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 a Squeeze Machine.Medical literatures state, Non-psychopharmacological studies were mainly randomized controlled trials (RCTs) with cognitive behavior therapy demonstrating moderate efficacy for anxiety disorders in youth with high functioning autism spectrum disorder (ASD). Although there are other treatments that are non-psychopharmacologic for treatment of anxiety in patients with ASD, these interventions require higher cognitive capabilities than this patient has. Researchers indicate that the risks of treatment with deep pressure are very limited, but the potential for harm without the deep pressure is quite high. The authors also state, Deep pressure appears to be of immediate benefit to this population with autism and severe intellectual difficulties. In this case, the patient has been diagnosed with autism. Additionally, there is a history of injuries due to the patients condition. However, other non-psychopharmacological interventions, like cognitive behavior therapy, would not be effective for this patient because she is not high functioning. The requested equipment would help in calming down anxieties and replace self-injurious behaviors. Therefore, the requested Squeeze Machine is medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an ovarian/pelvic venography with or without embolization. In this case, the records suggest a diagnosis of pelvic venous insufficiency. An ultrasound reported prominent vessels in the bilateral adnexa with PCS. Visit notes reported that computed tomography (CT) imaging showed a dilated 11 mm right ovarian vein, and two dilated left ovarian veins at 11 mm and 9 mm, compatible with reflux. Bookwalter and colleagues note that when pelvic venous congestion syndrome (PVCS) is caused by incompetent gonadal vein valves, treatment typically is performed by means of embolization via a minimally invasive catheter with excellent technical and clinical success rates. Medical and surgical treatments have been shown to be less effective than transvascular embolization in the setting of pelvic venous congestion syndrome due to pelvic venous insufficiency, and percutaneous catheter-directed embolization is a safe and effective procedure with a high percentage of symptom improvement post-procedure. Therefore, the requested ovarian/pelvic venography with or without embolization is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested ovarian/pelvic venography with or without embolization 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 diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for computed tomography (CT), heart, without contrast material, with quantitative evaluation of coronary calcium.Findings: Two out of three physician reviewers found that computed tomography (CT), heart, without contrast material, with quantitative evaluation of coronary calcium was likely to have been more beneficial for the enrollee than any available standard therapy.Kramer and Villines recommend the use of the CACS in selected asymptomatic adults 40 years of age or older at intermediate risk (7.5 to 19.9 percent 10-year ASCVD). However, the authors recommend against routine CAC measurement in patient at low (less than 5 percent 10-year risk) or high (20 percent or higher 10-year risk) ASCVD risk. In this case, the patient had a CACS of zero in 2012. However, this patients risk is increased by her strongly positive family history and elevated lipoprotein (a), therefore the coronary artery tomography scan and CACS are medically indicated. Therefore, computed tomography (CT), heart, without contrast material, with quantitative evaluation of coronary calcium 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 than any available standard treatment 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 board certified in internal medicine with sub-specialty certification in cardiovascular disease. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Dupixent (Dupilumab Subcutaneous Solution Pen-injector 300 mg/2 ml every 14 days) and a loading dose of Dupixent 600 mg filled by specialty pharmacy and self-administered at home by the patient. Findings:  The physician reviewer found that Holguin and colleagues indicate that Dupixent is appropriate as add-on therapy in patients with asthma that is uncontrolled on medium-to-high dose inhaled corticosteroids (ICS) and long-acting beta 2-agonists (LABA). The authors further reason that the add-on therapy may reduce exacerbations, improve asthma symptoms, and lung function. In this case, the patient does not have a history of uncontrolled asthma. The records indicate that the patient has good control of her symptoms on a low dose of Advair and has not reached maximum inhaled corticosteroid use. In addition, she has no history of exacerbations requiring oral corticosteroids. Therefore, the requested Dupixent (Dupilumab Subcutaneous Solution Pen-injector 300 mg/2 ml every 14 days and a loading dose of Dupixent 600 mg filled by specialty pharmacy and self-administered at home by the patient is not medically necessary for treatment of the patients medical condition.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 and allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for a functional electric stimulator (FES) (CPT E1399). There is a lack of proven improved function or other outcomes with the use of a FES cycle ergometer in this clinical setting of a traumatic brain injury complicated by large vessel stroke, resulting in hemiparesis/hemiplegia. In a systematic review and meta-analysis, Ambrosini and colleagues conclude that cycling training with FES cannot be recommended in terms of being better than usual care in subacute stroke survivors. Current medical literature and guidelines do not mention the use of this type of device as an evidence-based component of in stroke or other brain injury management, rehabilitation, or prevention of complications, and do not support its use over standard therapy, including occupational therapy or independent exercise and splinting, even if a full neurological and functional recovery is not elicited by these standard therapies. Therefore, FES (CPT E1399) is not 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 FES (CPT E1399) 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 reviewers 1 and 3 are board certified in physical medicine and rehabilitation and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine 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 Botox (botulinum toxin type A) injection.The American Headache Society (AHS) recommends preventive treatment when attacks significantly interfere with patients daily routines despite acute treatment; a patient has four or more attacks per month; or a patient has contraindication to, failure, or overuse of acute treatment. Currently, Botox (botulinum toxin type A) is approved by the U.S. Food and Drug Administration for the treatment of chronic migraines. In 2016, the American Academy of Neurology (AAN) updated its 2008 guidelines on using botulinum neurotoxin for brain disorders. Botulinum toxin type A is now recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. According to the AAN guidelines, botulinum toxin type A is established as effective and should be offered to increase headache-free days. A 2018 review of the current evidence of botulinum toxin type A in the prevention of chronic migraine by Frampton and colleagues noted that the totality of evidence from clinical trials and real-world studies indicates that botulinum toxin type A is an effective and generally well-tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to, or are intolerant of, commonly prescribed oral prophylactics. In this case, the patient has a history of chronic migraines that has not responded to multiple preventive and abortive medications. Based on the AHS statement, AAN guideline and study noted above, the patient is a candidate for prophylactic treatment with botulinum toxin therapy. Moreover, the patient experienced clinical improvement with botulinum toxin therapy. Therefore, the requested Botox (botulinum toxin type A) injection is medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for RT300 Functional Electrical Stimulating (FES) Therapy System.Findings: Two out of three physician reviewers found that RT300 Functional Electrical Stimulating (FES) Therapy System is not likely to be more beneficial for the enrollee than any available standard therapy.The RT300 FES Therapy System provides passive exercise in individuals with neurological weakness by using topical electrical stimulation leads to activate paralyzed limb muscles to drive a stationary cycle. The data from the medical literature, however, has not demonstrated that use of this device improves function or health outcomes in a clinically significant manner for persons with spinal cord pathology. According to Hofer and Schwab, FES does not promote neurological recovery beyond natural recovery and does not improve cardiovascular health, pulmonary health or other health parameters in a clinically significant manner. FES may help to improve or maintain muscle mass in weakened or totally paralyzed limbs, but this provides no significant health or functional benefit in this clinical setting because the muscle tissue that is gained or spared does not provide any clinical or functional benefit. According to Ong and colleagues, Individuals with spinal cord injuries require multidisciplinary care management to achieve optimal health outcomes. Moreover, Tweedy and colleagues state that health and well-being in this patient population should be promoted with active exercise using volitionally intact muscles and general encouragement of active participation in educational, social, recreational, avocational activities, and vocational activities. In this case, the patient sustained a traumatic injury to his cervical spinal cord. While standard medical care and rehabilitation measures may not resolve a person's neurological impairments due to their underlying spinal cord injury, a FES cycle ergometer, is not proven to improve cardiovascular health, pulmonary health, bony health or other health parameters in a clinically significant manner. The extant data have not demonstrated that this type of device improves health outcomes in any clinically significant manner. Therefore, RT300 Functional Electrical Stimulating (FES) Therapy System 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 equipment is not likely to be more beneficial than any available standard treatment 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 board certified in physical medicine and rehabilitation. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Wegovy.Findings: A study indicates that obesity is associated with increased risk of numerous chronic diseases including type 2 diabetes (T2D), hypertension, and cardiovascular disease. Additionally, the study states, Weight loss of 510% results in improvements in cardiometabolic risk factors. Wegovy (semaglutide) is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs. Another study states that semaglutide promotes weight loss by reducing energy intake, increasing satiety and satiation, and reducing hunger, as well as enhancing glycemic control. Another study found, In adults with obesity, once-weekly semaglutide 2.4 mg suppressed appetite, improved control of eating, and reduced food cravings, ad libitum energy intake and body weight versus placebo. In the study, body weight was reduced by 9.9% (10.4 kg) from baseline to week 20, in the absence of structured dietary and exercise intervention, compared with almost no change in the placebo group. In this case, the patient has a high BMI. Records reflect that the patient has tried and failed other medications used to manage weight gain. Therefore, Wegovy is medically necessary for treatment of 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 sub-specialty certification in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for Adaptive Rifton Tricycle (E1399). Young patients with autism present with a variety of behavioral and functional issues that can be problematic in their home, school, and community environments. These issues can include delays or inability to meet expected milestones in different domains of development, including sensory motor skills. As a result, multidisciplinary team involvement is essential to maximize the quality of life and well-being for the patient and the patients family. Acquisition of effective motor and sensory skills is required to perform many everyday abilities, such as language and communication, academic learning, social interaction, and self-care. Functional impairments can limit a patients ability to participate in age-appropriate and meaningful activities of childhood. Occupational therapy is the discipline that teaches patients to effectively interact with their environment and engage in desired daily activities. In this patients case, occupational therapy is appropriate to maximize sensory and motor functional independence, and participation in the school, home, and community settings. The potential benefits of occupational therapy in this patient population include improved toleration of sensory input, self-care, and upper extremity motor coordination, as well as stimulation of vocalization and language. Sensory integration therapy used by occupational therapy contributes to an improvement in motor, sensory, cognitive, emotional, communication, and social development in patients with autism. Currently, high-quality evidence is available to support the use of sensory-based therapies in patients with autism. However, there is a lack of quality research to support use of an adaptive tricycle as part of a sensory-based therapy program or a home exercise regimen that involves strategies for sensory retraining. Therefore, the requested Adaptive Rifton Tricycle (E1399) is not medically necessary to: 1) prevent disease, disability, and other health conditions or their progression; 2) prolong life; 3) promote physical and mental health and efficiency; or 4) correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Wegovy 1 mg/0.5 mL auto-injector.Gadde and colleagues indicate that obesity is associated with increased risk of numerous chronic diseases including type 2 diabetes (T2D), hypertension, and cardiovascular disease. Additionally, the authors state, Weight loss of 510% results in improvements in cardiometabolic risk factors. Wegovy (semaglutide) is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs. Kushner and colleagues state that semaglutide promotes weight loss by reducing energy intake, increasing satiety and satiation, and reducing hunger, as well as enhancing glycemic control. A study by Friedrichsen and colleagues found, In adults with obesity, once-weekly semaglutide 2.4 mg suppressed appetite, improved control of eating, and reduced food cravings, ad libitum energy intake and body weight versus placebo. In the study, body weight was reduced by 9.9% (10.4 kg) from baseline to week 20, in the absence of structured dietary and exercise intervention, compared with almost no change in the placebo group. In this case, the patient has been diagnosed with morbid obesity. The patients last recorded BMI was 35.35 kg/m2. Therefore, the Wegovy 1 mg/0.5 mL auto-injector is medically necessary for treatment of 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 sub-specialty certification in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.