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 Acthar Gel.Acthar is FDA approved for treatment of proteinuria associated with nephrotic syndrome. There are numerous published case reports (series) of clinical response to Acthar in IgA nephropathy. Zand and colleagues conducted a prospective open-label pilot study and concluded that patients with IgA nephropathy with proteinuria >1 g/24-hour and estimated glomerular filtration rate (eGFR) >30 ml/min had a significant reduction in 24-hour urinary protein with stable eGFR at 12-month follow-up after being treated with 6 months of Acthar Gel. Prasad and colleagues also conducted a study that concluded that Acthar is an effective agent that is well tolerated with minimal side effects and can be used as an alternative to prednisone in patients with IgA nephropathy. In this case, the patient has proteinuria and IgA nephropathy that has proven refractory to conventional therapy. Under these circumstances, the requested Acthar Gel is medically necessary to treat 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 subspecialty certification in nephrology, 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 left gonadal vein embolization procedure (CPT code 37241). This patient has clinical findings and imaging studies suggestive of pelvic congestion syndrome. There is limited data regarding the standard of care or optimal strategy to manage this diagnosis. For women with pelvic congestion syndrome, invasive treatment is an appropriate option. Case reports have shown the benefit of this procedure although these studies are difficult to compare due to varying diagnostic criteria and techniques for treatment. Despite these limitations, the reported technical and clinical success rates of ovarian vein embolization is up to 100%, with 53% of patients reporting no pelvic pain and 47% noting a reduction in pelvic pain at one-year follow-up. Gonadal vein embolization is safe, well tolerated, and allows for a minimally invasive approach. Given this support, the requested left gonadal vein embolization procedure (CPT code 37241) 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 left gonadal vein embolization procedure (CPT code 37241) 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 reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for hemoglobin meter for home use. This patients records document hematologic complications of pancytopenia, which is likely a major component of her lupus exacerbation. Adequate monitoring involves more than just hemoglobin monitoring. Researchers noted that as progressive anemia can be multifactorial in lupus, disease activity monitoring should involve more than just hemoglobin monitoring. The authors discussed that the current standard of care for lupus monitoring include full blood count, serum creatinine and albumin, C-reactive protein, and estimated glomerular filtration rate (eGFR). There is a paucity of data in the medical literature demonstrating that home monitoring of this patients hemoglobin will be more effective in managing her condition than standard of care recommendations. Therefore, the requested hemoglobin meter for home use 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 device 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 reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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

The enrollee is requesting authorization and coverage for Belsomra, 10mg at bedtime (30 tablets/30 days). The enrollee has a medical history of postural orthostatic tachycardia syndrome, connective tissue disease, Raynauds syndrome, fibromyalgia, migraines, and insomnia. The medications that the enrollee took were ineffective, resulted in side effects, or caused withdrawal symptoms. The enrollee reports that Belsomra is one of the only sleep medications that have effectively helped her sleep without side effects. A recently published, randomized crossover study showed the use of Belsomra in fibromyalgia enrollees increased sleep time and reduced wake-after-sleep onset, compared to placebo. As she has tried so many medications, including those on the approved medication list, and has tolerated and benefited from Belsomra, it is appropriate for her to take Belsomra. It does have potential addiction problems, but she has not displayed any such tendency.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 internal 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage, and reimbursement, for inpatient hospitalization services. The enrollee has a history of major depression, recurrent, severe, and anorexia nervosa. The enrollee reports residential and outpatient treatment in the past. She entered the inpatient level of care for treatment of her eating disorder. She reported struggling with anxiety and panic attacks, and admitted to daily use of marijuana. She reported purging five to six times per day. The enrollees provider reports the enrollee required around-the-clock monitoring for safety and for proper nutritional intake. This enrollee met criteria for inpatient level of care. Her ideal body weight was significantly below 85 percent, and continued to decline. She has comorbid psychiatric disorders, suicidal ideation and ongoing self-injurious behaviors. Due to multiple daily purging episodes, she requires supervision during and after meals. Considering her relationship with parents and lack of friends, she does not have a good support system.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for 30 excimer UVB laser phototherapy sessions. The enrollee has vitiligo. She has hypo-pigmented, non-scaly patches to her upper and lower eyelids, face, inner thighs, hips, trunk, arms, legs, and feet. Her physician reports a 75 percent improvement. Thirty additional sessions have been requested to achieve 100 percent clearance. A review of monochromatic excimer laser for vitiligo showed the excimer laser is effective in adults and children with vitiligo of all skin types; either as monotherapy or in combination with other established treatments. Researchers report the excimer laser has governmental approval for the treatment of psoriasis and vitiligo. Researchers indicate the treatment is generally well tolerated, with few adverse reactions.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollees parent requested reimbursement for a tryptase blood test. The enrollee was evaluated for food allergies. She had developed hives after eating bananas, and again after being bathed with a body wash that contained corn. The enrollee was prescribed an epinephrine injectable and scheduled for food allergy testing. She then underwent a Tryptase blood test. Literature reports tryptase testing is indicated for the evaluation of acute anaphylaxis and mast cell disorders. This enrollee has no indications of either of these; therefore, tryptase was not likely to be more beneficial than any other available treatment.Final Result: Three of the three reviewers determined that the requested service was not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in allergy and immunology and are actively practicing.  All three 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

The patient has requested authorization and coverage for breast implants removal surgery. The World Professional Association for Transgender Health (WPATH) states that medically necessary treatment for gender dysphoria includes chest reconstruction or augmentation as appropriate for each patient. Approximately 2% of transgender patients who surgically transition later detransition and some seek medical and surgical treatment to reduce gender dysphoria in detransitioning. This patient has a history of transitioning from male to female with placement of bilateral breast implants. Now that the patient has returned to living as male, he has gender dysphoria about his female-appearing breasts. Chest reconstruction is appropriate for this patient. The requested removal of implants for reconstruction of a male chest is likely to address the patients gender dysphoria related to the presence of female-appearing breasts. For these reasons, the requested breast implants removal surgery is medically necessary for 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 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: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for Synvisc-one injection in the right knee. The enrollee has a history of osteoarthritis of the right knee. He underwent a right knee arthroscopy, with a partial medical meniscectomy, and a left total knee replacement, after which he developed blood clots. His pain is aggravated by prolonged standing and walking. He has received Synvisc-one gel injections in the past. A professional society reports the use of intra-articular hyaluronic acid injections is indicated for the treatment of osteoarthritis in the knee in adults who are not good surgical candidates or who do not respond to other treatment options. This enrollees medical records show considerable arthritis in both the medial and lateral compartments. The enrollee has also failed previous non-surgical treatment; including arthroscopic surgery. The requested Synvisc-one injection is a qualified non-surgical option to help avoid a total knee arthroplasty for this enrollee at this time.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for the Afrezza titration pack, 3 boxes for 30 day supply (270 of the 4 unit cartridges and 270 of the 8 unit cartridges). The patient was diagnosed with type I diabetes at an early age. The provider reports the patient had quick correction of hyperglycemic and lower risk of hypoglycemia while on Afrezza. In order for Afrezza to be considered for treatment, it is important that clinicians perform a detailed medical history, physical examination, and testing of forced expiratory volume in all patients to identify preexisting lung disease. While the prior authorization form states the patient does not have lung disease and forced expiratory volume testing has been done, the medical records do not support this statement. Literature reports Afrezza should not be recommended for patients with asthma, chronic obstructive pulmonary disease or who smoke. Literature indicates Afrezza is contraindicated in patients with chronic lung disease because of the potential for acute bronchospasm.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 endocrinology 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: An enrollee has requested authorization and coverage for the medication Victoza (3 pens/30 day supply).Liraglutide (Victoza) is widely used for the treatment of type 2 diabetes mellitus. Researchers have noted that pharmacodynamic studies show multiple beneficial actions with liraglutide, including improved fasting and postprandial glycaemic control (mediated by increased insulin and reduced glucagon levels and minor delays in gastric emptying), reduced appetite and energy intake, and effects on postprandial lipid profiles. They have noted that the effects of liraglutide on insulin and glucagon secretion are glucose dependent, and hence the risk of hypoglycaemia is low. Researchers conducted a trial and concluded that liraglutide significantly improved glycaemic control compared to placebo in patients with type 2 diabetes, insufficiently controlled with sodium-glucose cotransporter-2 inhibitors (SGLT2is) with or without metformin, with no unexpected safety findings. Cardiovascular studies have also shown beneficial results in patients with diabetes type 2 treated with liraglutide.In this case, the patient has type 2 diabetes that has been treated with metformin, liraglutide (Victoza) and Lantus insulin from at least 2017 (3 years). The patient and her doctor report prior treatment with other GLP-1 receptor analogs, with historically reported side effects and adverse reactions. The patient has responded to well to Victoza and has been on this medication for many years. There is no medical basis in the submitted documentation to subject the patient to change at this time to another GLP-1 medication that could give her an adverse effect and adversely affect her diabetes control. Accordingly, the requested medication Victoza (3 pens/30 day supply) is medically necessary to treat 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 subspecialty 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

The patient has requested authorization and coverage for a series of three (3) injections of Gelsyn-3 to both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of chronic bilateral knee pain due to osteoarthritis. The patient has tried and failed non-steroidal anti-inflammatory drugs (NSAIDs) but experienced an excellent response to prior viscosupplementation with pain relief and functional improvement. Furthermore, the patients treatment options are limited with the alternative being bilateral total knee arthroplasties. Given these findings, a series of three (3) injections of Gelsyn-3 to both knees is medically necessary for 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for left breast oncoplastic reconstruction and contralateral right reduction mammoplasty. The patient presents significant abnormalities related to non-malignant disease. Her provider has recommended breast surgery to alter the contour of the breast given the severity of the deformity. Given the size of this area of enhancement, the patient would have significant deformity following partial mastectomy. The requested procedures are reconstructive in nature for treatment of this patient. The patients condition constitutes an abnormal structure of the body related to tumor or disease. In this case, there are inconclusive BRCA genetic results. The patient has an atypical lobular hyperplasia, which is significant in relation to the patients breast size. The requested procedures are being requested to create a more normal appearance to the extent possible. The surgery will likely provide more than a minimal improvement in the appearance of the patient as the large nature of the tumor has resulted in significant deformity of the breast and significant asymmetry with the opposite breast. All told, the requested left breast oncoplastic and contralateral right reduction mammoplasty are medically necessary and reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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.