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

The patient has requested authorization and coverage for Xifaxan 550 mg. The records provided for review document that this patient has irritable bowel syndrome, diarrhea-predominant (IBS-D). The patients provider has recommended treatment with Xifaxan. Xifaxan is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with IBS-D. In addition, Xifaxan has been demonstrated to be safe and effective for the treatment of IBS-D in randomized placebo-controlled trials (Schoenfeld, et al.; Lembo, et al.). Moreover, the American College of Gastroenterology (ACG) guidelines state that Xifaxan is effective for use in patients with IBS (Ford, et al.; Cangemi and Lacy). Overall, the peer-reviewed medical literature and current guidelines support the use of Xifaxan dosed at 550 mg three times daily for 14 days in this patients clinical setting. For these reasons, the requested Xifaxan 550 mg is supported as 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 subspecialty 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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lyrica 200 mg. Cruccu notes that trigeminal neuralgia is characterized by recurrent brief episodes of unilateral electric shock-like pains, abrupt in onset and termination, in the distribution of one or more divisions of the trigeminal nerve root. The author notes that carbamazepine (brand name Tegretol) and oxcarbazepine (brand name Trileptal) are the recommended first choice for long-term treatment of trigeminal neuralgia. Bendsten and colleagues note that lamotrigine, gabapentin, botulinum toxin type A, pregabalin (brand name Lyrica), baclofen and phenytoin may be used either alone or as add-on therapy. When used as a third line agent, Lyrica is typically prescribed in an adjunctive role, to be taken daily, rather than as needed. In this case, the patient has diagnoses of trigeminal neuralgia and lumbar degenerative disc disease. While an undated letter from the provider reports that the patient is stable on Lyrica for their degenerative disc disease, notes reported that the patient was using Lyrica as needed to manage symptoms of trigeminal neuralgia. In this clinical setting, given the limited data in current medical literature supporting the use of Lyrica as needed for the treatment of trigeminal neuralgia, the requested medication is not medically indicated. Therefore, Lyrica 200 mg is not medically necessary for the 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 sub-specialty 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for RT300 neuromuscular functional electrical stimulation (NMES) therapy device (E1399). The RT300 NMES provides passive range of motion in patients with neurological weakness by using topical electrical stimulation leads to activate paralyzed limb muscles to drive a stationary cycle. Current data have not demonstrated that use of the RT300 NMES improves function or health outcomes in a clinically significant manner for patients with spinal cord pathology (Hofer and Schwab). The RT300 NMES device has not been shown to improve cardiovascular health, pulmonary health, or other health parameters to support its routine use (Ralston, et al.; Nardone, et al.; Soleyman-Jahi, et al.; Phadke, et al.; Farrow, et al.). The current guidelines and the medical literature does not include use of an NMES as part of the functional rehabilitation of patients with spinal cord injuries. The health and well-being in this patient population should be promoted with active exercise using volitionally intact arm muscles and active participation in educational, social, and recreational activities at a wheelchair level (Tweedy, et al.). All told, the requested RT300 NMES therapy device (E1399) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for spinal decompression surgery at bilateral L2, L3, and L4. This patient presents with low to mid lumbar spine pain with radiation and numbness down both legs with MRI findings of degenerative changes of the lumbar spine with associated spinal canal stenosis, neural foraminal stenosis, and nerve root impingement. The records do not include documentation of symptoms of spinal stenosis such as neurogenic claudication or electromyographic evidence of radiculopathy. The patients lack of response to epidural steroid injections suggests that nerve root compression is not the likely the source of their pain. The patients mechanical pain in the lower back is worse than the leg pain, which does not follow a radicular pattern. Machado and colleagues reported that there is a paucity of evidence demonstrating the clinical efficacy of surgery for lumbar spinal stenosis, particularly when the diagnosis is not supported by clinical features, as in this patients case. Moreover, the requested decompression procedure could lead to iatrogenic instability and/or worsening of the patients symptoms. Given these findings, the requested spinal decompression surgery at bilateral L2, L3, and L4 is 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for coronary artery tomography scan. This patient presented with a history of lipid levels within the familial hyperlipidemia range and a family history of sudden cardiac death in her mother, father, and brother. The patient underwent evaluation with coronary artery calcium scoring with coronary artery tomography. Based on current guidelines published by the American College of Cardiology (ACC) and American Heart Association (AHA), for patients with borderline or low 10-year atherosclerotic cardiovascular disease risk, coronary artery calcium scoring can provide valuable, actionable information (Greenland, et al.). When a patients coronary artery calcium score is zero, this obviates the need for lifelong statin therapy. Per Greenland and colleagues, scoring has emerged as a widely available, consistent, and reproducible means of assessing risk for major cardiovascular outcomes, especially useful in asymptomatic people for planning primary prevention interventions such as statins and aspirin. Given these findings, the coronary artery tomography scan 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 coronary artery tomography scan 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 reviewer 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology 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 Trulicity 3 mg/0.5 mL. Trulicity is a member of a class of diabetic medications, the glucagon like peptide-1 receptor agonists (GLP-1RA). The GLP-1RA medications help regulate insulin secretion in proportion to environmental glucose levels and may also have beneficial effects on the cardiorenal system including reducing cardiovascular risk and improving renal outcomes. Given the effectiveness for hemoglobin A1C reduction, GLP-1RA agents are recommended as the preferred injectable glucose-lowering therapy for patients with type 2 diabetes, even before insulin treatment. The records provided for review document that this patient has responded well to Trulicity for the past three years. In addition, the provider noted that the patient did not achieve ideal glycemic control on other diabetes medications in the past including Actos and Byetta. Based on the provided documentation and the available peer-reviewed medical literature, the requested Trulicity 3 mg/0.5 mL 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 diabetes, endocrinology, 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: An enrollee has requested authorization and coverage for Hyalgan injection series.Findings: 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. 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 lasting relief from viscosupplementation in the past, with the relief lasting one year. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, including physical therapy and platelet-rich plasma injections. The alternative is a total knee arthroplasty. Therefore, the requested Hyalgan injection series is medically necessary for the treatment of the patients medical condition.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:  An enrollee has requested authorization and coverage for hyaluronic acid injection.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. 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 patients options are limited. The patient has tried other conservative treatments, including corticosteroid injections, which provided little improvement. The alternative is a total knee arthroplasty in the presence of mild osteoarthritis. Therefore, the requested hyaluronic acid injection is medically necessary for the treatment of the patients medical condition.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 authorization and coverage for left knee Orthovisc (J7324) injections weekly for four doses. Findings:  The physician reviewer found that 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 osteoarthritis of the left knee. The patient has tried and failed conservative treatment, including a corticosteroid injection that only provided slight relief, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, left knee Orthovisc (J7324) injections weekly for four doses 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) services including physical therapy, occupational therapy and/or speech therapy. The records provided for review document that this patient has chronic, severe functional impairments that have not substantially improved despite therapy attempts in the past. Specifically, the patient has multiple insults to the brain, dementia, and hemiplegia. The patient has been in a custodial care setting for a long time. She is not functionally ambulatory and is dependent for most of her care. There is a lack of evidence to suggest that participation in physical, occupational and/or speech therapy will provide clinically meaningful functional gain. The patient has significant cognitive and physical impairments, which are not expected to improve given the severity of the insults she sustained, the duration of time that has passed since the insults were sustained, and the lack of meaningful response to the prior efforts at rehabilitation (Kua, et al.; Montero-Odasso and Speechley; Stocchetti and Zanier). More recently, she has been documented to have lower limb impairments that preclude safe standing or attempts at walking. Overall, the records fail to report any medical indications for SNF level of care nursing or therapy services. For these reasons, the requested SNF services including physical therapy, occupational therapy and speech therapy 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 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 MitraClip procedure. Findings:  The physician reviewer found that the requested percutaneous mitral valve repair with MitraClip is an acceptable treatment for this patients severe symptomatic mitral regurgitation. Per current American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, MitraClip is appropriate for severely symptomatic patients (NYHA class III or IV) with primary severe mitral regurgitation and high or prohibitive surgical risk, transcatheter repair is reasonable if mitral valve anatomy is favorable (Otto, et al.). This patient has severe symptomatic mitral regurgitation, NYHA class III-IV symptoms and is not an acceptable surgical candidate due to COPD, which places him at high risk for respiratory complications of surgery. Moreover, the patients provider has determined that the patient is an appropriate candidate for the MitraClip procedure. For these reasons, the requested MitraClip 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 MitraClip 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 internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology 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.