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 (1) Qulipta 60 mg tablet, and (2) Trudhesa aerosol solution 0.725 mg/actuation, 1 mL nasal spray (12 mL per 28 days). Scuteri and colleagues report that calcitonin-gene related peptide (CGRP) antagonists play a fundamental role in migraine pharmacotherapy. Rustichelli and colleagues describe atogepant (brand name Qulipta), an orally active small molecule, as a potent, selective antagonist of the CGRP receptor and as the only gepant authorized exclusively for episodic migraine prophylaxis in adults. Qulipta is also an option for women of childbearing age, as it has a very short half-life in comparison to other medications that block CGRP activity such as Aimovig. This allows a much faster elimination time from the body if necessary. In this case, given the patients headache frequency, a prophylactic headache medication is medically indicated. The current medical literature supports the use of the requested medication. Therefore, (1) Qulipta 60 mg tablet is medically necessary for the treatment of this patient.In this case, the records note success with the patients use of Ubrelvy tablets as an abortive agent. While they have a history of nausea, the records do not indicate that nausea is limiting the patients use of Ubrelvy tablets. In a narrative review of dihydroergotamine (brand name Trudhesa), Silberstein and colleagues report that nasal spray formulation exhibit low bioavailability and high variability that limits its efficacy. The authors further note that of 19 clinical studies, some results have yet to be published, while other studies are currently underway. The nasal spray approach may be appropriate in the setting of significant nausea, which is not documented in this case. Therefore, (2) Trudhesa aerosol solution 0.725 mg/actuation, 1 mL nasal spray (12 mL per 28 days) is not medically necessary for the treatment of this patientFinal Result: The reviewer determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Keytruda. The U.S. Food and Drug Administration (FDA) has not approved Keytruda for the treatment of patients with pancreatic cancer. In addition, there is a paucity of medical literature demonstrating improved patient health outcomes with Keytruda. Currently, the treatment of patients with Keytruda is limited to the treatment of unresectable or metastatic microsatellite (MSI) high or deficient mismatch repair (dMMR) solid tumors that have progressed following prior treatment and have no satisfactory alternate treatment options. Moreover, the National Comprehensive Cancer Network (NCCN) does not include Keytruda as a recommended agent in the management of patients with pancreatic cancer. Overall, there is a lack of data to support use of Keytruda in addition to folinic acid, fluorouracil, irinotecan hydrochloride, and oxaliplatin (FOLFIRINOX) for neoadjuvant treatment of pancreatic cancer. For these reasons, the requested Keytruda 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 certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The child of an enrollee has requested reimbursement and authorization and coverage for skilled nursing facility care.Functional impairments due to a cerebral stroke can be severe to profound. While functional recovery may be amenable to natural recovery processes and rehabilitative measures, the extent of initial injury is a major determinant of functional outcomes as it defines the residual neuronal reservoir that is capable of engaging in recovery. Half of the variance seen at six months post stroke can be accounted for by the initial motor impairment. Notably, most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke, i.e., in the first 30 days, and gains are slower to come in the subsequent stages. There is a general consensus that initiating intensive rehabilitative measures earlier in the post-stroke course enhances outcomes (i.e., within the first few days and weeks post-stroke), but there are generally poor data guiding optimal practices regarding dose, manner, and venue of stroke rehabilitation in the more subacute and chronic stages.In this case, the patient was noted to have sustained multiple strokes and she has had minimal function as well as severe encephalopathy since that time. The patient has undergone extensive formal rehabilitation, but she has made minimal to no meaningful progress. Records indicate that the patient remains dependent for all care and mobility, that she is not following commands, and that she does not even recognize her family members. There is no realistic community disposition identified in the available documentation. Records reflect that the patient has been at a custodial level of care. Under these circumstances, the requested continued skilled nursing facility care services were not, and are not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services were not, and are not, medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of Vivistim Paired vagus nerve stimulation (VNS) system. The current mainstay of treatment for neurological deficits following stroke, including arm dysfunction, is intensive therapy. Arm dysfunction is particularly debilitating and can have major impacts on a patients quality of life. The records provided for review document that this patient sustained an ischemic stroke with severe arm dysfunction. Despite years of intensive therapy, her condition has only modestly improved. She has well documented deficiencies in functioning and her ability to perform activities of daily living (ADLs). The patients provider has recommended treatment with a Vivistim VNS system. Medical literatures performed a randomized controlled trial to evaluate the effect of VNS paired with rehabilitation in patients with severe upper extremity dysfunction after stroke. The authors concluded that after 90 days, a clinically meaningful difference was achieved in nearly 50% of the VNS-treated group. Similarly, researchers reported that, VNS paired with rehabilitation was acceptably safe and feasible in participants with upper limb motor deficit after chronic ischemic stroke. Given this support, the requested implantation of Vivistim Paired VNS system procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested implantation of Vivistim Paired VNS system procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in neurological surgery and is actively practicing. Physician reviewer 2 is board certified in neurological surgery and is actively practicing. Physician reviewer 3 is board certified in neurological 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Synvisc-One injection to 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, there is a history of immediate relief after the last injection that lasted six months. There is sufficient support for the requested service in this clinical setting. Therefore, the requested Synvisc-One injection to the right 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg tablets. According to Gatta and Scarpignato, rifaximin (brand name Xifaxan) treatment is effective and safe for the treatment of small intestinal bacterial overgrowth (SIBO).  Barkin and colleagues report that rifaximin is the most commonly prescribed antibiotic regimen for SIBO therapy as a highly effective therapy in providing symptom relief from the effects of SIBO. Rao and Bhagatwala report that rifaximin is shown to be effective against SIBO and well-tolerated. In this case, given that the patient has symptoms and testing consistent with small intestinal bacterial overgrowth, the requested medication is medically indicated. Therefore, Xifaxan 550 mg tablets are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right and left hip and/or MRI of the left knee. Findings:  The physician reviewer found that this patient has an established history of longstanding left knee pain that has persisted after ACL repair. Per the chart notes, the patient presented multiple times in 2018 regarding these symptoms. Three years later, the patient experienced an acute traumatic event resulting in left knee and bilateral hip pain. The patients provider has recommended MRI studies of the bilateral hips and left knee. The American College of Radiology (ACR) states that in the event of acute hip pain after trauma, x-rays are the first, most appropriate step. If the x-ray is negative, an MRI can then be considered to evaluate abnormalities not visualized on x-ray. Similar recommendations are provided for knee pain after trauma with x-rays given the highest recommendation level of 9 out of 9. Given that the patient has a prior history of surgery and pain in the left knee, the ACR recommendations for chronic knee pain may be reviewed as this may be a case of acute on chronic pain. However, the recommendations are consistent to suggest that the initial imaging after trauma should be radiography. MRI is superior to x-rays in the evaluation of the soft tissues, but it is not superior to x-rays in all respects, particularly in providing a relative quick assessment for fractures and joint effusions. Furthermore, providers correlate findings on x-ray with MRI making the two studies complimentary and additive in providing information regarding joint injury (George, et al.). At this time, first-line imaging with radiographs has not been performed. Thus, the requested MRI of the right and left hip and MRI of the left knee are not medically necessary for this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiology with subspecialty certification in diagnostic radiology 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 a colonoscopy. Findings:  The physician reviewer found that American Gastroenterological Association Institute (AGA), and American Society for Gastrointestinal Endoscopy (ASGE) guidelines note that the interval for follow-up repeat screening colonoscopies depends on the findings at the baseline colonoscopy and subsequent colonoscopies. Wilkins and colleagues report that screening colonoscopies performed in accordance with guidelines can prevent colorectal cancer. In this case, pathology findings from a colonoscopy showed one tubular adenoma. In this clinical setting, a repeat colonoscopy is recommended after five years for follow-up of the polyp. Therefore, a colonoscopy is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for nerve block injections. Occipital neuralgia is a debilitating pain condition that can be refractory to many treatment modalities. Conservative treatment options include medications, occipital nerve blocks, and surgical intervention for refractory patients. This patient has a history of chronic migraine and occipital neuralgia. The provider noted that the patient has experienced significant relief with occipital nerve blocks and is likely to have benefit with repeat blocks. Ebied and colleagues reported that, Occipital nerve block, consisting of a local anesthetic and/or corticosteroid, has been shown to be an effective treatment for the management of migraines. Similarly, Juskys and Sustickas concluded that, Occipital nerve block with a local anaesthetic and corticosteroids provides a safe, simple, and effective treatment method for the patient with medically-refractory occipital neuralgia. Given this support, the requested nerve block injections 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 nerve block injections 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injection series in both knees. 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 significant relief from prior injections. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested reimbursement for bilateral breast implant removal. Swezey and colleagues explain, When evaluating a potential implant rupture, important determinations to make include the makeup of the implant (saline implant or silicone implant), and the length of time the implant has been in place. The authors note, There is rarely pain with a saline implant rupture outside of the infrequent post-traumatic ruptures. The authors further note, Saline implant rupture results in the extravasation of a simple normotonic saline solution that is harmless and will be reabsorbed by the body over time. Tahir and Shamsudeen state, Mastalgia is a medical term used for breast pain, one of the most common complaints among women of 15 to 40 years of age (child-bearing age). Approximately two-thirds of women during their reproductive lives suffer from this condition and seek medical help. It is a dull, aching pain while some women may describe it as heaviness, tightness, discomfort, or burning sensation in the breast tissue, which may be unilateral or bilateral. Most often, it is located in the upper outer quadrant of the breast and can sometimes radiate to an ipsilateral arm. It is most common in premenopausal and perimenopausal women, but postmenopausal women can also rarely develop such pain. The breast pain ranges from mild to severe, could be intermittent or constant throughout the day, and may interfere with the female's quality of life. In this case, the patient reported bilateral, chronic breast pain, indicating mastalgia that may be due to a wide variety of causes and that was not caused by a recent unilateral rupture. While explantation may be appropriate following the rupture of a silicone gel breast implant due to concerns of the residual silicone gel, the rupture of a saline breast implant does not necessitate explantation, as the saline solution is absorbed by the body, and a flat deflated saline implant is as benign to the body as an inflated saline implant. Given that rupture of a saline breast implant presents no risk from the free released saline, which is reabsorbed into the body, the service at issue was not medically indicated. Therefore, bilateral breast implant removal was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.