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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Xeljanz (10 mg). Findings:  The physician reviewer found that Bressler and colleagues indicate that Xeljanz has a different mechanism of action than aminosalicylates, immunomodulators, anti-tumor necrosis factor therapies, Entyvio, and Stelara. Xeljanz is approved by the U.S. Food and Drug Administration for the treatment of ulcerative colitis. In a double-blind study by Sandborn and colleagues, Xeljanz was proven effective in patients with moderate-severe ulcerative colitis, with up to 78% clinical response and 41% clinical remission at eight weeks, both significantly higher than placebo. According to Bressler and colleagues, endoscopic remission rate was also significantly higher than placebo. American Gastroenterological Association (AGA) guidelines for the treatment of ulcerative colitis state, In adult outpatients with moderate to severe ulcerative colitis who have previously been exposed to infliximab, particularly those with primary nonresponse, the AGA suggests using ustekinumab or tofacitinib rather than vedolizumab or adalimumab for induction of remission. In this case, the patient has already failed infliximab and vedolizumab for ulcerative colitis, and he has required ongoing corticosteroid therapy. Current medical literature supports the use of Xeljanz for ulcerative colitis in this case after failure of multiple other therapies. Therefore, Xeljanz (10 mg) is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the lower back. Findings:  The physician reviewer found that the American College of Radiology (ACR) guidelines, when at patients lower back pain persists after four to six weeks of conservative management, and the patient is a surgical or intervention candidate, then MRI of the lumbar spine is the usually appropriate next examination. Records document that this patient presents with chronic low back pain with associated radiculopathy symptoms and numbness. The provider reported that the patient has failed conservative management in the past including physical therapy and NSAIDs. In this clinical setting, an MRI of the lumbar spine is an appropriate examination and could change the patients management, which may include surgical intervention or interventional pain management. Therefore, the requested MRI of the lower back is medically necessary for this patient. Final Result: The reviewer determined that the requested services are 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 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: An enrollee has requested authorization and coverage for Xeljanz (tofacitinib) tablets.Findings: Currently, there are no treatments approved by the U.S. Food and Drug Administration (FDA) for treatment of GA, and so any use of a drug or therapy would be considered off-label. Xeljanz is a highly active advanced small molecule that is currently undergoing an open-label trial for FDA-approval for treatment of GA. A study found, Topical Janus kinase inhibitors may be beneficial in patients with cutaneous granulomatous disorders with limited involvement. In another study, Tofacitinib resulted in dramatic improvement in patients with cutaneous sarcoidosis and GA. In this case, the patient has tried and failed alternatives, including steroids, phototherapy, and multiple disease modifying antirheumatic drugs (DMARDs). Additionally, there is support in the literature for the use of tofacitinib in the treatment of GA. Therefore, the requested Xeljanz (tofacitinib) tablets are medically necessary for treatment of the patients medical condition.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for intravascular ultrasound (IVUS) imaging (CPT 92978). Findings:  The physician reviewer found that (ACCF/AHA/SCAI) guidelines, Intravascular ultrasound (IVUS) provides a unique coronary artery assessment of lesion characteristics, minimal and maximal lumen diameters, cross-sectional area, and plaque area. Diagnostic uses for IVUS include the assessment of angiographic indeterminant coronary artery stenoses, determination of the mechanism of stent restenosis or thrombosis, and postcardiac transplantation surveillance of coronary artery disease (CAD). The authors conclude, IVUS is superior to angiography in the early detection of the diffuse, immune-mediated, cardiac allograft vasculopathy. Additionally, the authors also state, IVUS is reasonable for the assessment of angiographically indeterminant left main CAD.In this case, the IVUS was used to image the left circumflex. IVUS is an appropriate method to define the nature of this indeterminate coronary lesion, severity of stenosis and guide the percutaneous coronary intervention (PCI) procedure. IVUS is accepted and within current ACCF/AHA/SCAI guidelines. Therefore, intravascular ultrasound imaging (CPT 92978) provided on was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Three out of three physician reviewers found that IVUS imaging (CPT 92978) was likely to have been more beneficial for you than any available standard therapy.Final Result: The reviewers determined that the service at issue were likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease. All reviewers 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for proton beam radiation therapy (CPT-77370). Findings:  The physician reviewer found that According to Baxi and colleagues, the use of proton beam radiation therapy in head and neck cancer can provide for more conformal radiotherapy compared to standard treatment with photons and may reduce the dose to critical organs at risk. Some reports, however, suggest that patients may have worse toxicities, include dermatitis, neurologic toxicity and temporal lobe necrosis. Currently, there is a lack of clinical data to support the routine use of proton beam radiation therapy in head and neck cancers. Furthermore, there is a lack of  published randomized trials that support the use of proton beam radiation therapy over standard treatment with photons. Trials are currently ongoing to determine if patients who receive proton radiation therapy have improved local control and reduced side effects compared to patients who receive treatment with photons. Additionally, the current National Comprehensive Cancer Network guidelines also do not support the routine use of proton therapy in treatment of head and neck cancer. Therefore, proton beam radiation therapy (CPT-77370) is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 radiation oncology 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 authorization and coverage for Monovisc injection in both knees.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. Viscosupplementation stimulates the production of endogenous hyaluronic acid and slows the degradation of articular cartilage in the knees. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 had good response to viscosupplementation in the past. Furthermore, the patients options are limited as the patient is not a candidate for total knee arthroplasties due to the mild degree of osteoarthritis. Therefore, Monovisc injection in both knees is medically necessary for treatment of the patients medical condition.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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the lumbar spine. The American College of Radiology appropriateness criteria for low back pain notes that for subacute or chronic low back pain with or without radiculopathy, without red flags, or prior management or imaging, an MRI of the spine without contrast is usually not appropriate. The guidelines further note that for elderly patients, computed tomography (CT) is preferred, although MRI can be useful to evaluate for ligamentous injury or worsening neurologic deficit. Additionally, findings on MRI may not necessarily correlate with symptoms as a patient may have incidental findings on an MRI that are not symptomatic, and, conversely, may have relatively unimpressive findings on an MRI while experiencing significant symptoms. In this case, the records do not document specific signs of motor or sensory deficits. The submitted documentation did not indicate that the patient was being considered for surgery, that imaging studies would change the course of the patients management, that conservative management with physical therapy, focused exercises, and anti-inflammatory medications had been tried without relief, or prior imaging such as plain x-rays or CTs. Given that the records did not indicate that a surgical procedure was appropriate and as an intensive conservative approach to therapy was first warranted, the service at issue was not medically indicated. Therefore, MRI of the lumbar spine 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.Credentials/Qualifications: The reviewer is board certified 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for colonoscopy. The provided documentation indicates that this patient underwent an evaluation with a colonoscopy in 2020. The joint guidelines issued by the American College of Gastroenterology (ACG), American Gastroenterological Association Institute (AGA), and American Society for Gastrointestinal Endoscopy (ASGE) for surveillance after a screening colonoscopy state that the interval for repeat screening colonoscopy depends on the findings at the baseline colonoscopy and subsequent colonoscopies (Gupta, et al.). Based on these guidelines, a repeat colonoscopy is not medically necessary for evaluation of this patient. The reports provided do not document incomplete polyp resection, inadequate preparation insufficient to find polyps, or other indications during prior colonoscopy or colonoscopies to support a modified screening schedule departing from guideline recommendations. Additionally, the applicable guidelines recommend colonoscopy every five years for patients with a family history of colorectal cancer unless other findings warrant colonoscopy sooner. The records do not document the presence of symptoms such as hematochezia or unintentional weight loss, which would require assessment with a colonoscopy. For these reasons, the requested colonoscopy is 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent 300 mg/2 mL syringes. Kaye and colleagues report on the case of a patient with bullous pemphigoid who was successfully treated with dupilumab, an interleukin (IL)-4 alpha antagonist. Abdat and colleagues report in a case series of 13 patients that dupilumab may be an additional treatment for bullous pemphigoid, leading to disease clearance or satisfactory response in 92.3% of patients, including in those in whom previous conventional therapy had failed. Dupixent is not immunosuppressive and is well tolerated by most patients. Given the severity of the patients disease and this patients immunosuppressed status, the requested medication is medically indicated. Therefore, Dupixent 300 mg/2 mL syringes 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for Botox injections every three months. The records document that this patient presents with a medical history significant for term forceps delivery and torticollis noted at several months of age. He was treated with physical therapy and a cranial orthosis for plagiocephaly, with significant improvement in head shape. The patient has been started on a regimen of Botox injections. Botox has been used for patients with torticollis when more conservative measures such as repositioning, cranial orthoses, and physical therapy have failed to correct muscular torticollis (Qiu, et al.; Bourseul, et al.). In this case, the patient has failed treatment with months of physical therapy, repositioning, and use of a cranial orthotic. The patients torticollis is negatively impacting his ability to fully develop age-appropriate skills. For these reasons, Botox injections every three months as needed were and are medically necessary for the 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 pediatrics with subspecialty certification in pediatric critical care 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 superior fornix reconstruction, symblepharon lysis, amniotic membrane graft, excision of left upper eyelid lesion, and wedge excision for lid notching. The records provided for review document that this patient sustained a fireworks injury resulting in significant scarring of the conjunctiva and cornea. Fireworks injuries can lead to significant chemical and thermal injury to the surface of the eye. Cheung and colleagues reported that in fireworks injuries, Despite total ocular surface failure, these eyes can achieve good postoperative visual results following limbal stem cell transplantation and subsequent keratoplasty with appropriate compliance. Before a patient can undergo surgical repair of the cornea, conjunctival disease must be surgically addressed. In this case, fornix reconstruction, symblepharon lysis, amniotic membrane graft, excision of left upper eyelid lesion, and wedge excision for lid notching were indicated to attempt to adequately treat this patients significant scarring of the conjunctiva and cornea. Therefore, the superior fornix reconstruction, symblepharon lysis, amniotic membrane graft, excision of left upper eyelid lesion, and wedge excision for lid notching were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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 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 a medication increase, Humira injection pen (four pens per 28 days). Findings: The American College of Rheumatology (ACR) guideline for the treatment of rheumatoid arthritis, recommends the addition of a biologic disease-modifying antirheumatic drugs (DMARD), such as Humira, or a target synthetic DMARD, such as Xeljanz, for patients who have not achieved control with maximally tolerated doses of methotrexate. In this case, the patient is on methotrexate 15 mg weekly, with uncontrolled rheumatoid arthritis. The provider reported that the patients methotrexate dosage was being optimized. Given that ACR guidelines recommend optimizing the methotrexate dose while continuing Humira every other week, or two pens per month, the requested medication regimen is not medically indicated. Therefore, a medication increase, Humira injection pen (four pens per 28 days), is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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

Findings:  The physician reviewer found that an enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) (CPT 64566) received 6/16/21, 6/23/21, 6/30/21, 7/7/21, 7/14/21, 7/21/21, 7/28/21, 8/4/21 and going forward.According to the American Urology Association guidelines and current literature, the first-line treatments for patients with overactive bladders are behavioral therapies, followed by pharmacologic management. For patients who have failed behavioral therapies and pharmacologic management, such as intravesical botulinum injections, PTNS is the next non-surgical option for care. In this case, the patient has failed behavioral therapies and treatment with pharmacologic management, such as intravesical botulinum injections. Additionally, the patient has received PTNS, with no reports of adverse reactions. Therefore, PTNS (CPT 64566) received 6/16/21, 6/23/21, 6/30/21, 7/7/21, 7/14/21, 7/21/21, 7/28/21, 8/4/21 and going forward were and are medically necessary for treatment of the patients medical condition.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.