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 hyaluronan injections (Synvisc or Synvisc-One) to 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 benefit from prior viscosupplementation with Synvisc. The patient has tried and failed other conservative treatments. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, hyaluronan injections (Synvisc or Synvisc-One) to 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a LINX procedure. There is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. The American College of Gastroenterology (ACG) guidelines for the management of reflux disease note that while the LINX Reflux Management System has been approved by the U.S. Food and Drug Administration (FDA), more data is required before widespread usage can be recommended. Researchers concluded, Long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Likewise, a study reported that the long-term safety and efficacy of LINX  both alone and compared to current GERD therapies  remain to be determined. Researchers found that erosion of the LINX device is an important but rare complication to recognize. Researchers noted that LINX has significant potential adverse effects and may be associated with poorer outcomes. Therefore, a LINX procedure is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service is 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 internal medicine with sub-specialty 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency volumetric tissue reduction of the palatal tissues and tongue. Baba and colleagues report that temperature-controlled radiofrequency tissue ablation is clinically effective in reducing respiratory disturbance index levels and symptoms of sleepiness in patients with obstructive sleep apnea (OSA) syndrome when directed at the base of tongue or as a multilevel procedure. In this case, notes reported an apnea-hypopnea index (AHI) of 6. Notes reported that the patient had a history of mild OSA and had failed therapies with positive airway pressure (PAP) and oral appliance. The primary issues on drug-induced sleep endoscopy (DISE)  examination were tongue base and palatal issues. In this case, radiofrequency ablation of the tongue is a more effective method of treatment over standard PAP therapy, which the patient is unable to tolerate. Therefore, radiofrequency volumetric tissue reduction of the palatal tissues and tongue is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested radiofrequency volumetric tissue reduction of the palatal tissues and tongue 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 service is 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 reviewers 1 is board certified in otolaryngology with sub-specialty certification in neurotology and is actively practicing. Physician reviewers 2 and 3 are board certified in otolaryngology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested reimbursement for Guardant 360 CDx Molecular Pathology Testing. Numerous gene alterations have been identified that impact therapy selection for the treatment of non-small cell lung cancer (NSCLC). The National Comprehensive Cancer Network (NCCN) guidelines for NSCLC advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Rolfo and colleagues report that the isolation and analysis of circulating cell-free tumor DNA in plasma is a powerful tool with considerable potential to improve clinical outcomes across multiple cancer types, including NSCLC. This type of testing may be considered in specific clinical circumstances, including if a patient is unable to undergo invasive tissue sampling in the initial diagnostic setting, or if following pathologic confirmation of a NSCLC diagnosis there is insufficient material for molecular analysis, and if follow-up tissue-based analysis is planned if an oncogenic driver is not identified. Thus, the testing at issue was likely to identify potentially efficacious targeted therapies as well as to identify therapies to be avoided as unlikely to provide clinical benefit. Therefore, Guardant 360 CDx Molecular Pathology Testing was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Guardant 360 CDx Molecular Pathology Testing at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been 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 reimbursement and prospective authorization and coverage for (1) Orthovisc injection series in the left knee and (2) Orthovisc injection series in the right knee. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injection series. The patient has tried and failed other conservative treatments including NSAIDs, corticosteroid injections, and physical therapy. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, (1) Orthovisc injection series in the left knee and (2) Orthovisc injection series in the right knee was and is 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 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 XHANCE nasal spray. In a study with 223 patients with chronic rhinosinusitis treated with an exhalation delivery system with fluticasone (EDS-FLU), researchers report that most patients reported symptom improvement, and that in patients with nasal polyps, 54% had polyp elimination in at least one nostril and 83% had an improvement in polyp grade. Medical literatures conclude that in patients with chronic rhinosinusitis with nasal polyps who were symptomatic despite high rates of prior intranasal steroid use and/or surgery, EDS-FLU produced statistically significant and clinically meaningful improvements compared to placebo in multiple subjective and objective outcomes. Likewise, researchers state that EDS-FLU produces clinically and statistically significant improvement in all four diagnostically defining disease symptoms, polyp grade, and quality of life in patients with chronic rhinosinusitis with nasal polyps. In this case, given the patients history of nasal polyposis in the setting of sinusitis, the requested medication is medically indicated. Therefore, XHANCE nasal spray 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 allergy and immunology 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 mepolizumab (Nucala) 300 mg subcutaneously, every four weeks for one year. Findings:  The physician reviewer found that Mazori and colleagues report that eosinophilic fasciitis is a fibrosing disorder, and that first-line treatment is with systemic corticosteroids. The authors report that in a search for adjunctive therapies, methotrexate has emerged as the leading corticosteroid sparing agent for the treatment of eosinophilic fasciitis. Due to the rarity of eosinophilic fasciitis, there is a lack of randomized trials on therapies for the treatment of this condition. While there is support in current medical literature for first-line treatment with high dose system steroids, followed by immunosuppressive therapies including methotrexate, Cellcept, azathioprine, cyclosporine and even biologics such as infliximab and tocilizumab, there is a lack of evidence supporting the successful use of mepolizumab (Nucala) in the treatment of eosinophilic fasciitis. Therefore, mepolizumab (Nucala) 300 mg subcutaneously, every four weeks for one year, 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 internal medicine with sub-specialty certification 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for mastectomy/nipple reconstruction surgery (CPT codes 15839 - excision excessive skin & subcutaneous tissue other area x 1; 19350 - nipple/areola reconstruction x 1; 19303 - mastectomy simple complete x 1; 15200 - full thickness graft, free w/direct closure trunk 20 cm x 2). Chest surgery in transgender male minors is a common treatment for gender dysphoria. The World Professional Association for Transgender Health (WPATH) states, Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. Olson-Kennedy and colleagues reported that chest surgery in transgender youth and males is a safe and effective treatment for gender dysphoria, noting, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. While the criteria note a preference for one year of testosterone treatment, the guidelines also recognize that different approaches may be more suitable, and that the judgment regarding the patients readiness should be up to the treating providers. In this case, the patient has a diagnosis of gender dysphoria whose provider has recommended the requested service. Therefore, mastectomy/nipple reconstruction surgery (CPT codes 15839 - excision excessive skin & subcutaneous tissue other area x 1; 19350 - nipple/areola reconstruction x 1; 19303 - mastectomy simple complete x 1; 15200 - full thickness graft, free w/direct closure trunk 20 cm x 2) is medically necessary to promote physical and mental health and efficiency.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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections to be administered every 10 weeks.The International Headache Societys International Classification of Headache Disorders (ICHD) defines chronic migraine as headache occurring on greater than 15 days per month for greater than three months, which is not attributable to another disorder, and which has at least two characteristics of unilateral, pulsatile, moderate to severe in intensity, or aggravation by or causing avoidance of routine physical activity. Additionally, ICHD diagnostic criteria require that there must be one characteristic of nausea and/or vomiting, photophobia and phonophobia. Botox is a tool in the management of chronic migraine which has shown effectiveness in the PREEMPT trials. The PREEMPT 1 trial showed that significant reductions from baseline were observed for onabotulinumtoxinA (Botox) for headache and migraine days, cumulative hours of headache on headache days, and frequency of moderate/severe headache days, which in turn reduced the burden of illness in adults with disabling chronic migraine. The results of the PREEMPT 2 demonstrated that onabotulinumtoxinA was effective for prophylaxis of headache in adults with chronic migraine, and that repeated onabotulinumtoxinA treatments were safe and well tolerated. Both of these trials were designed, however, with twelve-week intervals between Botox administration. As of a result of these studies, Botox was approved by the Food and Drug Administration (FDA) for use in prophylactic management in chronic migraine. Therefore, the strongest evidence of Botox use is at the 12-week interval at which the trials were performed that supported FDA approval. Evidence supporting the use of Botox at alternative doses and frequencies is limited at best. Accordingly, the requested Botox injections to be administered every 10 weeks is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services 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 neurology, with subspecialty certification in vascular neurology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy. Medical literatures note that obesity remains a continuing global health concern, as it is associated with increased risk of numerous chronic diseases, including type 2 diabetes, hypertension, and cardiovascular disease. The authors further note that while lifestyle modification is recommended as the cornerstone of obesity management, as many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss, there are currently multiple pharmacologic therapies which are available for weight management. Researchers report that glucagon-like peptide-1 (GLP-1) analogs, such as Wegovy, improve glycemic control, reduce body weight, and decrease cardiovascular risk. Researcher notes that GLP-1 receptor agonists have an established efficacy and safety profile. Given that current medical literature supports the use of the Wegovy in promoting weight loss and the low likelihood of health risks associated with this medication, the requested medication is medically indicated. Therefore, Wegovy 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: The patient has requested authorization and coverage for Nurtec ODT. Findings:  The physician reviewer found that records provided for review document that this patient has been treated with several medications without appropriate relief of her migraines. The provider charted that the patient has failed to respond to treatment with Botox, celecoxib, pregabalin, gabapentin, and topiramate, among other agents. The patients current regimen including Nurtec has helped decrease the frequency of her migraines from 20 or more headache days per month, to about eight per month. The patients provider has recommended treatment with (rimegepant) Nurtec ODT. Migraine is a neurological disease with several treatment options. Nurtec is from the calcitonin gene-related peptide receptor (CGRP) antagonist family of medications. Several studies have demonstrated the safety and efficacy of Nurtec in the treatment of patients with migraine. Croop and colleagues found that Nurtec was more effective than placebo in the management of patients with acute migraine. In addition, the available evidence regarding Nurtec has garnered U.S. Food and Drug Administration (FDA) approval for the treatment of patients with migraine. Given this support, the requested Nurtec ODT 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 neurology with subspecialty certification in vascular neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.