Persius/hicric huggingface dataset:
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 accessories (HCPCS E1399 x 20) for an approved pediatric standing frame. The available documentation indicates that this patient presents with Pallister-Killian syndrome, which is a multi-system disorder that is characterized by hypotonia in infancy and early childhood. The patients provider has recommended use of a standing frame and related accessories. The current positioning methods for young patients with hypotonia and delayed motor development include use of weight bearing, standing, and mobility devices. Use of these devices depend on a patients ability to maintain a safe posture and functional alignment of the spine, pelvis, and extremities, as well as the risk of complications from their underlying medical condition. Current research has demonstrated that developmental benefits including social, language, and cognitive skill development, may be observed in young patients with motor disability who use standing and related accessories. In a cohort of children with motor delays the usual method of positioning needs to be the most efficient one for everyday tasks and environmental conditions (Paleg, et al.). In this patients case, the accessories are a crucial part of safe positioning and appropriate alignment of body parts, including trunk, pelvis, hips, knees and ankles. Given this support, the requested accessories (HCPCS E1399 x 20) for an approved pediatric standing frame are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested accessories 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. The records provided for review document that this patient was hospitalized after collapsing following a period of self-neglect, including severely reduced food intake. The patient was medically stabilized and functionally improved over a prolonged period of time, to ambulating household distances with a walker with stand-by assistance to supervision level. By the date of the Health Plans denial, the patient continued to require some ongoing physical assistance for self-care tasks, but this level of assistance could have been provided in the community. The patient did not require ongoing rehabilitation, skilled nursing services, or medical care in a SNF. The patient was able to undergo routine blood tests to monitor for anemia on an ambulatory basis. The patient has a history of chronic hip pain and was scheduled for an upcoming hip replacement, which is an elective intervention for end stage osteoarthropathy failing conservative care. The patient has not required SNF services to await hip replacement surgery. All told, the SNF services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a pulmonary function test (PFT) at a tertiary level of care. Wanger and Culver report that most, if not all, hospitals and many clinics and doctor offices now have a PFT laboratory that is staffed with technicians who are trained to use the instrumentation, provide instruction to patients, and assure that quality data has been obtained. The authors further report that simple and more complex PFTs have become more accurate, faster, and more sophisticated. Given that a PFT performed at the community hospital is likely be of the same quality as that done a tertiary level of care due to the wide availability, standardization, and universal quality measures, the requested service is not medically indicated.  Therefore, a PFT at a tertiary level of care is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for evaluation 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 certifications in pulmonary disease and in critical care 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: The patient has requested authorization and coverage for Supartz injections in both knees. The submitted documentation supports the medical necessity of the requested services. 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. 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, there is a history of lasting benefit from prior injections of Supartz in both knees. Therefore, the requested Supartz injections in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for artificial disc replacement at C5-6 and C6-7. Davis and colleagues performed a prospective, randomized, controlled multicenter clinical trial on patients with two-level symptomatic degenerative disc disease treated with cervical arthroplasty versus those who underwent two-level anterior cervical discectomy and fusion. The authors reported that their findings supported the use of cervical arthroplasty at two contiguous levels given the advantages over two-level anterior cervical discectomy and fusion. Coric and colleagues reviewed a prospective, randomized, controlled multicenter investigational device exemption clinical trial and concluded that total disc replacement was superior to anterior cervical discectomy and fusion for the treatment of patients with two-level contiguous pathology at five-year follow-up. This patient is being treated for cervical spondylotic radiculopathy with evidence of disc degeneration and stenosis at C5-6 and C6-7. The patients provider has recommended treatment with artificial disc replacement at C5-6 and C6-7. However, the imaging studies, including MRI and x-rays of the cervical spine demonstrated degenerative disc disease at C5-6 and C6-7 without compromise of the neural elements. MRI of the cervical spine was reviewed, including the amendment. The findings state no change. There is evidence of a previous anterior fusion at C4-5 and the imaging states the fusion is solid without evidence of any hardware or graft complications. There is limited evidence for any nerve impingement to support the need for the requested artificial disc replacement procedure. Additionally, there is limited published, large-scale, long-term peer-reviewed medical literature that shows artificial disc replacement next to a previously fused level to be an effective and safe treatment. Therefore, the requested artificial disc replacement at C5-6 and C6-7 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for positron emission tomography (PET) imaging. Findings: Based on the review of the peer-reviewed medical literature and guidelines, there is adequate evidence supporting the use of PET for significant modification in the initial staging of patients with newly diagnosed breast cancer. Per the National Comprehensive Cancer Network (NCCN) guidelines and American College of Radiology (ACR) recommendations, PET is an appropriate diagnostic test for initial tumor work-up when standard staging studies are equivocal or suspicious, or to identify regional nodal disease or distant metastasis. One study noted that PET imaging is best suited for patients who have at least Stage 2 breast cancer. The records provided for review document that this patient presented with Stage 2a breast cancer. The patient underwent evaluation with PET imaging. In this clinical setting, the utility of PET imaging was consistent with the current recommendations for evaluation and treatment of this patient. Therefore, the PET imaging was medically necessary for this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in radiology, with subspecialty certifications in diagnostic radiology, and vascular and interventional radiology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dosage escalation for Stelara 90 mg every four weeks. The peer-reviewed medical literature supports the requested dose escalation of Stelara to 90 mg every four weeks for management of this patients Crohns disease. The records document that the patients colonoscopy demonstrated findings consistent with active Crohns disease while on Stelara 90 mg every six weeks. Current data from clinical trials and studies have demonstrated the safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that is resistant to anti-tumor necrosis factor (TNF) therapy (Tuskey and Behm). Kopylov and colleagues found that Stelara induced a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of the responders maintained remission for one year. Additional studies have shown that a majority of patients responded well to Stelara dosing every four weeks after failing to symptomatically improve with dosing every eight weeks (Battat, et al.; Khorrami, et al.). In this case, the patient experienced disease symptoms and objective active disease on colonoscopy while being treated with Stelara every six weeks. The American College of Gastroenterology (ACG) guidelines for the treatment of patients with Crohns disease supports medication dose adjustments in order to attempt to optimize therapy for patients with suboptimal control of symptoms. (Battat, et al.). Furthermore, continuation of dosing every six weeks or a change to another medication may result in complications for this patient. For these reasons, the requested dosage escalation for Stelara 90 mg every four weeks is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication dosage 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Rituxan. There are several standard treatments for systemic lupus erythematosus that are steroid sparing agents permitting the safe discontinuation of chronic steroid use, including azathioprine, CellCept, Benlysta, and Saphnelo. Al-Adhoubi and Bystrom note that rituximab may sometimes be used for the treatment of disease manifestations such as refractory lupus nephritis or in the setting of diffuse alveolar hemorrhage due to systemic lupus erythematosus. However, in this case, the submitted records do not demonstrate that the patient has refractory lupus nephritis or active alveolar hemorrhage. Notes indicated that the patients systemic lupus erythematosus was clinically stable. The records do not document that the patient had tried and failed, or a reason why the patient had not been treated with, standard treatments other than hydroxychloroquine. The records noted concern regarding persistently elevated antiphospholipid antibodies including lupus anticoagulant and cardiolipin antibodies. Researchers found that patients with antiphospholipid syndrome should be treated with anticoagulants, corticosteroids, and possibly plasma exchange, and that in cases of catastrophic antiphospholipid syndrome, new therapies such as rituximab may be options but require further study. In this case, the submitted documentation did not indicate that the patient was experiencing active catastrophic antiphospholipid antibody syndrome. Rituximab may be used to treat rheumatoid arthritis; however, the records do not indicate the patient has refractory inflammatory arthritis secondary to systemic lupus erythematosus that has failed to respond to standard therapy. An examination did not reveal synovitis or bone tenderness. In the treatment of moderately-to-severely active systemic lupus erythematosus, there is a lack of data in current medical literature supporting the efficacy of rituximab. Therefore, Rituxan 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 medication 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 rheumatology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ingrezza capsules. Findings: There is a difference between oromandibular dystonia and tardive dyskinesia. ONe study reports that Ingrezza is the first treatment approved by the U.S. Food and Drug Administration (FDA) for the treatment of  tardive dyskinesia. Another study reports that Ingrezza significantly improved tardive dyskinesia in patients with underlying schizophrenia, schizoaffective disorder, or mood disorder. The American Psychiatric Association (APA) practice guidelines for the treatment of patients with schizophrenia support the use of vesicular monoamine transporter type 2 (VMAT2) inhibitors for moderate-to-severe tardive dyskinesia together with antipsychotics. In this case, there is disagreement on the patients diagnosis. The records note that one provider states that the patient has tardive dyskinesia, possibly related to a dental procedure but without a clear mechanism of injury. There is a lack of evidence in current medical literature of tardive dyskinesia being caused by a dental procedure, and the records did not include documentation of past neuroleptic/antipsychotic exposure that would cause tardive dyskinesia. The patients other providers have diagnosed the patient with dystonia. Given that further investigation of the patients diagnosis with specialty consultation is required and as Ingrezza is not supported as appropriate for the medical management of dystonia, the requested medication is not medically indicated. Therefore, Ingrezza capsules are 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 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 Tepezza 500 mg vial. Findings:  The physician reviewer found that records provided for review document that this patient presents with thyroid eye disease and bilateral proptosis. The patients provider has recommended treatment with teprotumumab (Tepezza). The U.S. Food and Drug Administration (FDA) has approved Tepezza for the treatment of patients with active thyroid eye disease with proptosis to prevent progression. In this case, the patient has signs of active inflammation and existing proptosis. Since she has not tolerated standard therapy with oral steroids, the use of Tepezza is the next logical therapeutic option. The patients history of glaucoma places her at higher risk for optic nerve damage due to her thyroid eye disease without appropriate treatment (Betzler, et al.). Smith and colleagues noted that, In patients with active ophthalmopathy, teprotumumab was more effective than placebo in reducing proptosis and the Clinical Activity Score. Given this support, the requested Tepezza 500 mg vial (CPT J3241) 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 ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel. The records reviewed document that this patient has a history of nephrotic syndrome (NS) secondary to membranous nephropathy. The patients NS has been refractory to treatment with the Ponticelli protocol and rituximab. The patients provider has recommended treatment with Acthar Gel. As noted in the medical literature, Acthar Gel is not supported for treatment of patients as first-line therapy. However, there are adequate data supporting the use of Acthar Gel in the treatment of patients who have failed to respond to first- and second-line agents, as in this patients case. Madan and colleagues concluded that, Acthar gel may meet an important treatment need in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. Based on this patients failure to respond to treatment with the Ponticelli protocol and rituximab, Acthar Gel is indicated for this patients refractory disease. Therefore, the requested Acthar Gel 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 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.