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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intracept Nerve Ablation System and destruction of intraosseous basivertebral nerve. The guideline published by International Society for the Advancement of Spine Surgery (ISASS) concluded that the intraosseous basivertebral nerve ablation for the treatment of chronic low back pain is a treatment option that has supporting Level 1 evidence for patients with clinical and radiologic findings supporting a vertebrogenic source of back pain. Moreover, the Intracept Nerve Ablation System has been demonstrated to be safe and effective in two randomized controlled clinical trials that showed statistically significant pain scores and functional improvements over a two-year period. This patients clinical and radiologic findings of Modic type 1 changes at L4 support a vertebrogenic cause of back pain. The patient has not experienced relief from comprehensive and multimodal treatment options. Extending his fusion would not provide symptomatic relief, as the records do not report substantial relief with prior fusion. Radiofrequency ablation of the intraosseous basivertebral nerve is likely to provide functional relief for this patient, especially given that etiology of his axial back pain is likely vertebrogenic. All told, the requested Intracept Nerve Ablation System and destruction of intraosseous basivertebral nerve 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 Intracept Nerve Ablation System and destruction of intraosseous basivertebral nerve 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 evaluation 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 anesthesiology with subspecialty certification in pain management 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 enrollee requested coverage for magnetic resonance imaging of the right shoulder received. This patient with a reported history of cervical radiculopathy. On 4/30/20, he had a telemedicine consultation with his neurosurgeon during which he reported right sided neck pain that radiated to the shoulder right arm for several days duration. He had been treated in the past with steroids for his cervical radiculopathy. The patient reported his shoulder hurts when he sleeps on his right side. He denied numbness, tingling, or weakness. Upon examination, he had good range of motion of his neck and shoulder. He had pain when he pushed on the front of his shoulder. The neurosurgeons impression was primary right shoulder pain, possibly due to impingement syndrome or possible cervical radiculopathy. The plan was for magnetic resonance imaging of the right shoulder with re-evaluation after completion of the magnetic resonance imaging. The magnetic resonance imaging was performed on 6/12/20. X-rays of the right shoulder were not performed first and the patient was not referred for treatment with a physical therapist. X-rays are necessary as preliminary screening tools prior to magnetic resonance imaging as most people do not need magnetic resonance imaging and care can be safely provided with use of x-ray data information. If unusual findings are noted on x-ray then magnetic resonance imaging may be obtained if necessary. Therefore, given this and the history provided in the medical record, magnetic resonance imaging was not indicated. Final Result: The reviewer determined that the magnetic resonance imaging of the right shoulder received on 6/12/20 was not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in neurosurgery 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 been diagnosed with osteoporosis. A bone mineral density test revealed an L1-4 spine T-score of -2.5, a right femur neck T-score of -2.8, and a left femur neck T-score of -2.9. The provider noted the patient had fractured her feet three times, and the last fracture occurred approximately 10 years prior.  The patient had been on Evista during the last 10 years and was on Fosamax for approximately 10 years before that. Physical examination findings were unremarkable. The patient has requested authorization and coverage for Prolia injections. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Prolia injections are medically necessary for the treatment of the patients medical condition. Researchers reported, Treatment is generally recommended in postmenopausal women who have a bone mineral density T score of -2.5 or less, a history of spine or hip fracture, or a Fracture Risk Assessment Tool (FRAX) score indicating increased fracture risk. Bisphosphonates (generic) and denosumab reduce the risk of hip, nonvertebral, and vertebral fractures. In this case, the patient has osteoporosis with a history of fragility fractures. Her prior treatment included Evista and Fosamax. Given her history, Prolia is a medically appropriate therapy. The current guidelines do not recommend one therapy over another, and there is no stepwise therapy. Prolia has been demonstrated to be an effective treatment for postmenopausal osteoporosis. Therefore, Prolia injections 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 internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for plecanatide (Trulance) 3mg tablets. This 38-year-old patient had a history of chronic abdominal bloating and constipation. She had a gastrointestinal work-up, including colonoscopy. She was treated with Linzess, but continued to complain of constipation. Placenatide is approved by the Food and Drug Administration (FDA) for chronic idiopathic constipation. The FDA approval was based on studies showing that placanatide increased the number of bowel movements. The patient has evidence of chronic idiopathic constipation and the FDA has approved plecanatide for this usage. The patient has continued to have symptoms despite treatment with Linzess. The scientific literature has shown that there is a benefit to plecanatide. Based on the patients medical history, the current scientific literature, and the FDA listed indication, plecanatide is an indicated treatment for this patient.Final Result: The reviewer determined that the plecanatide (Trulance) 3mg tablets are medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Humira. The patient is a 58-year-old male with psoriasis and psoriatic arthritis. The patient was seen by his rheumatologist in January 2020 for erosive disease in the feet with left 1st metatarsophalangeal joint ankylosis that was seen on x-ray. He also has signs of degenerative joint disease on x-ray. On 06/15/20, he reported joint pain, joint swelling, and more than 90 minutes morning stiffness. The treating rheumatologist has recommended Humira. The 2018 American College of Rheumatology / National Psoriasis Foundation Guidelines for the Treatment of Psoriatic Arthritis are a prominent set of guidelines for the treatment of rheumatoid arthritis. They report erosive disease is part of the definition of severe psoriatic arthritis. Anti-tumor necrosis factor therapy such as Humira is preferred over oral agents and other types of biologics as initial treatment for severe psoriatic arthritis. The use of Humira in this case is supported by the documentation and professional guidelines.Final Result: The reviewer determined that the Humira 40mg/ml Pen is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified 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 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 Ofev. Ofev may be recommended for the treatment of patients with idiopathic fibrosis and scleroderma related interstitial lung disease. In this case, there is no documentation to support a diagnosis of scleroderma interstitial lung disease. The patient underwent evaluation in a scleroderma clinic in January 2020. At that visit, the provider noted that the patient does not have evidence of pulmonary fibrosis or parenchymal lung disease as evidenced by review of high-resolution lung computed tomography (CT) scan performed in December 2019. The scleroderma specialist did not recommend any medications for the treatment of lung disease, but did recommend pulmonary rehabilitation. Given these findings, the requested Ofev 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Stelara 390 mg re-induction infusion and (2) Stelara 90 mg injections every four weeks Re-induction doses of biologic therapy in Crohns  disease have been reported as successful to regain response. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, researchers observed an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patient has severe Crohns  disease diagnosed before age 30, a history of stricture and fistula, and recent need for laparoscopic ileocolectomy. He has failed multiple biologic and conventional alternatives. His symptoms are consistent with active Crohns disease despite Stelara 90 mg every eight weeks. A Stelara level of at least 4.5 ug/mL is associated with effective disease control, however in this case, the patients Stelara level was 1.4 ug/mL. Continuation of dosing every eight weeks or a change to another medication may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Therefore, (1) Stelara 390 mg re-induction infusion and (2) Stelara 90 mg injections every four weeks are medically necessary for 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 internal medicine with sub-specialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with primary osteoarthritis of the left knee. Magnetic resonance imaging (MRI) of the left knee revealed osteoarthritis, most notably in the medial compartment with full-thickness cartilage fissures, subchondral marrow edema, and osteophytosis. The provider noted the patient had undergone three surgical procedures on the left knee, including anterior cruciate ligament reconstruction, and a tibial osteotomy. The patient reported left knee pain. The patient had been treated with a cortisone injection, a knee brace, anti-inflammatory medications, and physical therapy. The patient has requested authorization and coverage for Euflexxa injections in the left knee. 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 Euflexxa injections in the left knee 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 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 the requested services in this clinical setting. Therefore, Euflexxa injections in the left knee 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 nose surgery to fix damaged skin. A scientist noted, The closure of any circular or asymmetric defect results in excess tissue at the end of the wound known as dog-ears. Authors noted that curvilinear incisions are prone to dog-ear formation because of unequal wound lengths. Researchers stated that Scar revision timing: most scars improve in appearance without revision one to three years after the inciting event. Patients should be counseled to wait at least six to 12 months before undergoing a scar revision surgery, unless there are obvious scar characteristics that are not expected to improve. In this case, the patient underwent excision of a large ulcer on the dorsum of her nose. There is evidence of dog-ear formation at both lateral ends of the skin closure. The external surgery for the skin ulcer on the dorsum of the nose would have no effect on the structure or symptomatology of an internally deviated nasal septum. Revision of dog-ears from an excision can be performed after the scar has matured for approximately six months, and is not medically necessary prior to that time. Therefore, nose surgery to fix damaged skin is 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 plastic 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 myocardial perfusion imaging (CPT 78451). Based on the records reviewed, this patient has increased coronary risk and symptoms suspicious for coronary ischemia. His electrocardiogram was mildly abnormal. He has been unable to ambulate on a treadmill to complete testing. In the clinical circumstance of an intermediate likelihood of coronary ischemia, further evaluation with stress testing is appropriate and considered standard accepted practice in the medical community. Since this patient is unable to ambulate on a treadmill, a pharmacologic stress test, such as the requested persantine nuclear stress test, is appropriate for further evaluation. Therefore, the requested myocardial perfusion imaging (CPT 78451) is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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 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 ketamine infusions with a five-day inpatient hospital stay. Researchers evaluated the efficacy of a ketamine-containing compound in 13 patients with complex regional pain syndrome (CRPS). The authors found that nine patients experienced pain and symptom reduction, with six patients reporting sustained benefits after two months of treatment, and two patients with complete resolution of symptoms. Authors concluded that intravenous ketamine was safely administered in the hospital setting to patients with refractory chronic migraine. The authors noted that this treatment protocol was associated with short-term improvement in pain severity in six of six patients with refractory chronic migraine. This patient has history of refractory migraine headaches and CRPS. In each of these conditions, where traditional medical therapy has failed, the use of ketamine infusion has demonstrated short-term efficacy. Based on the records provided for review, this patient has undergone adequate treatment with traditional therapeutic regimens without substantial improvement. Given the support in the medical literature, the requested ketamine infusions with a five-day inpatient hospital stay are medically necessary for 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 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.