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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care services provided during a colonoscopy. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that, Anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine. In this case, the patient underwent a routine screening colonoscopy. There was no documentation of a history of significant heart, lung, kidney, or liver disease, or of alcohol or substance abuse. There was no detailed description of previous history of difficulties with anesthesia or sedation documented in the submitted records. The patient had an ASA classification score of 3; however, the submitted records did not document severe systemic disease processes to support this documentation. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the services at issue were not medically indicated. Therefore, monitored anesthesia care services provided during a colonoscopy were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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 Lupron or leuprolide acetate 11.25 mg every three months. The Endocrine Society clinical practice guideline for the treatment of gender-dysphoric/gender-incongruent persons notes, We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. The guidelines further state that serum testosterone should be less than 50 ng/dL in transgender females and that serum estradiol levels should be between 100 and 200 pg/mL. While these guidelines note that leuprolide and transdermal estrogen were as effective as cyproterone and transdermal estrogen in a comparative retrospective study, the cited study was based on a small sample of 40 patients, with 20 patients receiving Lupron. In guidelines for the primary and gender-affirming care of transgender and gender nonbinary people, Deutsch mentions the use of gonadotropin releasing hormone (GnRH)  analogs, noting that they are used routinely in the care of peripubertal transgender youth requiring pubertal delay and have also been described in the care of transgender adults. The author notes that drawbacks to the use of GnRH analogs include the need for either repeated injections, multiple daily nasal sprays, or surgical implantation. In this case, while the records document that the patient has failed to achieve the recommended serum testosterone and estradiol levels for transgender females, given the lack of large prospective studies in current medical literature supporting the use of Lupron in this population, the requested medication is not medically indicated. Therefore, Lupron or leuprolide acetate 11.25 mg every three months 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 pediatrics with sub-specialty certification in pediatric endocrinology and experience in gender dysphoria and transgender 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:  An enrollee has requested authorization and coverage for Dupixent solution pre-filled syringe 300 mg/2 mL.Dupixent is an interleukin-4 receptor alpha antagonist approved by the U.S. Food and Drug Administration for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. There are very few treatments approved for this condition, and Dupixent has quickly become a standard therapeutic option in this setting. The data supporting its use in moderate-to-severe atopic dermatitis (eczema) is substantial, and it has a favorable side effect profile in comparison to other systemic agents. In this case, the patient has been diagnosed with moderate-to-severe eczema (atopic dermatitis). The patients condition has been difficult to control with various topical therapies. Based on all of the information provided, the patient appears to be a good candidate for this treatment. Therefore, Dupixent solution pre-filled syringe 300 mg/2 mL is medically necessary for treatment of the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency volumetric tissue reduction of the tongue procedure (CPT 41530)Findings:  Three of the three physician reviewers found the radiofrequency volumetric tissue reduction of the tongue procedure (CPT 41530) at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Sonsuwan  and colleagues report that radiofrequency ablation can be considered as the second-line treatment in patients with mild-to-moderate OSA. In this case, the patient has failed a trial of PAP and a mandibular repositioning appliance. The patient was a good candidate for radiofrequency ablation due to the mild nature of her obstructive sleep apnea (OSA), low body mass index (BMI), large tongue base, and failure of first-line therapy. Therefore, radiofrequency volumetric tissue reduction of the tongue procedure (CPT 41530) was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with sub-specialty certification in sleep medicine and is actively practicing. Physician reviewers 2 and 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Afrezza. This patient with type 2 diabetes has been placed on a treatment regimen centered on maintaining strict glycemic goals. The patients provider has recommended treatment with Afrezza. As noted in the medical literature, Afrezza is a technosphere insulin in powder formulation of short-acting insulin taken by oral inhalation with meals (Mikhail). Pulmonary administration of Afrezza as a prandial insulin has been beneficial to help patients overcome many of the limitations of subcutaneous insulin formulations. Afrezza tends to have a more rapid onset of action and faster return of action to baseline levels, combined with lower intra-patient variability of insulin action (Heinemann and Parkin). While Afrezza may cause acute bronchospasm in patients with asthma and chronic obstructive pulmonary disease (COPD) and may be affected by smoking, the records document that this patient is a non-smoker without a history of chronic lung disease (Mohanty and Das). For these reasons, the requested Afrezza 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy solution auto-injector 24 mg/0.75 mL. Gadde and colleagues note that obesity remains a continuing global health concern, as it is associated with increased risk of numerous chronic diseases, including type 2 diabetes, hypertension, and cardiovascular disease. Friedrichsen and colleagues report that in adults with obesity, once-weekly subcutaneous semaglutide (brand name Wegovy) 2.4 mg suppressed appetite, improved control of eating, and reduced food cravings, ad libitum energy intake and body weight versus placebo. Given this patients history of obesity complicated by hypertension and hypertriglyceridemia, the requested medication is medically indicated. Therefore, Wegovy solution auto-injector 24 mg/0.75 mL 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 Rybelsus tablets. Findings: As noted in the peer-reviewed medical literature, glucagon-like peptide 1 (GLP-1)-based therapies represent a significant advance in the treatment of patients with diabetes. When compared with placebo, all GLP-1 receptor agonist use reduced hemoglobin A1C by approximately 1-1.2%. Recently, GLP-1 analogs have become available in oral rather than injectable formulations. The U.S. Food and Drug Administration (FDA) has approved Rybelsus as the first oral GLP-1 analog for the treatment of adults with type 2 diabetes. Recent trials have demonstrated that Rybelsus can produce results similar to the subcutaneous formulation. This patient reported that her obesity and prediabetes have benefited with use of Rybelsus. However, the records do not document a diagnosis of diabetes to support an indication for treatment with Rybelsus. Therefore, the requested Rybelsus 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement and prospective authorization and coverage for submucosal radiofrequency ablation of the tongue base. Findings: Two out of three physician reviewers found that submucosal radiofrequency ablation of the tongue base was and is likely to be more beneficial for you than any available standard therapy.Radiofrequency tongue base reduction has been found to be beneficial for the treatment of obstructive sleep apnea for patients with primarily tongue base abnormalities, especially in patients with a low body mass index (BMI). The standard of care for the treatment of OSA is continuous positive airway pressure (CPAP). In this case, the patient has a history of severe OSA with an apnea-hypopnea index (AHI) of 36.7. The patients BMI is low at 19.5. Records indicate that the patients primary issue on examination was a tongue base problem. The patient has been using a CPAP for several years but has been having difficulty tolerating it partly due to cumbersome equipment and claustrophobia. There is sufficient support for the services at issue in this clinical setting. Therefore, submucosal radiofrequency ablation of the tongue base was and is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue were and are likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1 is board certified in internal medicine with sub-specialty certification in sleep medicine. The reviewer 2 and reviewer 3 are board certified in otolaryngology. All reviewers are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for Euflexxa injection series.Findings 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 a chronic pain in both knees due to osteoarthritis. The records note a history of benefit from a series of prior injections completed in January 2021. The patient has not benefited from other conservative treatments, including physical therapy, and is not a candidate for 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 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 Tibsovo (ivosidenib) 500 mg. The available records document that this patient presents with grade II oligoastrocytoma in left frontal region and multiple sclerosis. The patient is status post resection in 2013. Serial MRI studies have demonstrated a progression of the tumor over the long-term. The provider started the patient on the Tibsovo. As noted in the medical literature, Tibsovo is a novel medication that specifically inhibits cells that harbor an IDH-1 mutation as with most cells of an oligoastrocytoma. Per the U.S. Food and Drug Administration (FDA), Tibsovo has been approved for use in acute myelogenous leukemias with an IDH-1 mutation. The reports on Tibsovo in the treatment of patients with oligoastrocytomas is limited, but promising (Mellinghoff, et al.). For this patient, treatment with additional radiation and/or chemotherapy is not recommended due to her comorbid diagnosis of multiple sclerosis. Given these findings, the requested Tibsovo (ivosidenib) 500 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 internal medicine with subspecialty certification in medical oncology 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 Privigen immune globulin (IVIG), intravenous, non-lyophilized, 2 gm/kg, given over three to five days, every 3-4 weeks, for three times for severe, intractable small fiber neuropathy (HCPCS J1459).Liu and colleagues state, Small fiber polyneuropathy (SFPN) has various underlying causes, including associations with systemic autoimmune conditions. Intravenous immune globulin (IVIG) is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. In a retrospective study by Liu and colleagues, 55 patients with objectively confirmed SFPN attributed to autoimmunity received IVIG for more than three months. The authors concluded that the results provide Class IV evidence suggesting that IVIG is safe and effective for rigorously selected SFPN patients with apparent autoimmune causality. Further, Oaklander reviewed various studies regarding immunotherapy for distal SFPN. The author notes, These reports provide a rationale for treating carefully selected patients with immunomodulatory therapies. Candidates should have symptoms consistent with SFPN, objective confirmation of diagnosis, exclusion of other causes, failure to improve with symptom management, and, ideally, serologic markers of immunity/inflammation. In this case, the patient has small fiber neuropathy, which is thought to be autoimmune in nature. The patients symptoms have not been controlled with conventional medical therapy. Based on the studies noted above, patients with autoimmune small fiber neuropathy may improve clinically with IVIG. Therefore, Privigen immune globulin (IVIG), intravenous, non-lyophilized, 2 gm/kg, given over three to five days, every 3-4 weeks, for three times for severe, intractable small fiber neuropathy (HCPCS J1459) are medically necessary for the treatment of the enrollee's 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 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.