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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Whole Exome Sequencing (WES) diagnostic testing.In this case, the patient has diagnoses of microcephaly, cerebral palsy, hypotonia, absent septum pellucidum, optic nerves hypoplasia, global developmental delay, hydrocephalus, retinopathy and eosinophilic esophagitis (EoE). The patient has been evaluated by a specialist in medical genetics, genetic testing performed to date has been normal, and a well-described genetic condition which would explain the patients findings has not been recognized. Her provider has explained that a positive result from whole exome sequencing would likely enhance medical decision-making, impact the treatment care plan and result in significant clinical impact. If mutations are identified, targeted medical care may be recommended and many of the mutations identified by whole exome sequencing can have associated medical issues, which may alter long term care. The medical literature supports the use of the requested testing under these circumstances. Accordingly, the requested Whole Exome Sequencing (WES) diagnostic test is medically necessary to treat the patients condition, as the results of testing may potentially prevent the progression of disease, disability, and other health conditions as well as prolong life and promote physical health and efficiency.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics and clinical genetics, with subspecialty certification in developmental-behavioral pediatrics, 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 Xiidra 5% eye drops. Researchers found that treatment with lifitegrast twice a day for six months improved both signs and symptoms of chronic dry eye. In this case, the patient has tried Restasis and artificial tears and is still symptomatic. The records document burning, discomfort, itching and dryness in both eyes.  Based on the records, the requested medication is medically indicated for this patient. Therefore, Xiidra 5% eye drops are 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 ophthalmology 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 been diagnosed with left knee osteoarthritis. Magnetic resonance imaging (MRI) of the left knee revealed moderate thinning and fraying of the patellofemoral articular cartilage. On 2/4/19, the patient reported anteromedial knee pain. The patient received left knee Orthovisc injections. In an undated letter, the patient reported being treated with seven knee surgeries and prior viscosupplementation injections provided her with five to six months of pain relief. The patient has requested authorization and coverage for Orthovisc injections in the left knee (J7324). The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections in the left knee (J7324) are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of lasting benefit from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports requested services in this clinical setting. Therefore, Orthovisc injections in the left knee (J7324) 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 Prevention Genetics Autism Spectrum Disorders and Intellectual Disability Comprehensive Panel gene testing (ASD-ID Panel Trio - test code 11865). In a systematic retrospective chart review of 48 patients with intellectual disability and global developmental delay who underwent an intellectual disability gene panel, Authors found the diagnostic yield was 21% overall, and 38% with more recent trio-based panels. They concluded that intellectual disability gene panels have a high yield and are a valuable diagnostic tool. Researchers noted that neurogenetics investigations and diagnostic yield in patients with autism spectrum disorder (ASD) have significantly improved over the last few years. The authors reported that high-throughput resequencing of reported intellectual disability/ASD genes to the screening procedure had a major impact on diagnostic yield in the 141 patients examined who had tested negative for fragile X syndrome and pathogenic copy number variants (CNVs). In this case, the testing performed to date, including the SNP test and gene panels for the RYR1 and BIN1 gene mutations, did not reveal a reason for the patients autism. A definitive genetic cause for the patients autism may be established by a comprehensive gene panel test, which may have additional implications for his health monitoring and interventions. Given that at present the cause for the patients autism has not been established, a comprehensive gene panel test is medically indicated. Therefore, Prevention Genetics Autism Spectrum Disorders and Intellectual Disability Comprehensive Panel gene testing (ASD-ID Panel Trio - test code 11865) is medically necessary to prevent disease, disability, and other health conditions or their progression. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special certification in child 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tandem t:slim X2 insulin pump (E0784) and related supplies. Insulin pump therapy has distinct advantages compared with multiple daily injections of insulin, including better glycemic control as measured by hemoglobin A1C and a decreased risk of hypoglycemia. There are multiple insulin pumps available and a recent trial demonstrated similar level of accuracy among 10 insulin pump systems. The Tandem t:slim X2 insulin pump has been shown to be safe and effective in improving glycemic control. This patient has experienced frequent skin infections with use of the Omnipod device and mechanical issues resulting in interruptions of insulin delivery with the Medtronic device. Given his difficulties with the Omnipod and Medtronic devices for his type 1 diabetes, this patient is an excellent candidate for treatment with the Tandem t:slim X2 insulin pump. Therefore, the requested Tandem t:slim X2 insulin pump (E0784) and related supplies are medically necessary for 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 subspecialty certification in diabetes, endocrinology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Intracept procedure at L4-5.Findings:  Two out of three physician reviewers found that the requested Intracept procedure at L4-5 is not likely to be more beneficial than any other available standard treatments for the patients medical condition.The Intracept procedure, or radiofrequency ablation of the basivertebral nerve, is a relatively new procedure. It involves minimally invasively cannulating the pedicles of both vertebral levels of the endplate-disc-endplate complex, targeting the location of the basivertebral nerve, and thermally ablating it with radio-frequency thermal ablation. The procedure is FDA approved and has the following very specific indications: 1) Chronic low back pain (CLBP) of greater than 6 months duration; 2) Failure to respond to other nonsurgical treatments for 6 months; and 3) MRI-demonstrated Modic changes in at least 1 vertebral endplate at 1 or more levels from L3 to S1.In this case, there is no mention in the submitted documentation of dynamic x-rays to rule out obvious instability as a potential pain generator. Records include an MRI that noted the presence of progressive degenerative changes at L3-4 (a level above the requested treatment level) with associated retrolisthesis. If the patient demonstrated clinically relevant dynamic instability on flexion/extension films, the recommended procedure may not be of utility. Modic changes are only identified at one level, with notable degenerative changes at adjacent levels. Under these circumstances, the requested Intracept procedure at L4-5 is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurological 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 (1) consultation with an orthopedic surgeon who performs cervical and thoracic spinal surgery, and (2) spine surgery with an orthopedic surgeon who performs cervical and thoracic spinal surgery. Hemangioma of the vertebral body is a fairly common and often incidental finding on MRI/CT imaging of the spine. The majority of benign lesions in the thoracic and lumbar spine are asymptomatic. In the absence of objective neurologic deficit, surgery is not indicated for hemangioma or thoracic disc herniation. In this case, the medical records do not document any neurologic deficit. The patient has a chronic 17 mm hemangioma in the right side of the T9 vertebral body that has not increased in size since March 2019. MRI/CT imaging does not show cord compression, and there is no evidence of neurocompression of the thoracic disc herniation at T8-9. Based on the records, surgical consultation and spine surgery are not medically indicated. Therefore, (1) consultation with an orthopedic surgeon who performs cervical and thoracic spinal surgery, and (2) spine surgery with an orthopedic surgeon who performs cervical and thoracic spinal surgery 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 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 NP Thyroid 60 mg without the completion of recommended lab work. Hennessey concludes that all of the most recent guidelines of major endocrine societies recommend levothyroxine mono-therapy for first line use in hypothyroidism. McAninch and Bianco found that while previously used, desiccated thyroid preparations, such as NP Thyroid, have fallen out of favor due to potential adverse effects, such as the risk of thyrotoxicosis, and the variability of serum thyroid hormone levels. In this case, without updated laboratory testing results, the patient is at an increased risk of adverse effects from NP Thyroid. Based on current medical literature, it may be advisable to consider treatment with levothyroxine. Therefore, NP Thyroid 60 mg without the completion of recommended lab work 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz XR 5 mg. Both alopecia areata and vitiligo are autoimmune diseases with a lack of established therapeutic treatment options. Current data from clinical trials, scientific research on pathogenesis, and case reports support treatment with Xeljanz in patients who fail to respond to standard therapies for alopecia areata. Resreachers reported on a consensus of 50 dermatology specialists from around the world and concluded that Janus kinase (JAK) inhibitors are the ideal choice of systemic therapy in adults. In addition, Ibrahim and colleagues support the use of JAK inhibitors as treatment for alopecia areata. Moreover, the use of a JAK inhibitor has been demonstrated to be safe and effective in the treatment of vitiligo. This patients records document adequate trial and failure of many standard treatments including squaric acid, topical and intralesional corticosteroids, Protopic, and narrowband ultraviolet B (UVB) phototherapy. As this patients conditions are both immune mediated and she has failed several standard treatments, the medical literature supports an indication for Xeljanz. Given these findings, the requested Xeljanz XR 5 mg 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the medications Crestor 10 mg tablets and Cozaar 50 mg tablets. Review of the records reveals only one blood pressure reading that was elevated on 2/10/17 as 160/80. There is no laboratory lipid data that would confirm whether the patient was or was not responding to the medication he was taking. There is also no evidence of a side effect that could be attributed the lipid lowering medications being taken, such as muscle aches. There is no information provided concerning response to the brand name medications requested compared to the generic equivalent. There is also no                                                                                                                                                                                                  information in the records of adverse drug effects to a generic version of both of these medications. Based on current literature, and medical records provided for review the requested brand name medications were not found medically necessary for this patient. Result: The reviewer determined that the medications Crestor 10 mg tablets and Cozaar 50 mg tablets are medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in cardiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a 12-week course of home infusions of Gammaplex, dosed at 50 grams per day for three days (150 gram loading dose) followed by 35 grams per day for two days (70 gram maintenance dose) every three weeks. Based on current standards of care, IVIG therapy demonstrates significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia. In this case, the patient has a history of chronic inflammatory peripheral neuropathy, commonly caused by autoimmune processes, and has failed conventional treatments. The use of Gammaplex as described in this patients setting is consistent with the current standard of care. Therefore, a 12-week course of home infusions of Gammaplex, dosed at 50 grams per day for three days (150 gram loading dose) followed by 35 grams per day for two days (70 gram maintenance dose) every three weeks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested treatment 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a FreeStyle Libre continuous glucose monitor (CGM). The American Diabetes Association (ADA) recommends the use of continuous glucose monitors for decreasing hemoglobin A1C levels and meeting glycemic targets. ADA guidelines state that, Intermittently scanned continuous glucose monitors in conjunction with insulin therapy are useful tools to lower A1C levels and/or reduce hypoglycemia in adults with type 2 diabetes who are not meeting glycemic targets. Scientists found that a high percentage of adults who received multiple daily insulin injections for type 2 diabetes and used a continuous glucose monitor had improved glycemic control. In this case, the patients A1C level is 13, and he is not currently meeting glycemic targets of less than 8, given his age and comorbidities. Therefore, a FreeStyle Libre CGM 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 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.