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 Annovera birth control ring.Combined (estrogen-progestin) hormonal contraception is highly effective and available in multiple forms and formulations, including as a vaginal ring. In the United States, there are two commonly available combined hormonal contraceptive rings, the etonogestrel/ethinyl estradiol ring and the segesterone acetate/ethinyl estradiol ring. This second formulation is known commercially as Annovera. The hormonal contraceptive vaginal rings offer the same benefits as the other estrogen-progestin combined methods but do not require daily or weekly use. More specifically, Annovera is a one-year reusable segesterone acetate/ethinyl estradiol ring. The ring is worn for three weeks and removed for one week, and that pattern is repeated for a total of 13 cycles. Annovera is approved by the U.S. Food and Drug Administration. Given that the patient has already tolerated this medication well, and that the formulation of progesterone is different from the other options (segesterone versus etonogestrel), it is medically appropriate to continue this treatment for the patient. Therefore, Annovera birth control ring 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 obstetrics and gynecology 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 sacroiliac joint arthrodesis.Findings: Three out of three physician reviewers found that left sacroiliac joint arthrodesis is likely to be more beneficial for treatment of the patient than any available standard therapy.Sacroiliac joint syndrome is commonly one reason for persistent low back pain, especially in patients with prior spinal surgery. If conservative treatments fail to improve symptoms, arthrodesis surgery may be considered. Minimally invasive approaches have emerged recently, providing a better alternative to conventional methods. A triangular implant system can be used without need for bone grafting or screw fixation to achieve an optimal fusion of the sacroiliac joint. Minimally invasive surgical arthrodesis of the sacroiliac joint is known to result in significant improvement in pain and function. Medical literature confirmed, Minimally invasive fusion of the sacroiliac joint using triangular implants provides superior six month outcomes compared to non-surgical management in patients with chronic sacroiliac joint dysfunction due to degenerative sacroiliitis and sacroiliac joint disruption and may therefore be a preferred treatment option for patients who have failed to respond adequately to conservative therapies. In this case, the patient has sacroiliac joint dysfunction. Therefore, left sacroiliac joint arthrodesis is likely to be more beneficial for treatment of the patients medical condition.Final Result: The reviewers determined that the requested service is likely to be more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in orthopedic surgery. All reviewers are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Prolia injections. In the treatment of osteoporosis, Camacho and colleagues note that approved agents with efficacy to reduce hip, nonvertebral, and spine fractures such as denosumab (brand name Prolia) are appropriate as initial therapy for most osteoporotic patients with high fracture risk. The authors note that indicators of high fracture risk include advanced age, frailty, glucocorticoids, very low T-scores, and increased fall risk. In this case, the patient has a diagnosis of osteoporosis, with a T-score of -2.9 in the lumbar spine. The records note that the patient is unable to tolerate oral medications such as Fosamax due to gastrointestinal side effects and reported that the patient had previously been treated with Prolia. In this clinical setting, the requested medication is medically indicated. Therefore, Prolia injections 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Intracept procedure (basivertebral nerve ablation). Current medical literature supports the requested services as safe and effective for relief of vertebrogenic pain. Medical literature notes that vertebrogenic pain is a frequently underestimated cause of chronic low back pain and that vertebral endplate degeneration, characterized by cortical bone damage and subchondral bone inflammatory reaction, is a significant source of low back pain transmitted by the basivertebral nerve. The authors further note that radiofrequency ablation of the nerve leads to a thermal injury of nerve tissue and relief of pain. In a study of 56 patients, the authors found that at three- and twelve-month follow-ups, Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) scores decreased significantly compared to baseline, with 54 out of the 56 patients achieving clinical success for pain and disability. The authors noted that computed tomography assisted targeting of the ablation zone was successful in 100% of patients. In this clinical setting, the requested service has been shown to lead to improvement of pain and function. Therefore, the Intracept procedure (basivertebral nerve ablation)  is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Intracept procedure (basivertebral nerve ablation) 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, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for use of an electric/power wheelchair. The records document that this patient has back pain and sciatica with a degenerative spine. She has fluctuating pain symptoms that are relieved by rest and analgesics. The patient does not have any documented neurological weakness or impairment. The provider observed the patient to have an abnormal, unstable gait when walking without an assistive device. However, the records lack a detailed functional history, physical therapy evaluation, or ambulation trial with a gait implement. Overall, the records indicate that the patients mobility complaints and difficulties could be addressed with a gait implement such as a cane, walker, or manual wheelchair. The patients low back pain, deconditioning, and obesity would be best addressed through increased levels of light, physical activity and exercise. For these reasons, the requested use of an electric/power wheelchair is not medically necessary for 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent. Findings: This patient presents with atopic dermatitis with involvement that ranges from 10-30% of their body surface area (BSA). After failing treatment with Elidel, Eucrisa, topical corticosteroids, and a course of prednisone, the patients provider recommended treatment with Dupixent. The provider noted that the patient has also failed treatment with histamines, Xyzal and H2 blockers. The U.S. Food and Drug Administration (FDA) has approved Dupixent for patients with moderate-to-severe eczema, or dermatitis. This patients condition meets the criteria for moderate to severe, given the percentage of BSA involvement. The provider reported that the patient required a course of prednisone to manage a severe flare. Per a study, Dupixent and cyclosporine are the most effective treatments for patients with atopic dermatitis after 16 weeks of therapy. The data suggests that cyclosporine has a less favorable risk profile than Dupixent. This patient meets the criteria for treatment with Dupixent, given their failure of Elidel and symptoms consistent with severe disease. Therefore, the requested Dupixent 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 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 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 (1) acupuncture services received (2) acupuncture services received (3) acupuncture services from three times per week. Findings:  The physician reviewer found that Acupuncture is effective for the treatment of chronic musculoskeletal, and osteoarthritis pain. Per the authors, Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. Kelly and Willis note that, for certain patients, especially those who are unresponsive or intolerant to standard therapies, acupuncture is a reasonable treatment option. Following an acupuncture trial of five or six sessions, additional acupuncture treatments should only occur based on progressively greater, incremental objective gains. Acupuncture should be combined with active care, such as conditioning, aerobics, and/or a stretching exercise program. Indications for care discontinuation include resolution, intolerance, lack of measurable improvements, or non-compliance including non-compliance with aerobic and strengthening exercises. In this case, while the patient reported benefits from prior acupuncture, the records did not document pre-acupuncture and post-acupuncture baselines for comparison purposes, and measurable, progressive, significant, or objective functional improvement. The documentation did not demonstrate significant medication intake reduction, or improvement of activities of daily living functioning directly attributable to prior acupuncture. The records did not document that the patient was undergoing an independent exercise program. Given that measurable, progressive, significant, objective functional improvement has not been documented, the services at issue were not and are not medically indicated. Therefore, (1) acupuncture services received and acupuncture three times per week were not and are not medically necessary for the 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 acupuncturist, board certified in oriental 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 Nerlynx. The U.S. Food and Drug Administration (FDA) approves the use of Nerlynx, in combination with capecitabine, for the treatment of patients advanced or metastatic HER2-positive breast cancer who have received two or more prior anti-HER2 based regimens in the metastatic setting. In this case, the patient has a diagnosis of metastatic HER2 positive breast cancer and has undergone multiple prior lines of HER2 based therapy. In this clinical setting, the requested medication is medically indicated. Therefore, Nerlynx 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 certifications in medical oncology and in hematology 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 Xeljanz 5 mg. Barton and colleagues report that topical corticosteroids are the preferred first-line treatment for pediatric patients with alopecia areata, as they hold the highest level of evidence, followed by contact immunotherapy. The authors further report that more clinical trials and comparative studies are needed to further guide management of pediatric patients with alopecia areata and to promote the potential use of novel therapies, including Janus kinase (JAK) inhibitors. Jabbari and colleagues note that open-label studies of ruxolitinib and tofacitinib (brand name Xeljanz) showed dramatic clinical responses in patients with moderate-to-severe alopecia areata. King and colleagues reported that treatment JAK inhibitors for 24 weeks in patients with alopecia areata was efficacious and generally well tolerated. In this clinical setting, given that the patient has failed first-line therapy with steroids and contact sensitizers, the requested medication is medically indicated. Therefore, Xeljanz 5 mg 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 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 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 facet nerve injections. In a randomized, double-blind, active-control trial to determine the clinical effectiveness of therapeutic thoracic facet joint nerve blocks with or without steroids in managing chronic mid back and upper back pain, researchers reported that the evidence for therapeutic facet joint interventions is fair for medial branch blocks. In this case, the patient has a diagnosis of thoracic spondylosis without myelopathy, a history of chronic back and knee pain, and is status post lumbar spine surgery. The records documented thoracic medial branch blocks with 80% relief of pain, improvement in activity level, and reduction in opioid usage. In this clinical setting, given that current medical literature shows that therapeutic medial branch blocks of the thoracic spine are effective for the management of chronic pain of the facet joint origin, the requested services are medically indicated. Therefore, facet nerve injections 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Monovisc injections.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 good benefit from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Therefore, the Monovisc injections are medically necessary for 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for food specific immunoglobulin G (IgG) allergy panel testing services.Findings: Three out of three physician reviewers found that food specific immunoglobulin G (IgG) allergy panel testing services are not likely to be more beneficial for the enrollee than any available standard therapy.Oral food challenges and oral food desensitizations have been performed successfully by allergists and immunologists. While oral food desensitization has been achieved in the majority of individuals in randomized controlled studies, few go on to develop tolerance or sustained unresponsiveness to the allergic stimulant. It is the standard of care to measure immunoglobulin E (IgE) levels to specific foods in question for a patient. However, an extensive array of blood tests examining foods to which a patient has not had a reaction to, in particular with immunoglobulin G4 (IgG4) testing, and proceeding with oral desensitization to a multitude of foods to which there is no history of anaphylaxis is not supported by the current medical evidence. In this case, the requested services are not evidence-based. Furthermore, while oral food challenges are medically appropriate to rule out IgE mediated food allergy, there is a lack of evidence in favor of oral dosing protocols for foods that are considered intolerances or IgE mediated allergies based on IgG and patch testing. Therefore, the requested Food Specific IgG Allergy Panel testing services are not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in allergy and immunology. All reviewers 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.