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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc 88 mg/4 m bilateral knee injections. Findings:  The physician reviewer found that 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 routine 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 has a history of inability to take non-steroidal anti-inflammatory drugs (NSAIDs). Previous treatment has included physical therapy as well as platelet rich plasma and corticosteroid injections. As such, the patients remaining treatment options are limited. For these reasons, the requested Monovisc 88 mg/4 m bilateral knee injections 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: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for onabotulinumtoxinA (Botox) injections (J0585). There is sufficient support for the requested services in this clinical setting. The American Headache Society (AHS) recommends preventive treatment when attacks significantly interfere with patients daily routines despite acute treatment; a patient has four or more attacks per month; or a patient has contraindication to, failure, or overuse of acute treatment. The U.S. Food and Drug administration has approved onabotulinumtoxinA for the treatment of chronic migraine. In 2016, the American Academy of Neurology updated its 2008 guidelines on using botulinum neurotoxin for brain disorders. Botulinum toxin A is now recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. Simpson and colleagues noted, Botulinum toxin A is established as effective and should be offered to increase headache-free days. Frampton and colleagues reported, The totality of evidence from clinical trials and real-world studies indicates that onabotulinumtoxinA is an effective and generally well-tolerated option for the prevention of chronic migraine that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. In this case, the patient has been diagnosed with chronic migraine, and has tried and failed multiple preventative medications. The current medical evidence supports the requested services in this clinical setting. Therefore, onabotulinumtoxinA (Botox) injections (J0585) 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name medication Lamictal XR (300 mg twice a day). In a retrospective study, Medical literatures reported that in previously seizure-free patients, switching the manufacturer of antiepileptic medications was associated with a higher risk for seizure recurrence. The authors concluded, It would be prudent to avoid switching the manufacturer of anticonvulsants in seizure-free patients. The Commission on Human Medicines guidelines on switching formulations of antiepileptic drugs notes, Patients with highly labile seizure control or optimal seizure control (i.e. seizure free or their seizure frequency has been markedly reduced) should not be switched to generics and should be maintained on their usual brand version for their antiepileptic drugs therapy. In this case, the records note that the patients seizures have been controlled on the brand name Lamictal and that she has previously tried and failed the generic formulation. In this clinical setting, given that current medical literature recommends against patients with controlled seizures being switched to the generic formulation of antiepileptic drugs, the requested medication is indicated. Therefore, brand name medication Lamictal XR (300 mg twice a day) 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 Orthovisc injection series in both knees. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections with lasting relief. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injection series in both knees 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 parent has requested authorization and coverage for Supartz injections in the right knee. 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. 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 patients case, the options are clearly limited. The only conservative option that has not been tried is viscosupplementation. There is sufficient support for the requested services in this clinical setting. Therefore, Supartz injections in the right knee 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 for implantation of a Medtronic biventricular cardioverter defibrillator. The American College of Cardiology Foundation (ACCF), American Heart Association (AHA), and Heart Rhythm Society (HRS) guidelines recommend biventricular cardioverter defibrillator implantation for the primary prevention of sudden cardiac death as well as cardiac resynchronization therapy addressing the left ventricular dysfunction and heart failure symptoms in patients with an underlying left bundle branch block (LBBB) with a wide QRS. In this case, given that the records document an underlying LBBB and a QRS duration of 180 ms, the service at issue was medically indicated. Therefore, implantation of a Medtronic biventricular cardioverter defibrillator was medically necessary for the treatment of this patientFinal Result: The reviewer determined that the service at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Repatha Solution Syringe. Findings: The American College of Cardiology (ACC) has developed an expert consensus decision pathway regarding the role of non-statin therapies for LDL cholesterol lowering for management of atherosclerotic cardiovascular disease risk. Per the ACC guidelines, Repatha may be considered if the goals of therapy have not been achieved on maximally tolerated statin and ezetimibe in higher risk patients with clinical atherosclerotic cardiovascular disease or familial hypercholesterolemia. The records provided for review do not document that this patient has undergone an adequate trial of treatment with ezetimibe. Moreover, there is a lack of evidence of clinical cardiovascular disease or subclinical atherosclerosis to support an indication with treatment. Furthermore, although the patient has a family history of early myocardial infarction, the records do not report that the cardiac event was related to familial hypercholesterolemia. The patients LDL cholesterol should be measured on ezetimibe alone to demonstrate that guideline recommended LDL lowering is indicated, prior to authorizing Repatha. Therefore, the requested Repatha Solution Syringe is not considered 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 cardiology 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 Ozempic 0.25-0.5 mg pen. The records reviewed for this patient document a history of obesity and comorbid obstructive sleep apnea (OSA). The patients provider has recommended treatment with Ozempic, given the patients limited response to treatment with phentermine. Although lifestyle modification is recommended as the cornerstone of obesity management, 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 (Gadde, et al.). There are currently multiple pharmacologic therapies which are available for weight management. Ozempic is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) agonists, which have been shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk (Knudsen and Lau). Multiple studies have demonstrated the efficacy of Ozempic in the promotion of weight loss, via reduced appetite and energy intake, and delayed gastric emptying (Cornell). Given this support, the requested Ozempic 0.25-0.5 mg pen 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 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 Synvisc One injection for the left knee. Findings:  The physician reviewer found that 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 routine 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 has a history of continuing long-term benefit from viscosupplementation using Synvisc One injections of the left knee every six months. In addition, the patient has failed treatment with non-steroidal anti-inflammatory drugs (NSAIDs), cortisone injections, bracing, and physical therapy. For these reasons, the requested Synvisc One injection for the left knee is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gammagard intravenous immunoglobulin (IVIG) 500 mg, quantity 70 units. On review of the current peer-reviewed medical literature and guidelines, there is a lack of support for the requested Gammagard IVIG for treatment of this patients identified glutamic acid decarboxylase antibodies (GAD Ab). Dade and colleagues noted that GAD Ab have been associated with multiple neurological syndromes, including stiff-person syndrome, cerebellar ataxia, and limbic encephalitis. There are limited data supporting the use of IVIG in the treatment of patients with GAD Ab who do not demonstrate symptoms consistent with a GAD antibody syndrome. The available documentation does not establish a known syndrome associated with GAD Ab such as stiff person syndrome, diabetes, autoimmune thyroiditis, pernicious anemia, limbic encephalitis, cerebellar ataxia, or seizure. Therefore, the requested Gammagard IVIG 500 mg, quantity 70 units, 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 neurology with subspecialty certification in vascular 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 intravenous immune globulin 2 g/kg initial dose, and then 1 g/kg monthly. Findings:  The physician reviewer found that Wynford-Thomas and colleagues describe myelin oligodendrocyte glycoprotein (MOG)  antibody associated disease as an inflammatory demyelinating condition of the central nervous system characterized by a monophasic or relapsing course of neurological dysfunction, which does not meet the typical criteria for multiple sclerosis or other known neuroinflammatory conditions and occurs in the presence of serum MOG antibodies detected using specific cell-based assays, with a relapsing course reported in 44% to 83% of patients that more commonly involves the optic nerve. The authors further note that while randomized control trials are limited, observational open-label experience suggests a role for high-dose steroids and plasma exchange in the treatment of acute attacks, and for immunosuppressive therapies, such as steroids, oral immunosuppressants, intravenous immune globulins and rituximab as maintenance treatment. Current medical literature supports the association of intravenous immune globulin with a reduction in MOG antibody associated disease relapse rates. Ramanathan and colleagues report that long-term treatments with prednisolone, intravenous immune globulins, rituximab, mycophenolate mofetil, methotrexate or azathioprine have all been reported to reduce the annualized relapse rate in MOG antibody associated disease. In a large retrospective multicenter study of 70 patients with MOG antibody associated disease, Chen and colleagues conclude that maintenance immunotherapy reduces recurrent central nervous system demyelinating attacks, with the lowest annualized relapse rate being associated with maintenance intravenous immune globulin therapy. In this case, the patient has MOG antibody associated disease. In this clinical setting, given that intravenous immune globulin therapy is associated with a reduction in relapse rates and is recommended as a maintenance therapy for MOG antibody associated disease, the requested service is medically indicated. Therefore, intravenous immune globulin 2 g/kg initial dose, and then 1 g/kg monthly, 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 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 Wegovy. Findings: This patients records document a history of obesity, hypercholesterolemia, and a family history of coronary artery disease. The patient started treatment with Wegovy with reported satisfactory results as evidenced by loss of 19 pounds. The provider has recommended continued treatment with Wegovy. Although lifestyle modification is recommended as the cornerstone of obesity management, 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. Ozempic is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) agonists, which have been shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk. Multiple studies have demonstrated the efficacy of Ozempic in the promotion of weight loss, via reduced appetite and energy intake, and delayed gastric emptying. Ozempic and Wegovy are both brand name products containing the same active ingredient, semaglutide. Given this support, the requested Wegovy 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 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.