Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections in both knees.Findings:  Two of the three physician reviewers found that this patient has a history of chronic bilateral knee pain and swelling. She has been diagnosed with bilateral knee osteoarthritis, although the severity of the osteoarthritis is not documented in the submitted medical records. Clinical examination findings have documented mild effusions. She reports increased difficulty in walking due to her bilateral knee pain. She is concerned regarding the chondrotoxicity of repeat corticosteroid injections. Given this patients clinical findings and failure of activity modification and medication trials, including corticosteroid injections, a trial of viscosupplementation is medically reasonable. In sum, Orthovisc injections in both knees are likely to be superior over other treatment options.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in 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 Percocet. Findings:  The physician reviewer found that the American Society of Interventional Pain Physicians (ASIPP) state that to support an indication for opioid therapy, it is essential to have a physical diagnosis and information on inadequacy of multiple modalities of treatments including conservative, various other alternatives, and consultations if necessary. The guidelines note that these interventions include non-controlled substance therapy, physical modalities, behavioral interventions, interventional pain management techniques, and any other alternatives. The Centers for Disease Control and Prevention (CDC) guidelines state that providers should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. This patients imaging studies demonstrate mild osteoarthritic changes of the cervical and lumbar spine as well as the knees and hands. The patient has been treated with ibuprofen, Vicodin and Tylenol. The records do not report that the patient has exhausted non-pharmacologic modalities including physical therapy and interventional pain treatments. The records do not include patients pain scale scores or treatment goals as part of an opioid therapy plan as recommended by the CDC guidelines. Based on the medical records provided for review and the current medical literature, the request for Percocet is not medically necessary for treatment of this patients pain. 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 anesthesiology with subspecialty certification in pain management 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 Botox injection for migraine prevention in combination with Aimovig.Findings:  Two of the three physician reviewers found that clinical experience shows that rational polypharmacy is often more effective than monotherapy. This is a standard of care in headache medicine, as well as other clinical areas, such as hypertension or epilepsy. Botox treatment has been an exclusion in trials of calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) for reasons of trial design, not for safety. There is evidence in favor of combined therapy with medications of this class. In this patients case, she has benefitted from the combination of Botox injections and Aimovig. There is sufficient support for the requested medication regimen in this clinical setting. Therefore, Botox injection for migraine prevention in combination with Aimovig is likely to be superior over other treatment options. Final Result: The reviewers determined that the requested medication regimen 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 neurology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The provider noted a diagnosis of migraine headaches. The provider noted the patient had 16 or more migraine headaches per month, each lasting more than four hours. The patient has requested authorization and coverage for Botox. The Health Plan denied the request and reported that Botox is not medically necessary for the treatment of this patient. At issue in this patients case is whether Botox is medically necessary for the treatment of the patients medical condition. Botox is a validated prophylactic therapy for chronic migraine headaches. The U.S. Food and Drug Administration (FDA) has approved Botox for this condition. Studies show that there is evidence supporting the use of Botox in the prophylaxis of chronic migraines. In this case, the patient has 16 or more migraine headaches per month, each lasting more than four hours. The current medical evidence supports Botox in this clinical setting. Therefore, Botox 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 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:  The enrollee requested reimbursement for advanced lipoprotein laboratory testing.  She has a history of hyperlipidemia.  This testing does not have support from the national cardiovascular societies. The medical literature indicates the requested testing of LDL particle analysis, apolipoprotein B testing, and lipoprotein (a) testing are considered a matter of ongoing clinical investigation. They do not represent the standard of care for cardiovascular risk reduction, their results do not predict or rule out the possibility of acute cardiovascular events, such as heart attacks and strokes, and offer no proven clinical benefit over conventional lipid testing in the context of cardiovascular risk assessment. There is no established proven efficacy of these technologies, either in clinical trials to support their benefit compared to conventional cardiovascular risk assessment methods, as their use has not been conclusively linked to improved cardiovascular outcomes. Despite these tests having FDA approval, the enrollee does not stand to benefit from their use over conventional lipid testing and established risk assessment strategies. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Cardiovascular Disease and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient was evaluated with a dual energy x-ray absorptiometry (DEXA) scan. Findings:  The physician reviewer found that the report noted osteopenia. The patient endorsed back pain due to L1-L5 compression fractures. The patients provider noted that treatment with Fosamax and Boniva was discontinued due to intolerable side effects. The patient has requested authorization and coverage for Forteo. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this patients case is whether Forteo is medically necessary for the treatment of the patients medical condition. Teriparatide (Forteo) was approved by the U.S. Food and Drug Administration (FDA) in 2002, and there is long-term safety data to support its use. A study found that in postmenopausal women with severe osteoporosis, the risk of new vertebral and clinical fractures is significantly lower in patients receiving teriparatide than in those receiving risedronate. In this case, the patient is a postmenopausal woman with a history of osteopenia. She has failed treatment with two bisphosphonates and has had a fracture while on therapy. The medical evidence supports the requested medication in this clinical setting. Therefore, Forteo 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested reimbursement for air ambulance services. The enrollee had a history of end stage renal disease (ESRD) secondary to diabetes mellitus type II.  He was evaluated previously and was placed on the waiting list for an organ transplant.  After receiving notification the enrollee was transported via air ambulance to the hospital for a kidney transplant. The health plan denied coverage for the air ambulance services as not medically necessary.  Transplant is time sensitive in the patient accepting the kidney and prolonged time can lead to dysfunction in the kidney.  The record indicates the enrollee had to travel over 1900 miles to receive his transplant. The offer was not available to him at a closer center. Travel by car or by commercial airline would have led to an undue delay in arrival at the transplant program. The medical literature supports air ambulance transportation was medically necessary for the enrollees medical condition and circumstance. A study showed the longer the organ is kept waiting for transplant into the recipient patient, there is an increased risk for acute kidney injury and delayed graft function. Also, this kidney injury significantly compromises the longevity of the allograft (implanted kidney) for the recipient patient.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is a board certified surgeon with experience in transplant surgery, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Diazepam. It was  discussed that current pharmacological and interventional modalities available for the treatment of spasticity. The authors noted that Diazepam depresses the action of the central nervous system (CNS) and induces significant sedation. Diazepam has a tendency to act primarily on flexor reflexes, but it can work on extensors in higher doses. Because spinal spasticity has a propensity toward flexor reflexes, diazepam is better suited for spinal spasticity than for cerebral spasticity. However, these drugs also produce tolerance and dependence, limiting their long-term use. In this case, there is no record of the patient trialing and failing other muscle relaxing agents other than gabapentin and baclofen. Currently, there is a lack of evidence in the medical literature to support the use of Diazepam over other muscle relaxers for spasticity due to spinal cord injury. Based on the available records for review and the lack of evidence supporting the use of Diazepam for long-term use in chronic spasticity, Diazepam is not medically necessary for 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 anesthesiology with subspecialty certification in pain management 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 Lazanda nasal spray. This patient has a history of lumbar post-laminectomy syndrome with back pain that radiates into the right lower extremity pain. She is currently taking methocarbamol, OxyContin, Soma, and Tramadol for pain control and uses Lazanda nasal spray for breakthrough pain. The patient has been unable to tolerate oral medications for breakthrough pain due to vomiting and patches due to skin sensitivity. The patient has requested treatment with Lazanda nasal spray. The U.S. Food and Drug Administration (FDA) states that, Lazanda is an opioid agonist indicated for the management of breakthrough pain in cancer patients 18 years of age and older who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain. The FDA has not approved this medication for non-cancer pain conditions such as lumbar post-laminectomy syndrome. The American Academy of Neurology (AAN) recommend opioids for chronic low back pain as a short-term therapy. The AAN noted that, opioid treatment should be limited to a finite course over a few weeks given the absence of evidence to suggest any long-term pain improvement from its use. A study concluded that, that, chronic opioid therapy for non-cancer paindoes not reliably improve long-term pain and function scores. The American Academy of Neurology (AAN) recommend opioids for chronic low back pain as a short-term therapy. The AAN noted that, opioid treatment should be limited to a finite course over a few weeks given the absence of evidence to suggest any long-term pain improvement from its use. Further, there is a paucity of medical literature demonstrating the safety and efficacy of Lazanda for patients with non-cancer pain. Given these findings, Lazanda nasal spray is not medically necessary for 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 anesthesiology with subspecialty certification in pain management 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 Rituximab (Rituxan).Findings:  The physician reviewer found that this patient did not tolerate treatment with prednisone and cyclosporin due to side effects. Given the support in the medical literature, the requested Rituxan 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for robot-assisted laparoscopic hysterectomy with the da Vinci Robot.Findings:  The physician reviewer found that this patient has had chronic pelvic pain and painful periods since her early teens. She has undergone treatment with a full complement of medical options for painful periods and pelvic pain without adequate relief. Other etiologies have been ruled out. She has consulted with two providers who concur that she is a candidate for hysterectomy, ideally by robotic laparoscopic approach due to her obesity. The providers have appropriately planned for surgery on the adnexae based on findings, plus an elective appendectomy due to her right lower quadrant pain, plus surgical management of endometriosis, if needed. There is an indication for proceeding with a hysterectomy is because at least some, perhaps all of her pain, is related to her uterus. In addition, the providers plan is to address any endometriosis at the time of surgery if found. All told, the requested robot-assisted laparoscopic hysterectomy with the da Vinci Robot is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested surgery 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections for the left knee. This patient presents with complaints of severe left knee pain with associated swelling, popping, grinding and giving out. She has documented functional limitations with activities of daily living. Clinical examination findings are consistent with imaging evidence of severe left knee osteoarthritis in the medial compartment. She has failed to achieve adequate improvement in pain and function with conservative treatment, including corticosteroid injections, physical therapy, activity modification, and medications. Due to the patients age, the provider and patient are interested in delaying total knee replacement. The American Medical Society for Sports Medicine (AMSSM) supports hyaluronic acid injections in the knees for patients with severe osteoarthritis who have failed to respond to conservative treatment and to potentially delay total knee replacement in patients with pain that interferes with functional activity. Therefore, the requested Euflexxa injections for the left 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.