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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oral device/appliance procedure. Researchers note that the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) recommend the prescription of oral appliances and periodic office visits for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy. In this case, the patient has moderate obstructive sleep apnea post tonsillectomy and pharyngoplasty, and is intolerant to CPAP. Given that the patient remains symptomatic, the requested equipment is medically indicated. Therefore, oral device/appliance procedure is medically necessary for the treatment of this patient. 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc (hyaluronic acid) injection in each knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 is trying other conservative treatments, with the alternative being a total knee arthroplasty at a relatively young age. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Monovisc (hyaluronic acid) injection in each knee is 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: The patient has requested authorization and coverage for hernia surgery on or before 12/11/20. Ramanan and colleagues note that observation is an acceptable management strategy for asymptomatic and minimally symptomatic inguinal hernias. However, in this case, the patient has a symptomatic inguinal hernia, which he reports as increasingly painful and interfering with activities of daily living. In this clinical setting, the requested service is medically indicated. Therefore, hernia surgery on or before 12/11/20 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 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 referral to a gastroenterologist that provides tertiary level of care and an irritable bowel syndrome (IBS) Smart Test. The requested evaluation by a gastroenterologist at a tertiary center is supported as medically necessary for this patient. Specialist consultation is recommended for patients with IBS when there is a family history of colorectal cancer, as in this case. Moreover, when a patient with difficult to manage IBS requires multiple specialty consultations, care by a specialist multidisciplinary team at a tertiary care center can be helpful. Moreover, the records provided for review document that the patients gastroenterologist recommended a second opinion, supporting the need for a tertiary center gastroenterology evaluation to address unresolved issues. However, the requested IBS Smart Test is not medically necessary. The IBS Smart Test assesses a patient for anti-cytolethal distending toxin B and anti-vinculin antibodies and is not supported for use in the current medical literature. Overall, the diagnostic utility of the IBS Smart Test is insufficient to guide clinical practice. For these reasons, the requested referral to a gastroenterologist that provides tertiary level of care is medically necessary for this patient, while the requested IBS Smart Test is not medically necessary. Final Result: The reviewer determined that a portion of the requested services is 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 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: The patient has requested authorization and coverage for an upper endoscopy and a thoracotomy. Surgical procedures that are considered standard of care for GERD include the LINX procedure and laparoscopic Nissen fundoplication. Thoracotomy or anti-reflux procedures performed via thoracotomy are not considered standard of care due to increased morbidity and risk. Surgical anti-reflux treatments are associated with higher risk for patients with a BMI over 35. In this case, the patients GERD is controlled on medication and her BMI is over 35. In this clinical setting, surgical anti-reflux procedures and thoracotomy are not medically indicated. Therefore, the requested upper endoscopy and  thoracotomy are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 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 Monovisc injections for both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Researchers 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, there is a history of relief lasting over a year from prior viscosupplementation. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Monovisc injections (HCPCS code J7327) for both knees 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: The patient has requested authorization and coverage for Euflexxa injection series in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 several years of history of relief from prior injections of Euflexxa. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injection series in both knees 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for H.P. Acthar Gel. The U.S. Food and Drug Administration (FDA) approves the use of H.P. Acthar for the treatment of rheumatic disorders as an adjunctive therapy for short-term administration, to tide the patient over an acute episode or exacerbation of rheumatoid arthritis (RA). However, there is a lack of current medical literature supporting the use of  Acthar or repository corticotropin injections (RCI) for the treatment of RA. In a study of eight patients, Gillis and colleagues concluded that while RCI could be an effective add-on therapy for patients who have exhausted several classes of treatments, larger clinical trials were necessary to further confirm the efficacy of RCI in patients with refractory RA. Singh and colleagues note that the American College of Rheumatology guideline for the treatment of RA recommends methotrexate and a tumor necrosis factor inhibitor (TNFi) in patients who have failed DMARD monotherapy. In patients with active RA who had previously received treatment with one or more TNFi therapies, Smolen and colleagues assessed the efficacy and safety of a second TNFi, golimumab, and found that golimumab reduced the signs and symptoms of RA. In this case, the patient has a history of seronegative rheumatoid arthritis (RA). While the records note the patient has tried and failed multiple therapies, they fail to demonstrate an acute exacerbation of RA. Given the current medical literature, the requested medication is not medically indicated. Therefore, H.P. Acthar Gel 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 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 patient has requested authorization and coverage for Saxenda. A study describes liraglutide as a glucagon-like peptide 1 (GLP-1) receptor agonist that has emerged as an effective therapy for type 2 diabetes and obesity. The study further notes that as an adjunct to a reduced-calorie diet and increased physical activity, treatment with liraglutide 3.0 mg may provide statistically significant and clinically meaningful weight loss. The study notes that obesity treatment guidelines recommend the use of pharmacologic therapy in adults who have a BMI of 30 or higher. Given this patients history of obesity and that the patient has responded well to Saxenda, the requested medication is medically indicated. Therefore, Saxenda 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent Syringe 300 mg/2 mL. The initial treatment of atopic dermatitis involves the use of nonpharmacologic interventions such as emollients, which is followed by use of topical corticosteroids or calcineurin inhibitors, like Elidel or Protopic. According to the American Academy of Dermatology (AAD) guidelines for the treatment of atopic dermatitis, topical calcineurin inhibitors like Elidel and Protopic are recommended for this patient given his failure to improve despite treatment with Claritin, fluocinonide, hydrocortisone, oral prednisone, triamcinolone, and Eucrisa. This patients records do not include documentation of failure or contraindication to treatment with standard first-line treatments to support an indication for treatment with Dupixent, which is a systemic medication. Dupixent is reserved for patients who fail nonpharmacologic interventions and first-line topical therapy. For these reasons, the requested Dupixent Syringe 300 mg/2 mL 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 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 intravenous immunoglobulin (IVIG) infusions with Gamunex-C. Based on the patients medical history of recurrent sinus infections requiring antibiotics on a monthly basis in the context of low IgM levels, treatment with IVIG replacement therapy is appropriate. IgM levels are considered deficient for an adult when the value is below 30, and this patient had two documented levels that are considered deficient. Although her response to pneumococcal vaccination has been appropriate, IgM deficient patients have demonstrated normal polysaccharide vaccine responses and yet are unable to mount a defensive response to sinus and pulmonary infections. For these reasons, the requested IVIG infusions with Gamunex-C are medically necessary for treatment of this 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a facet joint injection procedure (CPT 64493).Patients with chronic low back pain of facetogenic origin comprise 15% to 45% of all low back pain patients based on the criteria of the International Association for the Study of Pain. The treatments utilized in managing chronic low back pain of facetogenic origin include intraarticular injections, medial branch nerve blocks, and radiofrequency ablation of medial branch nerves. A randomized controlled trial performed to evaluate the effectiveness of lumbar facet joint nerve blocks found that participants experienced significant improvement with significant pain relief (ClinicalTrials.gov Identifier: NCT00355914). The trial included 60 patients in Group I with local anesthetic, and 60 patients in Group II with local anesthetic and steroid. The inclusion criteria were based on a positive response to the diagnostic lumbar facet joint blocks using local anesthetic. Results were documented at baseline, 3 months, 6 months, and 12 months. Trial results were excellent in both groups of patients, requiring approximately 3 to 4 treatments in 12 months, with an average relief of 15 weeks per episode of treatment. This study concluded that therapeutic lumbar facet joint injections, with or without steroid, provide a good option for pain relief in patients with confirmed facetogenic low back pain. In this case, the patient has been diagnosed with facetogenic pain and his last sets of injections provided him with 50 percent relief. As such, the requested repeat facet injections at L4-5 and L5-S1 bilaterally are reasonable, appropriate, and medically necessary for management of the patients low back pain. Accordingly, the requested facet joint injection procedure (CPT 64493) is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for 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: The patient has requested authorization and coverage for a heavy duty power wheelchair with accessories (E2392, E2386, E2394, K0108, E2623, E2363, and K0739). Moore and colleagues reported that using a 30-degree tilt reduces the incidence of pressure ulcers. Titus and Polger noted that a power tilt wheelchair allows independence in changing body position to address a variety of needs throughout the day. A power tilt-in-space is medically necessary for a power mobility device user to provide pressure relief for pressure injury prevention, comfort and pain relief, and posture realignment. In this case, the patient has paraplegia with neurologically intact upper extremities, but is unable to perform pressure relieving maneuvers independently. He has stage 2 sacral pressure ulcers. The patients wheelchair is over ten years old and the power tilt-in-space functionality is not working. Given that repair of the power tilt functionality, including the actuator, hydraulic cylinder, and other parts, is medically necessary for the treatment of his pressure ulcers, and prevention of future pressure injuries, K0108 is medically indicated. As the battery is not holding its charge, battery replacement, E2363 is medically indicated to prevent loss of power functionality for mobility and power tilt. E2392 is medically indicated as the tires are documented to be worn. E2386 and E2394 are medically indicated as the wheel drive and assemblies are documented to be damaged. Given that these repairs require technician labor, K0739 is medically indicated. As there is no documentation that an attempt has been made to reinflate or repair the patients ROHO cushion, a replacement seat cushion, E2623, is not medically indicated. Therefore, a heavy duty power wheelchair with accessories (E2392, E2386, E2394, K0108, and K0739) is medically necessary for the treatment of this patient. Per the submitted documentation, E2623 is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested equipment is partially medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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.