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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for left knee arthroscopy (with partial medial and lateral meniscectomy, chondroplasty patella and excision of plica). This patients knee pain was evaluated with magnetic resonance imaging (MRI), which is an accurate modality for evaluation of meniscal tears. The negative MRI with regard to the medial and lateral menisci indicates absence of a significant tear. The fraying of the meniscal edge may represent a minor degenerative change but does not generally constitute a significant meniscal tear and thus did not require an arthroscopic partial meniscectomy. When discovered at the time of arthroscopy, shaving is an option. The synovial plica may become symptomatic due to inflammation or trauma and cause knee pain, requiring arthroscopic partial synovectomy. The patients records document that conservative measures were exhausted, and surgery was indicated. On review of the operative report, the arthroscopy of the left knee with partial synovectomy with excision of the synovial plica and chondroplasty were indicated and consistent with medical literature recommendations. However, the partial medial and lateral meniscectomies were not medically necessary based upon the operative report description of normal meniscus with small fraying in the posterior horn of the medial meniscus and some fraying of the root of the lateral meniscus. Given these findings, a portion of the left knee arthroscopy services (chondroplasty patella and excision of plica) was medically necessary for this patient, while the partial medial and lateral meniscectomies were not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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 Hetlioz (tasimelteon). Findings: The U.S. Food and Drug Administration (FDA) approves the use of Hetlioz (tasimelteon) for the treatment of non-24. A study describes non-24 as a circadian rhythm disorder, occurring most commonly in blind individuals without light perception, characterized by a persistent cycle of nighttime insomnia and daytime sleepiness. The author notes that clinical trials in healthy individuals confirmed the circadian phase-shifting potential of tasimelteon, and that safety assessments indicated that tasimelteon is well tolerated. In this case, the submitted records did not include documentation supporting a diagnosis of non-24, such as actigraphy, melatonin level measurement, or a sleep diary. Given that non-24 may be confused with other causes of insomnia, in the absence of testing by an experienced sleep physician to appropriately diagnose the patient with non-24, the requested medication is not medically indicated. Therefore, Hetlioz (tasimelteon) 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 sleep 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

The patients parent has requested authorization and coverage for speech therapy services (a reevaluation for speech therapy and two 60-minute sessions per week). Liu and colleagues note, The ability to communicate effectively with others is central to children's development. Delays or disruptions due to isolated expressive language delay, articulation errors, multiple sound production errors with motor planning deficits, or mixed expressive and receptive language delay, often bring widespread consequences. Capone Singleton reports that late talking children who do not receive professional intervention are placed at risk for life-long disability. OHare and Bremner emphasize the need for comprehensive speech and language assessment, along with speech therapy, for children with speech and language difficulty. In this case, the records note that the patient has been compliant with attending therapy sessions and has been making progress towards goals, albeit slowly, in excess of incremental progress. In this clinical setting, given that discontinuation of speech therapy would place the patient at increased risks of disability, mental health disorder, and behavioral issues due an inability to communicate, and as continued speech therapy will optimize the patients communication potential, the requested services are medically indicated. Therefore, speech therapy services (a reevaluation for speech therapy and two 60-minute sessions per week) are medically necessary to prevent disease, disability, and other health conditions or their progression, to promote physical and mental health and efficiency, and to correct or ameliorate any physical or behavioral conditions. 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 neurology with special certification in child 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 Xyrem. Findings: Idiopathic hypersomnia is a central hypersomnia disease that causes excessive daytime sleepiness. Diagnosis is determined by multiple sleep latency testing (MSLT) consistent with sleep latency less than eight minutes with no sleep onset rapid eye movement (REM) episodes, which differentiates it from narcolepsy. This patient was diagnosed with idiopathic hypersomnia on MSLT with a mean sleep latency of four minutes and no sleep onset REM periods consistent with pathologic hypersomnia. The patient was treated with modafinil, but he experienced a superior outcome with Xyrem. Recent studies discussed by the Sleep Research Society and clinical trials have showed that Xyrem is effective in treating patients with idiopathic hypersomnia. This patient did not sufficiently respond to modafinil, which supports an indication for treatment with Xyrem. Moreover, the patient has already reported improvement with Xyrem treatment. Given this support, the requested Xyrem 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 subspecialty certification in sleep 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 for  Erchonia XLR8 handheld cold laser device. As noted in the medical literature, one tool in the management of pain is low level laser therapy. The Erchonia XLR8 laser can provide temporary relief of chronic neck and shoulder pain, reduce pain after liposuction of the thighs, hips and stomach, or reduce post-surgery pain after breast augmentation. The U.S. Food and Drug Administration (FDA) has approved the Erchonia XLR8 laser in the setting of chronic pain in the neck and shoulder areas originating from osteoarthritis, muscle spasms, and cervical and thoracic spine strain. This patients records document a history of back pain, neck pain, and extraspinal subluxation in the left hip. The letter from the patients provider states that laser therapy was recommended for foot neuropathy, which is not an FDA-approved indication. There is a lack of evidence that the patient has any of the FDA-approved indications for treatment with the Erchonia XLR8 laser device. For these reasons, the Erchonia XLR8 handheld cold laser device was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the device at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology with 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 Dupixent (600 mg loading dose followed by 300 mg every two weeks). This patients records document a history of moderate-to-severe atopic dermatitis that has failed to substantially improve despite treatment with HPR Plus, hydrocortisone, triamcinolone, and tacrolimus. The patients provider has recommended treatment with Dupixent, noting that immunosuppressant therapy is contraindicated for long-term treatment of the patients face, neck, and arms. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. The data supporting use of Dupixent in patients with moderate-to-severe atopic dermatitis is substantial and report a favorable side effect profile in comparison to other systemic agents that are available to this patient. Based on the information provided, this patient is a good candidate for treatment with Dupixent. Therefore, the requested Dupixent (600 mg loading dose followed by 300 mg every two weeks) 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 with subspecialty certification in dermatopathology 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 Orthovisc injections in both knees for three weeks. This patient presents with a history of chronic bilateral knee pain due to osteoarthritis. The provider noted that the patient is unable to take non-steroidal anti-inflammatory drugs (NSAIDs) due to a history of liver disease and topical NSAIDs cause a rash. Corticosteroid injections into the knees have been ineffective in relieving the patients knee pain. The patient has previously benefitted from viscosupplementation with Orthovisc injections in the past. Thus, the patients provider has recommended repeat viscosupplementation with Orthovisc injections series into both knees. A review of the medical record indicates that the last injections were approximately six months ago. 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 routine 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 excellent relief from prior viscosupplementation. Furthermore, the patients remaining treatment options are limited. The patient has tried and failed multiple conservative treatments, with the alternative being bilateral total knee arthroplasties. All told, the requested Orthovisc injections in both knees for three weeks are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a hysterectomy.A hysterectomy is indicated for heavy, painful periods or pelvic pain and pressure from large fibroids in patients who do not respond to hormonal treatments and when the benefit of surgery will outweigh the risks of surgical complication. In this case, there is no clinical documentation to describe her bleeding pattern, assess severity, acuity, or impact of her bleeding on her quality of life. Furthermore, there is no evidence of anemia from her periods to indicate definitive surgery as the next step. Additionally, there is a lack of clinical documentation describing her pelvic pain, possible etiologies, and why surgical intervention may benefit her. While she does have a fibroid, the patients overall uterine size is normal (10 cm). There is no clinical documentation to describe the impact of her fibroid uterus in terms of bulk symptoms or pain. The patient has no documentation of other factors suggestive of malignancy or high risk for malignancy. There is a lack of documentation addressing why the patient has declined medical therapy, or if she has any contraindications to hormones or tried hormones in the past. Based on the available clinical documentation, there are no unique circumstances to support that a total hysterectomy is indicated in this patient. Therefore, the requested hysterectomy is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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 magnetic resonance-guided high intensity focused ultrasound (MRgHIFU). Findings:  The physician reviewer found that MRgHIFU is a totally noninvasive procedure that has shown promising results in the management of numerous malignant and nonmalignant conditions including desmoid tumors. Griffen and colleagues report that MRgHIFU is ideally suited for the treatment of extra-abdominal desmoid fibromatosis due to its noninvasiveness, lack of ionizing radiation, low morbidity, and good safety profile over conventional treatments including surgery, radiation, and chemotherapy, which may carry significant morbidity. In this clinical setting, MRgHIFU is associated with high rates of local tumor control and expected to reduce the rate of acute and chronic morbidity as compared to other standard management options such as surgery or radiation. Therefore, MRgHIFU 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 MRgHIFU 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 and 2 are board certified in radiation oncology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Euflexxa injections to the right knee.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 lasting relief from viscosupplementation in January 2021. The injections relieved his pain and improved mobility. Therefore, Euflexxa injections to the right knee 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 Cosentyx pens (secukinumab), start with loading dose of 300 mg every week for five weeks, then 300 mg every four weeks thereafter for maintenance dose.Findings: Two of the three physician reviewers found the requested Cosentyx pens (secukinumab), start with loading dose of 300 mg every week for five weeks, then 300 mg every four weeks thereafter for maintenance dose are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The current medical literature supporting the use for secukinumab for the treatment of hidradenitis suppurativa is limited to case reports of a few open label and retrospective studies without randomization or a control group. Of note, researchers report that there are cases of secukinumab inducing hidradenitis suppurativa. In a retrospective study of 31 patients with hidradenitis suppurativa treated with secukinumab, researchers concluded that the effectiveness of secukinumab in the treatment of moderate-to-severe hidradenitis suppurativa was not entirely confirmed. Researchers do not include secukinumab in clinical management guidelines for hidradenitis suppurativa. Rather, the authors recommend approaches including but not limited to ertapenem, cyclosporine and oral retinoids. Therefore, Cosentyx pens (secukinumab), start with loading dose of 300 mg every week for five weeks, then 300 mg every four weeks thereafter for maintenance dose, are 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 regimen 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 dermatology 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.