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

The patient has requested authorization and coverage for Dupixent 300 mg/2 ml syringe. The patient has been diagnosed with atopic dermatitis (AD). Researchers states that the authors agreed that the general approach should be an intensive clearance period with a topical corticosteroids (TCSs) followed by a safe and individualized regimen of intermittent TCSs, topical calcineurin inhibitors (TCIs), or emollients to prevent flares. The patient has not had a successful clearance period. In this case, the patients atopic dermatitis is widespread, and he has failed topical treatment and two systemic steroid treatments. The difficulty controlling this patients disease and his involved body surface area merit systemic treatment. The medical evidence supports the requested medication in this clinical setting. Therefore, Dupixent 300 mg/2 ml syringe 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 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: Upheld Decision of Health Plan

An enrollee has requested reimbursement for gene analysis testing including coagulation factor II, coagulation factor V, and 5, 10-methylenetetrahydrofolate reductase. This patient presented with concerns about her fertility, which were likely due to her infrequent ovulation. At the time her fertility evaluation, she did not meet the criteria for infertility. According to the American College of Obstetricians and Gynecologists (ACOG), the diagnosis of recurrent miscarriage is made after three spontaneous pregnancy losses. In addition, there is a paucity of support in the peer-reviewed medical literature to support an association of heterozygosity of the methylenetetrahydrofolate reductase mutation and miscarriage. All told, the gene analysis testing including coagulation factor II, coagulation factor V, and 5,10-methylenetetrahydrofolate reductase, 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 reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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: Overturned Decision of Health Plan

The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. This gives the patient a composite score which is consistent with high intensity community based services, such as IOP. Per CALOCUS, minimal oversight should be required for this level of services and reviews should not be required more often than every two weeks for persons with acute conditions and every two months for those with more slowly evolving conditions. The patient qualifies for up to two more months of IOP services. Accordingly, the mental health IOP services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for a Synvisc-One injection to the left knee. The patient has been diagnosed with osteoarthritis of the left knee. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of excellent lasting pain relief from prior viscosupplementation injections. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One injection to the left knee 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Gammagard infusions, 21 grams every four (4) weeks. Based on the available documentation, there is a lack of laboratory data to support immunoglobulin replacement therapy for treatment of this patient. The records include documentation of mildly decreased total IgG levels in the setting of dermatologic and pulmonary infections. However, there is a lack of work-up to determine the patients antibody function or IgA and IgM levels. A diagnosis of common variable immunodeficiency requires reports of low IgG levels in addition to either low levels of IgA or IgM, and poor response to vaccines such as Pneumovax, diphtheria, and tetanus. Therefore, the requested Gammagard infusions, 21 grams every four (4) weeks, are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Gammagard intravenous infusions. The records provided for review do not support a diagnosis of Lyme disease or Powassan disease in this patient. The positive serological testing that is represents likely cross-reactions with other antigens given the lack of clinical signs and symptoms reported in the patients chart. There is a lack of documentation to support a tick-borne illness. As noted by the Centers for Disease Control and Prevention (CDC), Powassan disease confirmation is required to make a diagnosis, which is not present in the records provided for review. Accordingly, the requested Gammagard intravenous infusions are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in infectious 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

The patient has requested authorization and coverage for Rybelsus (semaglutide) 2 mg tablets, 30 quantity. The American Diabetes Association (ADA) guidelines support the use of a GLP-1 RA for patients with diabetes and cardiovascular disease in patients not reaching glycemic targets with use of non-GLP-1 RA oral agent regimens. Moreover, the ADA supports treatment with a GLP-1 RA with cardiovascular benefit for patients with comorbid arteriosclerotic cardiovascular disease. This patient has cardiovascular disease complicating his uncontrolled diabetes type 2. The advance in therapy to changing to Rybelsus in lieu of Tradjenta is appropriate to improve his diabetes control and decrease cardiovascular risk. Accordingly, the requested Rybelsus (semaglutide) 2 mg tablets, 30 quantity, is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 diabetes, endocrinology, 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

The patient has requested authorization and coverage for Euflexxa injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. The patient has tried and failed conservative treatments. The patients remaining treatment options include a total knee arthroplasty in the presence of moderate patellofemoral arthritis but no tibiofemoral arthritis or viscosupplementation. The patient underwent a series of viscosupplementation in 2018, and the provider has repeatedly recommended additional Euflexxa injections since that time due to its long-term efficacy. All told, the requested Euflexxa injections in both knees are 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for brand name Anucort-HC 25 mg suppositories. The American College of Gastroenterology (ACG) guidelines for management of benign anorectal disorders do not support use of Anucort suppositories for proctalgia. Moreover, Anucort suppositories are not recommended for the treatment of IBS. Guidelines from the American Society of Colon and Rectal Surgeons (ASCRS) report that rectal corticosteroids are safe and effective for the treatment of hemorrhoids and ulcerative colitis, but neither is documented in this patients case. Additionally, the peer-reviewed medical literature has not demonstrated that the brand name formulation is safer and more effective than the generic formulation. All told, the requested brand name Anucort-HC 25 mg suppositories are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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: An enrollee has requested reimbursement for left knee arthroscopic surgery (CPT 29882 and 29881).The patient presented with worsening left knee pain following a sports twisting injury. The patient had diffuse severe pain with associated mechanical symptoms of swelling, popping and clicking. Significant functional limitations in activities of daily living were reported. Clinical exam findings were consistent with imaging evidence of a lateral meniscus tear and potential medial meniscus tear, with mild to moderate chondral wear in all three compartments. X-rays of the left knee showed moderate degenerative changes. Conservative treatment had included activity modification and anti-inflammatory medications. The patient underwent a left knee diagnostic arthroscopy and partial lateral meniscectomy. Current evidence based medical literature supports knee surgery under these circumstances. There was evidence of a traumatic event with onset of severe pain and mechanical symptoms resulting in significant functional limitations. Clinical exam findings were consistent with imaging evidence of meniscal pathology, including significantly positive McMurray's test. Reasonable conservative treatment had been attempted for two months. There was also no evidence of greater than mild to moderate osteoarthritis prior to surgery. Surgery was therefore indicated for functional restoration in this young patient. Accordingly, the left knee arthroscopic surgery (CPT 29882 and 29881) at issue was medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for 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

The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine and MRI of the right shoulder. The American College of Radiology (ACR) guideline indicates that MRI of the cervical spine may be appropriate for patients with prior cervical spine surgery with new or increasing non-traumatic cervical or neck pain or radiculopathy. This patient presents with a history of chronic neck pain with left upper extremity radicular symptoms. Prior cervical spine imaging demonstrated multilevel and multifactorial stenosis with cord flattening and indentation. The patients current symptoms include a wobbly gait, which represents a possible neurologic progression. There is evidence of failure of physical therapy and home exercise. The provider referred the patient to a neurosurgeon, who has requested an updated MRI prior to evaluation. Current evidence based medical literature support an updated cervical spine MRI for progressive neurologic symptoms, failure of conservative treatment, and for treatment planning purposes. Therefore, the requested MRI of the cervical spine is medically necessary for this patient. There is no lack of documentation of referral to a pain management physician or evidence that additional diagnostic studies are required to determine a treatment plan. Accordingly, the requested MRI of the right shoulder is not medically necessary for evaluation of this patient.Final Result: The reviewer determined that a portion of the requested services is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially 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

The patient has requested authorization and coverage for Xeljanz XR 11 mg tablets. Xeljanz is U.S. Food and Drug Administration (FDA) approved for the treatment of psoriatic arthritis in patients who are unable to take a tumor necrosis factor (TNF) inhibitor, or prefer an oral medication. In this case, the patient has failed a TNF inhibitor and has anti-nuclear antibodies. Thus, treatment with a TNF inhibitor is not recommended. The records also document that treatment with methotrexate, sulfasalazine, and Otezla were not substantially effective. Her psoriatic arthritis is not severe enough to support treatment with Cosentyx or Stelara. Given these findings, the requested Xeljanz XR 11 mg tablets are 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 certifications in allergy and immunology and 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 Levemir FlexTouch 100 unit/mL (3 mL). The patient has been diagnosed with type 1 diabetes mellitus.Researchers reported that all insulins have the same mechanism of action on target tissues (i.e., all insulins have the same action if administered intravenously). Therefore, the different timeaction profiles of various insulins result from differences in their behavior in the subcutaneous space, which then affects the rate of absorption into the circulation. The Health Plan noted that Levemir may be approved where there is an inadequate response to intolerance to Basaglar. In this case, the patient has responded well to Levemir insulin and has had suboptimal control on Basaglar. The medical evidence supports the requested medication in this clinical setting. Therefore, Levemir FlexTouch 100 unit/mL (3 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 with sub-specialty certification in endocrinology 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Simponi. The U.S. Food and Drug Administration (FDA) approved Simponi for the treatment of patients with ulcerative colitis. This patient has failed three other anti-tumor necrosis factor alternatives for treatment of his Crohns disease. Other treatment was initially effective, until the patient developed antibodies. Given the findings in current medical literature, the requested Simponi is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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.