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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral facet joint injection at three (3) levels (CPT 64493, 64494, 64495, HCPCS J1100). Authors studied the effectiveness of different lumbar facet blocks, concluding, This study establishes that facet blocks are not therapeutic. The higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation. Researchers supported the use of lumbar facet joint nerve blocks as a diagnostic tool, while evidence for therapeutic facet joint interventions was limited for intraarticular injections. In this case, the patient had low back pain without radiation into the lower extremities. Her physical examination findings were notable for lumbar paraspinal tenderness and a limited range of motion with lumbar extension. There was no documentation that the recommended bilateral lumbar medial branch blocks of L3-4 to L5-S1 were for diagnostic purposes to evaluate for a future radiofrequency ablation procedure at these levels. Rather, the provider notes suggest that these injections are intended for therapeutic purposes only. Based on the current medical literature and this patients medical records, the requested services are not medically indicated. Therefore, bilateral facet joint injection at three (3) levels (CPT 64493, 64494, 64495, HCPCS J1100) are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are 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 anesthesiology with sub-specialty certification in pain 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: This is a female with diagnoses of seizures, Raynauds phenomenon, asthma, and systemic lupus erythematosus (SLE). The patients record reports she is allergic to methotrexate (itching) and Plaquenil (rash and tongue swelling). She was doing well and decided with the rheumatologist to wean off the use of Benlysta. However, the record reports that her lupus symptoms of fatigue, aching and malar rash slowly increased, and after ruling out an infection, the rheumatologist recommended that the patient restart Benlysta. At issue is whether the requested medication, belimumab (Benlysta) 200 mg/ml, is medically necessary to treat the patients medical condition. The treating rheumatologist documented that despite a negative antinuclear antibody test and anti-double stranded DNA test, the patient has SLE with arthritis, oral ulcers, malar rash, leucopenia, Raynauds phenomenon and positive SSB antibody testing. The patient cannot use methotrexate or Plaquenil and has received Benlysta in the past with good results. Her SLE has worsened off Benlysta, and she is requiring prednisone. The FDA labeled indication for Benlysta is as follows: Benlysta is indicated for the treatment of patients aged 5 years and older with active, autoantibody positive, SLE who are receiving standard therapy. The patients clinical picture is consistent with an SLE diagnosis. There is no evidence for active renal or central nervous system disease, where Benlysta does not work. She has received standard therapy and is on prednisone, and cannot take methotrexate or Plaquenil due to allergies. Benlysta is appropriate for this patient.  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 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 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 Saxenda 18 mg/3 mL pen injector. Saxenda is a glucagon-like peptide-1 (GLP-1) receptor agonist that, in addition to stimulating insulin release and inhibiting glucagon secretion, slows gastric emptying and increases satiety after eating. It is labeled as an adjunct to diet and exercise for weight management in overweight or obese adults. This medication is recommended for patients that have features of the metabolic syndrome or insulin resistance syndrome, which this patient has. Hyperlipidemia and hypertension can be improved with weight loss. Researchers performed a study on obese/overweight individuals who lost at least 5% of initial weight during a low-calorie diet. The individuals were randomly assigned to liraglutide 3.0 mg per day or placebo for 56 weeks. The authors noted, Liraglutide, with diet and exercise, maintained weight loss achieved by caloric restriction and induced further weight loss over 56 weeks. Improvements in some cardiovascular disease-risk factors were also observed. Researchers performed a study on adults with a BMI from 30 to 40. The authors noted, Liraglutide is well tolerated, sustains weight loss over two years and improves cardiovascular risk factors. In this patients case, phentermine is not recommended due to hypertension. Given the patients BMI of 29.4 kg/m2 with comorbidities of hypertension and hyperlipidemia, the requested medication is medically indicated. Therefore, Saxenda 18 mg/3 mL pen injector is medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, 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: This dermatologist diagnosed the patient with chronic ulcerative colitis that is being treated with Humira since 2015, and that psoriasis is listed as a side effect of Humira. Further notes report that the patient has greater than 20% body surface involvement with active, scattered psoriasis. The physician reports that Otezla samples tried in August 2019 were beneficial and recommends that Otezla treatment for psoriasis continue, along with Humira for her colitis. At issue is whether the requested medication, Otezla 30 mg tablets, is medically necessary to treat the patients medical condition. A known side effect of Humira is plaque type psoriasis, which this patient has acquired. Otezla has been effective for this patients psoriasis. The patient is not being treated with Humira for psoriasis; she is being treated with Humira for ulcerative colitis. Humira and Otezla are being used for two different conditions. Literature reports that Otezla can safely be combined with biological medications, such as Humira, for patients with psoriasis.  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 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 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 laparoscopy, surgical, gastric restrictive procedure (CPT 43775), laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed (CPT 43281), and esophagogastroduodenoscopy (CPT 43239). The records support a diagnosis of obesity in this patient with a body mass index (BMI) between 37.6 kg/m2 and 41.3 kg/m2. The patient has requested bariatric surgery. Part of the standard evaluation for bariatric surgery involves a psychological evaluation. The patient underwent a psychological evaluation in December 2019. The provider recommended that the patient see a psychiatrist to consider medications and to repeat the psychological evaluation to determine appropriate candidacy for surgery. Her provider recommended six months of nutritional counseling. The records document that the patient has completed two months of nutritional counseling. The patients nutritional counseling notes suggest that she is not an appropriate surgical candidate at this time. Based on the available documentation, the requested laparoscopy, surgical, gastric restrictive procedure (CPT 43775), laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed (CPT 43281), and esophagogastroduodenoscopy (CPT 43239) are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are 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 surgery with expertise in minimally invasive and bariatric 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: This is male with hypertension, gastric reflux, degenerative arthritis of the spine, and irritable bowel syndrome. The patients primary care physician (PCP) reports he is being seen for ongoing back pain and medication management. Naproxen 375 mg twice a day for 15 days was ordered, as well as salicylate-menthol ointment for relief of back pain three times day. The PCP stated in the requests for diclofenac sodium 3% gel that the patient has persistent symptoms of back pain that have not responded to or been tolerated (stomach upset), with ibuprofen, aspirin, Tylenol, Bio Freeze topical and naproxen. At issue is whether Diclofenac Sodium 3% Gel is medically necessary to treat the patients medical condition. The patients medial records document one 15-day trial of naproxen for relief of back pain. The treating physician writes that ibuprofen and naproxen were not effective and/or resulted in stomach upset. No other NSAIDs were prescribed, prior to prescribing the requested Diclofenac Sodium 3% Gel. Literature reports that topical NSAIDs, including topical diclofenac sodium 3% gel used on patients with OA of the hands or knees, provide similar pain relief, improvement in physical function, and reduction of stiffness compared with oral NSAIDs in patients with OA of the hands or knees, and have fewer systemic adverse events. The FDA reports that diclofenac sodium 3% gel is indicated for the relief of osteoarthritis joint pain of the knees and hands. However, diclofenac sodium 3% gel has not been evaluated and approved for use on joints of the hip, shoulder or spine. The patient is being treated for arthritis of the spine, and therefore, diclofenac sodium 3% is not appropriate for his condition. Based on FDA recommendations and documentation in the medical records provided, the requested medication is not indicated for this patient for treatment of the spine. 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 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 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 fecal pancreatic elastase (EL-1) laboratory testing (CPT 82656). This patient presented with lower abdominal cramping and a provisional diagnosis of irritable bowel syndrome. The patient was assessed for infectious pathogens such as giardia and Clostridium difficile, which were ruled out. Her systemic inflammatory markers were low and celiac disease was excluded based on serology. Fecal elastase-1 is the most sensitive and specific indirect test of pancreatic function. Fecal elastase-1 is an enzymatic product of pancreatic secretion that remains relatively stable during transport through the gastrointestinal tract. There is a direct correlation in pancreatic elastase-1 concentrations in pancreatic fluid and stool. The sensitivity of fecal elastase-1 for mild, moderate, and severe exocrine pancreatic insufficiency in patients with chronic pancreatitis are 63, 100, and 100%, respectively. Fecal elastase has a specificity of 93% in patients with exocrine pancreatic insufficiency. All told, the fecal pancreatic elastase (EL-1) laboratory testing (CPT 82656) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the fecal pancreatic elastase (EL-1) laboratory testing (CPT 82656) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Spravato intranasal spray treatment. An author noted, Treatment- resistant depression is a prevalent, disabling, and costly condition affecting 1% to 4% of the U.S. populationContinued depressive symptoms are associated with ongoing functional impairmentand a greater risk of suicide and overall increased mortality. Treatment-resistant depression is defined as failure of at least two antidepressant treatments of adequate dose and duration. In this patients case, he has been on adequate doses of both Trintellix and Remeron. He has also had a sufficient trial of Pristiq, and continues to have severe depressive symptoms. As such, he meets diagnostic criteria for treatment-resistant depression. Per the provider, genetic testing supported that Pristiq is the best fit from a gene-medication interaction. This further supports need for more aggressive treatment, as he has failed a sufficient trial of Pristiq. This patient is not a candidate for transcranial magnetic stimulation, and he has been medically cleared for Spravato. Therefore, Spravato intranasal spray treatment 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/upheld.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Intracept procedure. Although there are conservative nonsurgical treatments for chronic low back pain, in certain refractory patient populations, there are limited options for highly effective and sustained relief. This patient presents with a history of chronic low back pain without radiculopathy for at least 18 months. The provider reported that the patient has tried a number of modalities to improve his pain without sustained success. The provider noted concern about chronic use of non-steroidal anti-inflammatory drugs (NSAIDs) and opioid dependence. The patient previously underwent a facet rhizotomy with reported improvement, indicating that at least some of his pain syndrome appears to be facet-mediated. However, the provider did not report the extent of improvement or whether repeated injections were performed. The records lack recent MRI findings to support an indication for surgical intervention. Specifically, there is no recent report of substantial degenerative changes at other levels (Modic changes). In addition, there is no documentation of dynamic x-rays to rule out instability as a potential pain generator. Moreover, there is a paucity of data in the peer-reviewed medical literature establishing a clinical role for the Intracept procedure for the treatment of chronic low back pain. Based on the records provided for review, the requested Intercept procedure is not 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 Intercept procedure 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 services are 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. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurological surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Botox injections. The patient has been diagnosed with migraine headaches associated with visual disturbances. Prior treatment with Propranolol caused side effects that required an emergency room treatment for hypotension and bradycardia. The provider noted that the patient has been unable to tolerate other abortive medications for headache management. The patient reported that treatment with Zoloft has minimized her headaches, but not completely resolved them. The current peer-reviewed medical literature supports the use of Botox for the management of migraine headaches that have been refractory to other traditional therapies. Researchers concluded that the available clinical trial data has demonstrated that Botox is an effective and well-tolerated treatment modality for the prevention of chronic migraine, especially for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. Given these findings, the Botox injections 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 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 the S-ICD System subcutaneous implantable cardioverter defibrillator (CPT 33270). S-ICD lead placement is a reasonable and recommended option in patients with vascular access issues. Younger, active patients have a higher likelihood of an intravascular lead failure sometime during their lifetime, requiring lead extraction and replacement with the associated risks attached. The current medical evidence supports the safety and efficacy of the requested device in this clinical setting. In this case, the patient has a definitive indication for prophylactic implantable cardioverter-defibrillator (ICD) implantation for treatment of hypertrophic cardiomyopathy under guidelines from the American Heart Association (AHA), American College of Cardiology (ACC), and Heart Rhythm Society (HRS) based on a family history of sudden death and late gadolinium enhancement. Due to her young age and active lifestyle, with a conventional ICD lead, the patient is likely to be at a higher risk of ICD lead failure or fracture, requiring lead extraction and the substantial additional risks related to extraction and replacement. Based on the current medical literature and this patients specific clinical situation, the requested device is medically indicated. Therefore, the S-ICD System subcutaneous implantable cardioverter defibrillator (CPT 33270) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 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.