published criteria for Vascepa therapy. Thus, Vascepa is not medically necessary for the treatment of the patients medical condition.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 sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Epclusa 400 mg-100 mg tablets. According to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive genotype 2 patients, based on clinical trials which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Given this patients diagnosis of chronic hepatitis C infection, genotype 2 without evidence of cirrhosis, the requested treatment with Epclusa is appropriate. For these reasons, the requested Epclusa 400 mg-100 mg tablets are 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 subspecialty certification in gastroenterology 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 rimegepant (Nurtec ODT). According to the 2015 American Headache Society (AHS) assessment of the evidence for individual pharmacological therapies for acute migraine treatment, non-steroidal anti-inflammatory drugs (NSAIDS) and triptans are effective for the treatment of acute migraine attacks (Marmura, et al.). Small molecule calcitonin gene-related peptide (CGRP) receptor antagonists are a newer drug class called gepants. The U.S. Food and Drug Administration (FDA) approved Nurtec ODT, an orally administered CGRP receptor antagonist, for the acute treatment of migraine with or without aura in adults based on the results of a randomized, double-blind, placebo-controlled trial by Croop and colleagues. The study reported that the percentage of patients achieving headache pain freedom and MBS freedom two hours after a single dose was statistically significantly greater in patients who received Nurtec ODT compared to those who received placebo. Pringsheim and colleagues recommend that, when an initial treatment (for an acute migraine) does not provide meaningful and sustained benefits, a treatment from a different medication class is typically chosen. In this case, the patient has a history of migraines that have not responded to multiple oral abortive and preventative medications. Nurtec ODT is an alternative treatment and a different medication class approved by the FDA for the treatment of acute migraines in adults. Given this support, the requested rimegepant (Nurtec ODT) 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Intracept procedure. According to the U.S. Food and Drug Administration (FDA), Intracept is recommended for use in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain of at least six months duration that has not responded to at least six months of conservative care. Patients should also have features consistent with Type 1 or Type 2 Modic changes on an magnetic resonance imaging (MRI). Fischgrund and colleagues concluded patients treated with radiofrequency ablation of the basivertebral nerve for chronic low back pain exhibited significantly greater improvement at three-month follow-up and a higher responder rate than sham treated controls. This patient is being treated for spondylosis without myelopathy or radiculopathy in the lumbar region. She noted the symptoms are worsening and now radiate into pelvis, hip, and thigh areas. The patients records lack detailed documentation to support the patients spinal vertebral bodies as the primary generators of her chronic persistent pain. The available clinical and imaging findings suggest significant plausible symptom contribution from disc herniation, nerve root impingement, and/or spinal stenosis. Overall, there is a lack of long-term, published peer-reviewed literature showing that the Intracept procedure is an effective and safe treatment at long-term follow-up. Therefore, the requested Intracept procedure 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 Intracept procedure 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Inspire upper airway stimulation system (hypoglossal nerve stimulation). The records provided for review document that this patient has obstructive sleep apnea (OSA) without evidence of nasal obstruction. The patients drug induced sleep endoscopy (DISE) showed no concentric collapse at velum and primarily anterior posterior collapse. The provider noted that the patient has an apnea/hypopnea index (AHI) of 36 events per hour. The patient has not been able to tolerate treatment with a continuous positive airway pressure (CPAP) device. The Inspire Upper Airway Stimulation System is U.S. Food and Drug Administration (FDA) approved for the treatment of OSA. Based on these findings, the patient is a candidate for Inspire device given intolerance to CPAP, no concentric collapse at velum, no central apnea, and BMI and AHI within FDA criteria. Therefore, the requested Inspire Upper Airway Stimulation System (hypoglossal nerve stimulation) 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 upper airway stimulation system (hypoglossal nerve stimulation) 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 reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in sleep medicine and is actively practicing. Physician reviewer 3 is board certified in otolaryngology with subspecialty certification in sleep 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 evaluation for bioidentical hormone therapy. Findings:  The physician reviewer found that this patient presents with post-menopausal symptoms. The patient reported that she has been treated with bioidentical hormone for more than 10 years. Bioidentical hormones refer to custom-compounded, multi-hormone regimens that are dose-adjusted based upon serial hormone monitoring. The American College of Obstetricians and Gynecologists (ACOG) have advised against the use of custom-compounded hormones due to the lack of stringent quality controls regarding purity and dosing of these regimens. Due to the lack of U.S. Food and Drug Administration (FDA) supervision, these hormones are not recommended for routine use in the treatment of patients with post-menopausal symptoms. All told, the requested evaluation for bioidentical hormone therapy is not medically necessary for 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 obstetrics and gynecology 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 Neulasta Onpro kit (pegfilgrastim solution prefilled syringe kit 6 mg/0.6 mL) every 14 days, quantity of 12. Onpro is method of delivering pegfilgrastim that does not require the patient to return the following day for an injection. Pegfilgrastim is used for the prevention of neutropenic fever in patients receiving chemotherapy regimens with a risk of neutropenic fever of 20% or more. This patient is receiving dose dense Adriamycin and cyclophosphamide followed by paclitaxel. Per the National Comprehensive Cancer Network (NCCN) guidelines, the Adriamycin and cyclophosphamide portion of the regimen requires the use of pegfilgrastim, and patients receive up to four cycles (Becker, et al.). For paclitaxel, when administered in a dose dense fashion, then an additional four cycles would be performed with pegfilgrastim. Thus, this patient will likely require eight doses of Neulasta Onpro. Accordingly, the medical records support that Neulasta Onpro kit (pegfilgrastim solution prefilled syringe kit 6 mg/0.6 mL) every 14 days, quantity of eight (8) is medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested medication regimen 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Victoza.Findings: Victoza (liraglutide) is a glucagon-like peptide-1 (GLP-1) receptor agonist that, in addition to stimulating insulin release and inhibiting glucagon secretion, slows gastric emptying and increases satiety after eating. Liraglutide has been demonstrated to reduce food intake, promote weight loss, and improve indices of metabolic function in both animal and human studies. A study states that the primary mechanisms associated with these effects are proposed to be due to actions of GLP-1 on peripheral (vagal) and central pathways that affect food intake and metabolism via hindbrain and hypothalamic activation, as well as those brain areas associated with motivation and reward processes. While obesity may not be a direct cause of PCOS, obesity does exacerbate many aspects of the phenotype, according to another study. While lifestyle intervention is first-line in the management of PCOS to both prevent weight gain and induce weight loss, another study states that medications such as GLP-1 agonists have been used to help promote weight loss and thereby prevent potential long-term complications in this patient population. In this case, the patient has had success with Victoza. Additionally, the medical literature supports the use of GLP-1 antagonists to help promote weight loss in patients with PCOS. Therefore, Victoza is medically necessary for the 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: An enrollee has requested authorization and coverage for Synvisc injections in both knees.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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, 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, there is a history of excellent lasting benefit from prior injections. Furthermore, the options are limited. The submitted documentation shows that the patient is unable to use corticosteroid injections because of stated contraindications. Therefore, Synvisc injections in both knees are medically necessary for the treatment of the patients medical condition.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested authorization and coverage for Xeljanz (tofacitinib).Findings: According to the most recent published guidelines, standard of care for the treatment of alopecia totalis would include methotrexate and contact sensitization with diphenylcyclopropenone (DPCP) or squaric acid. Additionally, few treatment methods have been evaluated by randomized control trials to determine the most efficacious modalities to treat alopecia areata. Therefore, it is challenging for clinicians to guide patients regarding the best therapeutic options. JAK inhibitors, like Xeljanz, show excellent promise and some great results in treating extensive alopecia. In this case, the patient has been diagnosed with alopecia areata. They have tried and failed treatments such as topical steroids, intralesional steroids, and oral steroids. There is sufficient support for the requested medication in this clinical setting. Therefore, Xeljanz (tofacitinib) is medically necessary for the 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 hypoglossal nerve stimulation (Inspire upper airway stimulation system). In this case, the records provided for review document that this patient has obstructive sleep apnea (OSA). A drug-induced sleep endoscopy (DISE) reported no concentric collapse at velum and primarily anterior posterior collapse. The records noted that the patient had been unable to tolerate continuous positive airway pressure (CPAP) therapy. The provider recommended treatment with hypoglossal nerve stimulation. The Inspire device is a U.S. Food and Drug Administration (FDA) approved device for the treatment of OSA . Given these findings, the patient is a candidate for the Inspire device, given his intolerance to CPAP and anterior posterior collapse. Therefore, hypoglossal nerve stimulation (Inspire upper airway stimulation system) 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 hypoglossal nerve stimulation (Inspire upper airway stimulation system) 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 and 2 are board certified in otolaryngology and are actively practicing. Physician reviewer 3 is board certified in otolaryngology with sub-specialty certification in sleep 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.