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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for morphine sulfate CR 15 mg tablets. The Centers for Disease Control and Prevention (CDC) guidelines recommend providers avoid use of IR opioids in combination with extended-release/long-acting (ER/LA) opioids when possible. The guidelines state that providers should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. In this case, the patient has been on chronic opioid therapy for non-cancer pain for many years. The patients provider documented that treatment with the requested morphine sulfate tab CR 15 mg is not supported by current guidelines. Further, the provider noted that the risk-to-benefit ratio was unfavorable to the patient by having two different doses of ER/LA opioid medications. The provider recommended IR morphine along with the morphine sulfate CR 30 mg tablet but did not endorse use of morphine sulfate CR 15 mg tablets. The CDC guidelines recommend against the use of ER/LA opioid formulations due higher risks of adverse outcomes. Moreover, the guidelines do not support use of two different ER/LA opioid formulation to be used concurrently along with an IR opioid. For these reasons, the morphine sulfate CR 15 mg tablets are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for long-term acute rehabilitation services. Functional impairments due to acquired brain insults such as stroke can be profound. Some recovery is expected with time and many impairments are addressable by compensatory measures and directed rehabilitation efforts. Standard of care for this condition includes rehabilitation services, first in the inpatient setting if necessary, followed by rehabilitation in the community setting if still indicated, based on impairments and the potential for achieving practical, functional goals. Most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke and gains are slower to come in the subsequent stages (Alawieh, et al.; Kubis). Rehabilitation efforts are indicated at a level of intensity commensurate with deficits until care can be safely and effectively transitioned to a less intensive level of care. In the present case, the patient sustained multiple bilateral lacunar infarcts. There has been persistent encephalopathy, cognitive impairment, aphasia, dysphagia, and profound overall functional impairment. Based on the available documentation, she has not been able to meaningfully participate in therapies or make functional progress. There is a lack of verbal communication or demonstration of potential capacity to participate in intensive rehabilitation services. Thus, intensive rehabilitation services are not expected to be provide this patient with substantial benefit. Therefore, the requested long-term acute rehabilitation services are not medically necessary for 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiotherapy (IORT) (CPT 77424 and 77469). Current guidelines endorse the use of IORT in the treatment of breast cancer (Gradishar, et al.). Based on the available documentation, this patient meets all of the criteria for the use of IORT in patients with invasive ductal cancer. Phase 3 studies have shown equivalent outcomes in patients who undergo standard radiation therapy and IORT (Correa, et al.). The benefits of undergoing IORT include fewer treatment visits and treatment of a smaller volume than with standard modalities. Furthermore, IORT would decrease toxicities for this patient, who is undergoing radiation for a second time to an adjacent field. Therefore, the requested IORT (CPT 77424 and 77469) 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 IORT (CPT 77424 and 77469) 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 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for power seat elevation for the approved Group 3 powered wheelchair. Researchers describe facioscapulohumeral muscular dystrophy as a common form of muscular dystrophy that presents clinically with progressive weakness of the facial, scapular, and humeral muscles, with later involvement of the trunk and lower extremities.  The patient has requested power seat elevation, as he reported that this would improve his ability to transfer, and he does not like using a Hoyer lift. In this case, the documentation indicates that the patient is dependent for transfers, and there is no indication that he could safely perform independent transfers. The DME evaluation noted that the Hoyer lift was the safest mode of transfer. Due to the patients minimal upper extremity range of motion and his dependence for transfers, the requested modification is not medically indicated in this case. Therefore, power seat elevation for the approved Group 3 powered wheelchair is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested modification 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a left knee arthroscopy. In a trial to determine if exercise therapy was superior to arthroscopic partial meniscectomy for knee function in middle-aged patients with degenerative meniscal tears, Kise and colleagues found that there was no clinically relevant difference between exercise therapy and arthroscopy at two-year follow-ups. Katz and colleagues found that patients who underwent arthroscopic partial meniscectomy for a degenerative meniscal tear generally did not show more improvement than those who underwent sham meniscal resection or an intensive course of physical therapy. In this case, the records do not document a history of frequent locking or other mechanical problems associated with the degenerative tear, and an arthroscopic partial meniscectomy that removes  cushioning from the meniscus may result in progression of osteoarthritis. Therefore, a left knee arthroscopy is not medically necessary for the treatment of this patient.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 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 Vascepa (icosapent ethyl) 1 gm oral capsules. In this primary prevention setting, studies suggest there is a benefit to lowering triglycerides in patients with established coronary artery disease. In this patients case, the records document a pretreatment triglyceride level of 708 mg/dL in August 2018 but do not substantiate pre-existing coronary artery disease. On this date, hemoglobin A1c level was 9.5%, indicating poor diabetic control as the likely cause of hypertriglyceridemia. She had a mildly elevated low-density lipoprotein (LDL) level of 107 in May 2020, which suggested that medication to further lower LDL levels may be more important for the treatment of this patient than medications to lower triglyceride levels. In this clinical setting, the requested medication is not medically indicated. Therefore, Vascepa (icosapent ethyl) 1 gm oral capsules are 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 cardiovascular 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an oral mandibular device. Findings:  The physician reviewer found that oral appliances that reduce upper airway collapse by advancing the mandible are generally well tolerated and an alternative to continuous positive airway pressure (CPAP) therapy. In this case, the patient has sleep disordered breathing, likely resulting from upper airway resistance, and an Epworth score of 10. Given that the provider has recommended an oral mandibular device and that these devices work to open the posterior airway space, the requested device is medically indicated. Therefore, an oral mandibular device is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Wound treatment (amniotic membrane allograft skin transplant (CPT 15275 and HCPCS Q4150). The records provided for review document that this patient sustained extensive left lower extremity crush injuries due to a motorcycle accident in 2017. He underwent multiple left foot surgeries and all of his extensive bony and soft tissue injuries have healed. He continued to have a 2 x 1 cm open wound over the lateral calcaneus that would did heal despite more than one year of Silvadene and wet-to-dry dressing changes. He underwent left heel application of skin substitute graft, utilizing dehydrated human amnion/chorion membrane (dHACM). Based on current peer-reviewed medical literature, there is a lack of large volume, long-term outcome studies to support the use of dHACM allograft for this patient (Caporusso, et al.; Kogan, et al.). Zelen and colleagues reported substantial preclinical and clinical evidence supporting the rationale and effectiveness of dHACM as a treatment modality. However, there is a lack of adequate clinical support to establish the value of dHACM for chronic tissue repair and regeneration in lieu of standard of care medical products. For these reasons, the wound treatment (amniotic membrane allograft skin transplant (CPT 15275 and HCPCS Q4150) was not 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 wound treatment (amniotic membrane allograft skin transplant (CPT 15275 and HCPCS Q4150) 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 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 Acthar gel.Findings: A research team was formed to comprised of rheumatologists, neurologists and dermatologists to establish a multidisciplinary treatment consensus to standardize patient care for patients with polymyositis (PM) and dermatomyositis (DM). According to their treatment consensus, the first line treatment for polymyositis is glucocorticoids for remission induction. According to the consensus statement, immunosuppressants can be given to patients who are resistant to glucocorticoids. Immunosuppressants are also useful to assist with the tapering of glucocorticoids. Under the consensus statement, immunosuppressants which can be utilized for the treatment of polymyositis include tacrolimus, cyclosporine, CellCept, methotrexate and azathioprine. IVIG can be used in refractory cases, and biologic agents such as rituximab can also be utilized.In this case, the patient had demonstrated ongoing polymyositis symptoms manifested by flares of muscle weakness, increased creatine kinase (CK), inflammatory arthritis and mechanics hand. Based upon the submitted documentation, the patient has been unable to taper and discontinue prednisone due to these symptoms. Records also reflect that the patient attempted and failed to respond to several immunosuppressants/steroid sparing agents including cyclosporine, tacrolimus, CellCept, and methotrexate. The patient also developed an infusion reaction when attempting rituximab therapy for polymyositis. The patient has been on IVIG with continued polymyositis symptoms and has been unable to taper off prednisone. There is no indication in the submitted records, however, that the patient has utilized azathioprine, which was supported by the consensus statement, as a steroid sparing agent in the treatment of their polymyositis. Furthermore, the use of Acthar Gel is not supported by the consensus statement. There is very limited data to support the use of Acthar Gel in the treatment of polymyositis. Accordingly, the requested Acthar gel is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Vascepa capsule.Findings: This patient has carotid artery disease. There is no ultrasound data available to determine the severity of the patients coronary artery disease. The patients pre-treatment level of triglycerides in 2018 is 96 mg/dL and they have been maintained on maximally tolerated statin therapy. Given these data, the patient does not meet U.S. Food and Drug Administration (FDA) indications or published study criteria for the use of Vascepa. The patient has established coronary artery disease. However, given their triglyceride level below 150 mg/dL they do not meet FDA criteria, and another study required a minimum triglyceride level of 135 mg/dL. Vascepa is therefore not indicated in this situation based on either FDA indications or published study criteria. For these reasons, Vascepa capsule was not and is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was not and 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 subspecialty certification in cardiovascular 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.
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 300 mg/2 mL syringe. Atopic dermatitis is an immunologic disorder that primarily involves TH2 helper cell dysfunction per a study. Dupixent is a monoclonal antibody targeted therapy that significantly reduces disease and its associated symptoms. Dupixent is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with atopic dermatitis. A study found that Dupixent improved clinical responses in adults with moderate-to-severe atopic dermatitis in a dose-dependent manner, without significant safety concerns. Moreover, Dupixent has been shown to be more effective than methotrexate and other immunosuppressive medications in this clinical setting. The available documentation supports Dupixent as appropriate for treatment of this patients chronic atopic dermatitis in conjunction with topical agents and non-pharmacokinetic measures. Therefore, the requested Dupixent 300 mg/2 mL syringe 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 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 platelet rich plasma (CPT 0232T) to the left foot. A meta-analysis of nine randomized controlled trials comparing the efficacy of platelet-rich plasma and corticosteroids for the treatment of plantar fasciitis found that significant differences were not observed between short and intermediate effects. Vannini and colleagues reported that, Considering the literature currently available, no clear indications for using platelet-rich plasma in the foot and ankle district emerged. In this case, the patient is being treated for chronic plantar fasciitis. Overall, there is a lack of quality evidence to support the use of platelet-rich plasma for the treatment of this patients plantar fasciitis. Accordingly, the platelet rich plasma (CPT 0232T) to the left foot that was not 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 platelet rich plasma (CPT 0232T) to the left foot that 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 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.