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 MRI of the jaw and an oral prosthesis.The current, well accepted, universally performed test to identify the presence or absence of temporomandibular disorder (TMD), or one of its subcategories, is a comprehensive evaluation of the patients history and clinical examination, and when indicated, select imaging such as magnetic resonance imaging (MRI) of the jaw. MRI in open and closed mouth positions is standard when evaluating for internal derangement. It provides the most information regarding the soft tissue structures and disk position. In this case, the patient has a history of jaw pain, and his oral surgeon has noted that the patient has limited opening, pain, and an examination that is consistent with internal derangement. Under these circumstances, MRI of the jaw is medically necessary to treat the patients medical condition.Splint therapy has been shown to be beneficial in patients with TMD and Myofascial pain. Splint therapy has been shown to decrease symptoms in 70 to 90% of cases. There are various types of splints used to treat myofascial pain, however, a single maxillary or mandibular splint is the well accepted method for treating such patients. In this case, the patient has jaw pain and suspected TMD, and an oral prosthesis is an appropriate treatment to accomplish a decrease in his symptoms. Accordingly, the requested oral prosthesis is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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 authorization and coverage for a lumbar/sacral facet joint block injection. In a systematic review of the effectiveness of therapeutic facet joint interventions in managing chronic spinal pain, researchers noted evidence of long-term improvement with the use of therapeutic facet joint nerve blocks and lumbar intra-articular injections. In this case, the patient has a history of relief from intra-articular injections into the lumbosacral facet joints, confirming the source of pain. Given current medical literature, the requested service is medically indicated. Therefore, a lumbar/sacral facet joint block injection  is medically necessary for the treatment of this patient. 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 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 reimbursement for Botox injection. The provider noted that this patient presented with a history of gastroparesis with nausea and vomiting. The provider noted that the patient received a Botox injection for the treatment of his gastroparesis. Injection of Botox has not been demonstrated to be safe and effective for the treatment of gastroparesis in randomized controlled clinical trials. Moreover, the American College of Gastroenterology (ACG) guideline for the management of gastroparesis states that intrapyloric injection of Botox is not recommended for patients with gastroparesis. Given these findings, the Botox injection was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the Botox injection was 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 services at issue were 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 subspecialty certification in gastroenterology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy. Currently, there is inadequate clinical data demonstrating that proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues reported on the comparative effectiveness of intensity modulated radiation therapy (IMRT), proton beam therapy, and conformal radiation therapy for prostate cancer. The authors found that in the comparison between IMRT and proton therapy, IMRT patients had a lower rate of gastrointestinal morbidity. The authors noted that no other significant differences were observed. The American Society of Radiation Oncology (ASTRO) noted that, The comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. In this case, the provider noted that due to the patients previous surgical history and complex anatomy, proton beam therapy is recommended over standard alternatives. However, there is a lack of data that patients with a prior history of surgery have improved outcomes when treated with proton therapy. Enrollment of the patient in a national study is insufficient justification for the use of proton therapy. All told, the requested proton beam radiation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested proton beam radiation therapy 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 services are 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 radiation oncology 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 patient has requested authorization and coverage for armodafinil. Researchers noted, central hypersomnias are manifested by excessive daytime sleepiness not caused by disturbed nocturnal sleep or misaligned circadian rhythms. Thus, evaluation with a sleep study and multiple sleep latency test (MSLT) is used as an objective tool for diagnosis of narcolepsy and hypersomnias. This patients records include adequate documentation to support a diagnosis of idiopathic hypersomnia given the results of his sleep study and MSLT test. The patient has reportedly benefited from armodafinil, which is indicated for idiopathic hypersomnia. For these reasons, the requested armodafinil 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Firdapse (amifampridine) tablets three times a day. Congenital myasthenic syndromes are a genotypically and phenotypically heterogeneous group of neuromuscular disorders, which have in common an impaired neuromuscular transmission. There is a lack of standardized treatment protocols or guidelines to manage patients with these conditions. In this case, the patient has congenital myasthenic syndrome with GFPT1 mutation. The patients condition has not improved despite treatment with pyridostigmine. Based on a review of the literature, the addition of amifampridine is appropriate and is likely to be beneficial in congenital myasthenic syndromes and patients with the GFPT1 mutation, as in this patients clinical scenario. For these reasons, the requested Firdapse (amifampridine) tablets three times a day is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Firdapse (amifampridine) tablets three times a day 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 medication 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 reviewer 1 is board certified in neurology and is actively practicing. Physician reviewer 2 is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 3 is board certified in neurology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Comprehensive genomic profiling test (FoundationOne CDx). As noted in the medical literature, the standard of care for patients with metastatic colon cancer includes testing for KRAS, NRAS, BRAF, HER2, and microsatellite instability (MSI). Per the National Comprehensive Cancer Network (NCCN) guidelines, this testing can be performed individually or as part of next-generation sequencing, which has the ability to detect actionable mutations. The American Society of Clinical Oncology (ASCO) recommends genetic testing on colon cancer tumors. Next-generation sequencing offers the advantage of identifying markers known to have targeted therapy as well as potential clinical trials. Given this patients metastatic disease, comprehensive molecular profiling was appropriate. Accordingly, the comprehensive genomic profiling test (FoundationOne CDx) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the comprehensive genomic profiling test (FoundationOne CDx) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and 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: The patient has requested authorization and coverage for increase in dosage for Remicade infusion from 10 mg/kg every eight weeks to 10 mg/kg every four weeks. Remicade is U.S. Food and Drug Administration (FDA) approved and recommended for the treatment of ulcerative colitis. Moreover, the requested increase in dose is oftentimes required during maintenance therapy with Remicade. Current data from randomized double-blind placebo-controlled trials have reported 69% rate of remission at eight weeks with infusion of 10 mg/kg, rather than 64% with infusion of 5 mg/kg. The American College of Gastroenterology (ACG) guidelines for management of ulcerative colitis support the requested increase in Remicade dosage in patients with uncontrolled disease. Additionally, the American Gastroenterological Association (AGA) recommends an increase in Remicade dosage rather than change to an alternative medication in patients with low Remicade level when anti-Remicade antibodies are absent or at a low level, as in this patients case. The AGA guidelines for therapeutic drug monitoring state that a Remicade level of 5 ug/mL is recommended, and over 10 ug/mL is likely to be effective. This patients level is significantly lower. For these reasons, the requested increase in dosage for Remicade infusion from 10 mg/kg every eight weeks to 10 mg/kg every four weeks is supported as 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Evrysdi (risdiplam).Spinal muscular atrophy (SMA) is an autosomal, recessive, inherited, genetic disease that is characterized by degeneration of alpha motor neurons in the spinal cord. In August 2020, the FDA approved Evrysdi for the treatment of SMA in adults and children age 2 months and older. Evrysdi is a survival of motor neuron 2 (SMN2) splicing modifier designed to treat SMA caused by mutations in chromosome 5q that lead to SMN protein deficiency. A press announcement by the FDA noted that the efficacy of Evrysdi for the treatment of patients with infantile-onset and later-onset SMA was evaluated in two clinical studies. The FDA press announcement stated that patients with later-onset SMA were evaluated in a randomized, placebo-controlled study that included patients with SMA aged two to 25 years. An open-label Phase 2 trial is evaluating Evrysdis safety and tolerability in a broad range of SMA patients, ages 6 months to 60 years, all previously treated with another SMA-targeted therapy. In this case, the patient is over 60 years old and has a diagnosis of spinal muscular atrophy. Although the FDA has approved Evrysdi for the treatment of SMA in adults and children over the age of 2, it was based on studies on patients with infantile-onset SMA (average age 6.7 months) and later-onset SMA (aged 2 to 25 years). The safety of the medication Evrysdi for patients up to 60 years of age,  is still under review. Accordingly, the requested medication Evrysdi (risdiplam) is not medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patient's 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for psychophysiological therapy services provided and continued psychophysiological therapy services. Per the American Psychiatric Association (APA), the standard of care for major depressive disorder involves treatment with different classes of antidepressants. After a patient fails antidepressant trials from multiple classes, the APA recommends adding an adjunctive medication, such as aripiprazole, quetiapine, risperidone, or brexpiprazole. This patients records do not include documentation that the patient has undergone an adequate trial of these adjunct medications. Cognitive behavioral therapy (CBT) is also supported for first-line treatment, as well as the combination of pharmacotherapy and psychotherapy. This patients records do not include documentation that she has failed treatment with pharmacotherapy and psychotherapy. There is a lack of peer-reviewed medical literature demonstrating that biofeedback is superior to standard therapeutic approaches for the treatment of this patients major depressive disorder. Per the records provided for review, this patient was demonstrating improvement in depression and anxiety with her standard medication regimen, and there is a lack of information to support continued use of biofeedback is required for maintenance. All told, the psychophysiological therapy services provided and continued psychophysiological therapy services were not and are not medically necessary for treatment of this patient. Findings:  Three of the three physician reviewers found the psychophysiological therapy services provided and continued psychophysiological therapy services were not and are not medically necessary for treatment of this patient.Final Result: The reviewers determined that the services at issue were not and are 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for albendazole (400 mg) and ivermectin (200 mg) each daily for 28 days, then off for two weeks, then repeat this for two more cycles for a total of three cycles. In this case, the records do not document parasitic infection. Given that there are no pathologic specimens documenting a parasitic infection, the requested medications are not medically indicated. Therefore, albendazole (400 mg) and ivermectin (200 mg) each daily for 28 days, then off for two weeks, then repeat this for two more cycles for a total of three cycles are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in infectious disease 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.