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

The patient has requested authorization and coverage for Intravenous immunoglobulin (IVIG) treatment Gamunex-C. Gamunex-C is U.S. Food and Drug Administration (FDA) approved for the treatment of immune-mediated peripheral nerve disorders including Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. IVIG has been used increasingly with significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia, which are most often small fiber polyneuropathies. Small fiber neuropathy is the most common cause of neuropathic pain in the peripheral neuropathies. Several open-label studies have suggested an immunological basis in small fiber neuropathy and have reported efficacy of treatment with IVIG (Wakasugi, et al; Weinstock, et al.). As such, immunological mechanisms may play a role in small fiber neuropathy. This patient has tried other types of medical therapies without improvement. Therefore, IVIG treatment Gamunex-C is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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

An enrollee has requested authorization and coverage for residential treatment center services.The submitted documentation supports that the requested residential treatment center services were, and are, medically necessary. Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient has met Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. Progress notes document that the patient fulfilled criteria for Dimension 1, as they indicate that the patient displayed moderate withdrawal symptoms, restlessness, irritability, agitation, anxiety and muscle/joint aches as well as post-withdrawal symptoms including hallucinations. For dimension 2, biomedical conditions and complications, the patient has chronic back pain and she is noted to require assistance with mobility, thereby having biomedical problems that require staff attention. For dimension 3, emotional, behavioral, or cognitive conditions and complications, the patients major depressive disorder and posttraumatic stress disorder fulfill this dimension. For dimension 4, readiness to change, the patient is noted to blame others and have a defensive attitude. Records reflect that the patient had been in the denial stage but has progressed to pre-contemplation, thereby showing progress but limited readiness to change. For dimension 5, relapse, continued use, or continued problem potential, the patient has a high relapse history and has required more time in treatment to fully develop tools to overcome risk of relapse. For dimension 6, recovery environment, records indicate that the patients recovery environment is filled with people who use alcohol, tobacco, and/or other drugs, and she has not yet identified her triggers well enough. The submitted documentation thereby reflects that the patient has multiple underlying conditions that require effective treatment and that she faces imminent danger if not in a supportive 24-hour treatment setting. Given the severity of the patients illness, residential treatment center services are clinically appropriate for the patient's illness. Accordingly, residential treatment center services were, and are, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services in issue and requested services 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 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 bilateral Euflexxa injections to the 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 patient reports six months of excellent relief from Euflexxa injections. Corticosteroid injections only give her six weeks of relief. The patient has tried and failed other conservative treatments. As such, her remaining treatment options are limited. Therefore, bilateral Euflexxa injections to the knees are medically necessary for treatment of this patients osteoarthritis. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollees parent has requested authorization and coverage for Gammagard (J1569). The records provided for review do not support a diagnosis of Ehlers-Danlos syndrome. Specifically, there is no report that the patient has clinical evidence of other features of dysautonomia such as gastrointestinal dysmotility, neurogenic bladder or complex regional pain syndrome, although she does have abdominal pain, constipation and weight loss. In addition, the records provided for review do not demonstrate that the patient has exhausted standard therapies for her medical condition. The provider recommended increasing water and salt intake, use of compression stockings, physical therapy, and propranolol 10 mg. The records do not describe use of these modalities or their outcome. In addition, there is no report of a diagnostic work-up to include anti-neuronal antibodies, Sjogrens syndrome, and antiphospholipid antibodies (Schofield and Chemali). One study evaluated the sera of patients with postural orthostatic tachycardia syndrome (POTS) found organ-specific autoantibodies, particularly thyroid-specific, to be more common in patients with POTS. The preliminary nature of these findings prohibit conclusions on immunomodulatory or immunosuppressive treatments (Blitshteyn). All told, the requested Gammagard (J1569) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the requested Gammagard (J1569) 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 medication is 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication Zepatier. The enrollee has a history of Hepatitis C. She was treated with Interferon-based therapy. She achieved a high viral response from this treatment, but her viral loads are now high.  A sonogram of the liver showed normal hepatic elasticity. Laboratory results showed moderately elevated liver enzymes. She has a metavir score of FO-1. This places her in the absent-to-mild fibrosis, low-risk category for significant fibrosis/stenosis. The recent progress note documents her gastroenterologist recommended Zepatier because she has had Interferon treatment in the past. The health plan has denied authorization, indicating Zepatier is covered for the treatment of chronic Hepatitis C, genotype 1 for patients that have compensated liver disease by fibroscan ultrasound or biopsy documenting stage 2,3, or 4 fibrosis, NS5A resistance testing is required.  For the treatment of Hepatitis C, the preferred agents are Epclusa, Harvoni, and Vosevi. The enrollee has a history of hepatitis C and was previously treated with interferon.  The genotype is reported to be 1a.  She does not have cirrhosis. Professional societies  recommended Zepatier as a treatment for HCV genotype 1a, interferon-experienced persons; but only if they do not have resistance variants.  To utilize this medication regimen, resistance testing needs to be performed.  There was insufficient evidence in the record that resistance testing was performed. Epclusa, an alternative medication, is also a recommended regimen for HCV genotype 1a interferon-experienced patients and does not require resistance testing.   Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with bilateral knee osteoarthritis. The patient reported right knee pain, swelling, and functional limitations. The physical examination revealed right knee patellofemoral tenderness. The patient had been treated with viscosupplementation injections in the past. Prior right knee viscosupplementation injections were noted to provide 90% pain relief for five months. The patient has requested authorization and coverage for Orthovisc injections in the right knee only. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections in the right knee only are medically necessary for the treatment of the patients medical condition. 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. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, there is a history of lasting benefit from prior viscosupplementation injections. Additionally, the options are limited, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections in the right knee only are medically necessary for the 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) and partial hospitalization program (PHP) services. Per the American Society of Addiction Medicine (ASAM) treatment criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services such as RTC level of care. ASAM criteria note that not all social and psychological problems will be resolved in the Level 3.5 treatment stay. Such complex and often lifelong challenges will need an ongoing treatment process to enhance wellness and recovery. Thus, the treatment in Level 3.5 is best viewed as just one part of a persons treatment and recovery process seamlessly integrated into a flexible continuum of services. ASAM includes six dimensions to determine the appropriate level of care for adults. For dimension 1, intoxication and withdrawal potential, this patient has a history of medical withdrawal from alcohol and Ambien. Dimension 2 considers a patients biomedical conditions. This patients records do not report any biomedical conditions. For dimension 3, emotional, behavioral, cognitive conditions, the patient has comorbid anxiety leading him to use to cope with stress. Dimension 4 evaluates a patients readiness to change. This patient is noted to be in the preparation stage toward making substantial changes. For dimension 5, relapse and continued use problem potential, the patients history is positive for continued use despite negative consequences. Currently, the patient has underdeveloped coping skills and plans in place to prevent relapse. For dimension 6, recovery environment, the patients work pressure is related to his substance use. Further, the patient has a tendency to filter information to protect others, which leaves him isolated and not seeking support from his recovery environment. Given the severity of the patients illness, RTC and PHP 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 expertise in addiction 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for DecisionDx  Melanoma genetic testing. The enrollee was diagnosed with cutaneous melanoma after a biopsy of a lesion on his left lateral mid-back. The DecisionDxMelanoma genetic testing report noted it was Class 1, subclass 1A. The enrollees dermatologist believes the results from the DecisionDxMelanoma testing, in conjunction with other clinical assessments, help identify a persons risk profile, which aids in optimal treatment planning. Literature describes the DecisionDx-Melanoma gene panel as a diagnostic not currently recommended by professional societies as part of standard treatment. This diagnostic requires additional analysis and research regarding the sensitivity and specificity of the test, conducted in individuals who are representative of the general primary melanoma population. Additionally, interpretation of the results is of critical importance. Clinicians may suggest that those for whom test results predict a high risk for metastasis undergo more frequent clinical evaluations and surveillance imaging; particularly those who have negative sentinel lymph node biopsies. However, in settings in which adjuvant therapies are either contraindicated or not available, this categorization may increase anxiety without realizing any true benefit. Those with a Class 2 Gene Expression Profile (GEP) score have been shown to be 1.5 times more likely to have a poor outcome, which means these individuals could receive life-saving preventive therapies. Staging is determined by the tumor, node, and metastasis (TMN) system developed professional societies.  Criteria include microstaging of the primary melanoma and pathologic information about the regional lymph nodes after partial or complete lymphadenectomy. Survival and recurrence rates for melanoma follow the pathologic stages set forth by the professional societies. This data is used for follow-up treatment planningFinal Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in dermatology and are actively practicing.  All three 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 enrollee is requesting authorization and coverage for a bilateral blepharoplasty procedure. The enrollee has experienced gradual drooping eyelids over the last year. She also has cataracts; left greater than right. An eye test showed ptosis. The test demonstrated the need for blepharoplasty surgery to lift her eyelids so her vision would no longer be hampered. The enrollee was referred to an ear, nose and throat-otolaryngologist, who confirmed the enrollee needed surgery. The physician recommended a brow lift and an eyelid lift. The enrollee is requesting authorization of bilateral blepharoplasty. An exam showed brow ptosis and plus-two dermatochalasis bilaterally. Automated visual field testing, performed within 24 degrees of fixation, found the superior visual field restricted to about 18 degrees in both eyes (OU) and increasing to at least 24 degrees OU with taping of the eyelids. Color external photos show dermatochalasis with excess upper eyelid resting 2-3 millimeters above the base of the lashes. Some ptosis is induced with marginal reflex distances of less than 2 millimeters OU. Photos are consistent with visual field testing. The main objective finding in the notes is a superior defect bilaterally, which improved with taping of the eyelids; suggesting blepharoplasty would likely be beneficial. Literature notes repair of blepharoptosis and upper eyelid dermatochalasis significantly improves vision and quality of life activities. According to general standards of practice supported in the peer reviewed literature, blepharoplasty procedures and repair of blepharoptosis are considered medically necessary when performed as functional/reconstructive surgery to correct impairment of near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis and/or symptomatic redundant skin weighing down on upper lashes.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in ophthalmology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees representative is requesting reimbursement for InCourage Airway Clearance Therapy high frequency chest compression device (E0483). The enrollee has a history of cerebral palsy, Down syndrome, blindness, deafness, developmental delay, and seizures. His provider is requesting coverage for the InCourage Airway Clearance Therapy high frequency chest compression device (E0483). The enrollees provider indicates the enrollee is entirely dependent on others for his care and has a history of hospitalizations for respiratory illness. He has a continued need for a chest percussion device that keeps him from getting bronchitis and pneumonia. The enrollee also suffers from gastroesophageal reflux disease, (GERD) and recurrent aspiration pneumonia. He is treated with Keppra and recurrent antibiotics. He saw his medical specialist on nine occasions with a normal pulmonary exam. The medical literature, in an extensive review found that evidence for most respiratory interventions for young people with cerebral palsy is absent or weak. No controlled trials demonstrated significant effects on respiratory morbidity, owing to their scarcity, weak designs, and inadequate power. There is an urgent need for well-designed prospective controlled studies investigating prevention and management of respiratory disease in young people with cerebral palsy.  This is consistent with the lack of support for airway clearance devices in cystic fibrosis, which has been the area most studied with these devices. In a review of such devices in cystic fibrosis, while some areas showed better results with oscillating devices, there was also data suggesting a higher rate of exacerbations requiring antibiotics compared to use of PEP- positive expiratory pressure. The medical literature does not show gastroesophageal reflux disease (GERD) is an absolute contraindication for manual chest physiotherapy.  The record has insufficient evidence of failed manual chest physiotherapy.  Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pulmonary medicine 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 similar medical condition.