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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral genicular blocks and ablation of the knees. The records provided for review document that this patient has a history of bilateral knee pain that has not substantially improved despite treatment with physical therapy, medications, and a Euflexxa injection. Fogarty and colleagues found that, there is moderate-quality evidence that fluoroscopically guided genicular radiofrequency ablation is effective for reducing pain associated with knee osteoarthritis at minimum of six months. Guler and colleagues reported that ultrasound-guided genicular nerve block is more effective than physical therapy alone in the treatment of knee pain secondary to chronic osteoarthritis. This patients bilateral knee osteoarthritis has not substantially improved despite treatment with medications, physical therapy, and hyaluronic acid injection. There are adequate data in the medical literature to support the safety and efficacy of the requested genicular nerve blocks and ablation for management of this patients bilateral knee pain. Therefore, the requested bilateral genicular blocks and ablation of the knees are 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 bilateral genicular blocks and ablation of the knees are 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 orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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

Findings:  The physician reviewer found that The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility services. Prusynski and colleagues report that while there is moderate evidence that higher intensity therapy was associated with higher rates of community discharge and shorter lengths of stay there was low evidence indicating that higher intensity therapy is associated with improvements in function. In this case, the records do not document that the patient requires skilled nursing or therapy services. Such services typically refer to treatment regimens that start in the hospital and need to be continued such as complex medication schedules, wound care, or rehabilitation. In this case, the patient had a stable tracheostomy and enteral feedings, and did not have complex wound care needs. The patients functional level did not require the skills of a professional therapist on an inpatient basis. The records noted extensive prior therapy training. Given that the patient does not have ongoing skilled nursing needs, such as professional physical or occupational therapy, that can only be administered in a skilled nursing facility and as the care can be safely and effectively met at a lower level, the services at issue were not and are not medically indicated. Therefore, 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel. High-dose corticosteroid therapy is the mainstay of treatment for acute exacerbations of multiple sclerosis (MS). Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) approves the use of Acthar Gel, an adrenocorticotropic hormone (ACTH), for the treatment of exacerbations of multiple sclerosis in adults. Other therapies include plasmapheresis, generally reserved for treatment of relapses that are severe or refractory to treatment with high-dose corticosteroids or ACTH, and intravenous immunoglobulin (IVIG), sometimes used in patients for whom high-dose corticosteroids are contraindicated or not tolerated, but for which there is no consistent evidence regarding use in relapse management. Ross and colleagues state that Acthar Gel, May be considered as an alternative treatment of MS relapses. In our experience, reasons for using ACTH include a lack of benefit established with corticosteroids, inability to tolerate corticosteroids or adverse effects, and poor intravenous access. Its efficacy has been studied in several published investigations, and treatment outcomes may be comparable to those seen with corticosteroids. In a randomized, open-label, crossover study evaluating 18 patients with MS treated with subcutaneous Acthar Gel and intravenous methylprednisolone (IVMP), Bell and colleagues report that preliminary results suggest that fewer drug-related adverse effects occurred with Acthar Gel than intravenous methylprednisolone for treatment of MS exacerbations. In a randomized, rater-blinded trial evaluating 23 patients randomized to ACTH or IVMP experiencing breakthrough disease in relapsing forms of MS while on disease modifying therapy with interferon , Berkovich and colleagues found that over 15 months, the cumulative number of relapses per patient was 0.08 with ACTH versus 0.80 with IVMP. In this case, the patient has MS with acute exacerbations. Given that current medical literature supports the use of Acthar Gel in this clinical setting, with less adverse effects and comparable efficacy and treatment outcomes to intravenous corticosteroid therapy, the requested medication is medically indicated. Therefore, Acthar Gel 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 Xifaxan 550 mg. This patient has symptoms and testing consistent with small intestinal bacterial overgrowth, and symptoms can improve with treatment. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. Per the medical literature, Xifaxan has greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones. Results are sustained for several weeks after treatment. As noted by Achufusi and colleagues, Xifaxan has emerged as the preferred agent among clinicians for the treatment of small intestinal bacterial overgrowth. The dose and duration of 550 mg three times daily for 14 days is consistent with regimens used in studies, which vary widely. There is sufficient support for the requested medication in this clinical setting. Therefore, Xifaxan 550 mg 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 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 Freestyle Libre - continuous blood glucose monitor (CGM).Findings:  The physician reviewer found that A CGM system is one of several devices approved by the U.S. Food and Drug Administration (FDA) that record blood sugar levels at repeated intervals throughout the day and night. 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. Zheng and colleagues report 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. CGM systems have become a useful tool for real-time monitoring of blood glucose in clinical and public diabetes management settings, and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. Given that current medical literature supports the safety and accuracy of CGM systems, the requested equipment is medically indicated. Therefore, Freestyle Libre  CGM 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel. Findings: A study reports that repository corticotropin injection may be a safe and effective option for patients with refractory psoriatic arthritis who failed therapy with multiple previous treatments. The author notes that repository corticotropin injection may be used to bridge with another psoriatic arthritis therapy. In this case, the patient is being treated with the biologic medication Tremfya. Given that current medical literature supports the use of the requested medication as an adjunctive therapy in combination with a biologic medication to prevent exacerbation of the disease, the requested medication is medically indicated. Therefore, Acthar Gel 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Saxenda. Gadde and colleagues note that obesity remains a continuing global health concern. The authors further note that while lifestyle modification is recommended as the cornerstone of obesity management, as many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss, there are currently multiple pharmacologic therapies which are available for weight management. Knudsen and Lau report that glucagon-like peptide-1 (GLP-1) analogs, such as Saxenda, improve glycemic control, reduce body weight, and decrease cardiovascular risk. Cornell notes that GLP-1 receptor agonists have an established efficacy and safety profile. These medications promote weight loss by reducing appetite and energy intake and delaying gastric emptying. In this case, the patient has failed other therapies including metformin, Rybelsus, and Ozempic. Given that current medical literature supports the use of the Saxenda in promoting weight loss and the low likelihood of health risks associated with this medication, the requested medication is medically indicated. Therefore, Saxenda 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 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 patients parent has requested authorization and coverage for Molift RgoSling HighBack net sling and/or Molift RgoSling ambulating vest with groin/pelvic straps for use with an authorized Molift Smart 150 electric Hoyer lift. Caregiving for children with cerebral palsy may contribute directly to both the psychological and the physical health of the caregivers, with practical day-to-day needs of the child creating challenges for parents. Darragh and colleagues note that caregivers for individuals with chronic physical disability reported high levels of physical strain and musculoskeletal discomfort, and identified several activities related to mobility and self-care as the most physically demanding. In investigating the effects of passive versus dynamic loading interventions on bone health in nonambulatory children, Damcott and colleagues report that increases in bone mineral density (BMD) were observed during dynamic standing, whereas passive standing appeared to maintain the baseline BMD. The authors further reported that increases in bone mineral content were observed in each standing intervention, with dynamic standing inducing greater increases. In this case, the patient has quadriplegic cerebral palsy, and requires moderate-to-complete assistance for transfers. The patient weighs 72 pounds, and his mother, described as slightly built, has already sustained injury in her wrists and pain in her back due to caring for the patients transfers.  In this case, a net sling is medically indicated to safely connect the patient to the Hoyer lift so that he may be transferred, and an ambulating vest with groin/pelvic straps will permit the patient to weight-bear on standing, and to use a treadmill to maintain bone health. Without these essential adjuncts to the Hoyer lift, the requested device is an unusable piece of equipment. Given that the requested equipment with allow the patient to stand and use a treadmill, which may also decrease the risk of osteoporosis, which is common in children with cerebral palsy, the requested equipment is medically indicated. Therefore, Molift RgoSling HighBack net sling and/or Molift RgoSling ambulating vest with groin/pelvic straps for use with an authorized Molift Smart 150 electric Hoyer lift 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 neurology with special qualification in child neurology with sub-specialty certification in neurodevelopmental disabilities 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 the prescription drug Ajovy. The U.S. Food and Drug Administration (FDA) approves the use of Ajovy, a calcitonin gene-related peptide (CGRP) antagonist, for the preventive treatment of migraines in adults. The American Headache Society (AHS) notes that treatment with monoclonal antibodies to CGRP may be indicated for patients with chronic migraines with an inability to tolerate a tricyclic antidepressant such as amitriptyline and a serotoninnorepinephrine reuptake inhibitor such as duloxetine. The AHS recommends that clinicians and patients reassess the benefits of CGRP monoclonal antibody therapy after three to six months and continue treatment if benefits, such as a reduction in mean monthly headache days, can be documented. In this case, the patient has a history of chronic migraines that has not responded to multiple preventative medications including duloxetine and amitriptyline. The records note that Ajovy has been effective in decreasing the frequency of the patients migraines. Given that the patient fits AHS criteria for treatment with CGRP monoclonal antibody therapy, the requested medication is medically indicated. Therefore, the prescription drug Ajovy 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 parent of an enrollee has requested authorization and coverage for speech therapy sessions (1x a week for 60 minutes)). Findings:  The physician reviewer found that Areas of speech impairment in individuals with Down syndrome involve voice, speech sounds, fluency and prosody, and intelligibility. Vocal and phonatory abnormalities are common. Speech sounds are impaired due to delayed development and errors not seen in typical development. Fluency and prosody are frequently impaired due to stuttering and cluttering, which are seen in 10-45% of children with Down syndrome compared with 1% of the typical population. Intelligibility of speech can be markedly impaired in individuals with Down syndrome. Speech and language development in individuals with Down syndrome is often delayed and/or disordered and speech disfluencies appear to be more common. The achievement of speech intelligibility by persons with Down syndrome facilitates their participation in society. In adolescents with Down syndrome, speech-language therapy during vocational training was found to lead to positive changes in the social behavior of individuals with Down syndrome, as evidenced by an increase in their autonomy and communication.In this case, the patient has Down syndrome, with resultant severe mixed receptive and expressive language disorder. Records indicate that the patient has been receiving speech therapy services by telehealth throughout the pandemic. The patients father notes that the patient makes better progress with in-person therapy, and this is the consistent with the observation that there has been significant regression or slowed progress of speech and language skills in children with Down syndrome who had to change to telehealth during the Covid pandemic. Records reflect that in this case, the patient is making slow but meaningful progress with speech therapy. Under these circumstances, speech therapy sessions (1x a week for 60 minutes) are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the enrollees medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology, with subspecialty certification in neurodevelopmental disabilities, 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 Humira 40 mg/0.4 mL pen injector subcutaneous every 14 days. Findings:  The physician reviewer found that According to the American College of Rheumatology (ACR) and National Psoriasis Foundation (NPF) guidelines, this patient has severe psoriatic arthritis based on the presence of active disease that impairs quality of life (Singh, et al.). The patient reports chronic daily severe pain due to her psoriatic arthritis that impairs her quality of life. In addition, the patient also fulfills the criteria for having severe psoriatic arthritis based on having an elevated C-reactive protein and functional limitation with impaired ambulation due to her disease. According to the guideline recommendations, tumor necrosis factor inhibitor (TNFi) therapy, such as Humira, is appropriate and is preferred for the treatment of patients with severe psoriatic arthritis over other oral therapies such as methotrexate, sulfasalazine, and leflunomide. In addition, the patient has axial disease with inflammatory back pain according to the clinic notes. It is noted that TNFi therapy, with a medication such as Humira, is considered a first-line option for the treatment of axial disease in patients with psoriatic arthritis. For these reasons, the requested Humira 40 mg/0.4 mL pen injector subcutaneous every 14 days 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 internal medicine with subspecialty certification 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.