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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genicular nerve radiofrequency ablation of the bilateral knees. Findings:  The physician reviewer found that the patient presents with bilateral knee pain associated with osteoarthritis. The patients provider has recommended genicular nerve radiofrequency ablation of the bilateral knees. Radiofrequency ablation of genicular nerves is a potential therapeutic alternative for chronic pain associated with osteoarthritis of the knee, particularly for some patients with comorbidities who are not considered ideal surgical candidates. Bhatia and colleagues found that, Radiofrequency treatments on the knee joint (major or periarticular nerve supply or intra-articular branches) have the potential to reduce pain from osteoarthritis or persistent postarthroplasty pain. However, the authors cautioned that, Ongoing concerns regarding the quality, procedural aspects, and monitoring of outcomes in publications on this topic remain. The authors concluded that additional studies are needed to determine whether genicular nerve radiofrequency ablation is a safe and effective modality at long-term follow-up. For these reasons, the requested genicular nerve radiofrequency ablation of the bilateral knees is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested genicular nerve radiofrequency ablation of the bilateral knees is 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 requested services are 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 reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management and is 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: An enrollee has requested authorization and coverage for Xeljanz tablets.Findings: According to the most recent published Alopecia Areata Consensus of Experts (ACE) guidelines, treatment of alopecia totalis/universalis includes systemic steroids, methotrexate, cyclosporine, and contact sensitization with diphenylcyclopropenone (DPCP) or squaric acid. Few treatment methods have been evaluated by randomized controlled trials to determine the most efficacious modalities to treat alopecia areata. Therefore, it is challenging for clinicians to guide patients regarding the best therapeutic options. According to the ACE, there was consensus on the effectiveness of monotherapy with oral corticosteroids, cyclosporine, and Janus kinase (JAK) inhibition therapy. In this case, the patient has seen improvement with Xeljanz. There is support for the requested medication in this clinical setting. Therefore, Xeljanz tablets are medically necessary for the 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monovisc injection in both knees and Monovisc injection in both knees every six (6) months.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 history of lasting response to prior viscosupplementation. Furthermore, physical therapy was not effective Additionally, the patient is not a candidate for total knee arthroplasties because she only has mild osteoarthritis. Therefore, Monovisc injection in both knees and Monovisc injection in both knees every six (6) months are medically necessary for the treatment of the patients medical condition.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) treatment. Current medical literature supports the use of TMS as a safe and effective treatment for refractory bipolar depression. Researchers note that TMS is effective in the bipolar depressed population where episode-focused intervention can be specifically offered. In this case, visit notes reported diagnoses of bipolar depression and anxiety. The records noted that the patient endorsed passive suicidal thoughts in the past six weeks. Given this patients continued symptoms despite a documented prolonged treatment history and numerous medication trials, including electroconvulsive therapy (ECT), the requested service is likely to be more beneficial than any available standard treatment. Therefore, TMS treatment is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested transcranial magnetic stimulation (TMS) 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 psychiatry 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: An enrollee has requested authorization and coverage for bilateral Triluron injections to the knees.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 history of prior viscosupplementation, with good results. The patient has also tried other conservative treatments, with the alternative being surgery. Therefore, the requested bilateral Triluron injections to the knees are medically necessary for the treatment of the patients medical condition. 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 weekly counseling appointments with a provider specializing in eye movement desensitization and reprocessing (EMDR).Findings:  The physician reviewer found that the patient is a high medical services utilizer, driven by her psychiatric issues, which have not been addressed given that she is not currently in individual psychotherapy. The patient would benefit from psychotherapy, including and particularly weekly individual psychotherapy with EMDR, given her diagnosis of post-traumatic stress disorder (PTSD) and continued trauma-related symptoms. The American Psychological Association (APA) guidelines provide specific recommendations for EMDR for patients with PTSD. Additionally, in the International Society for Traumatic Stress Studies guidelines, EMDR is considered a valid option for the longer-term treatment of this complex disease entity. Overall, there is adequate support in the peer-reviewed medical literature and practice guidelines to support a trauma-focused psychotherapy as standard of care for PTSD, which includes EMDR. Given this patients trauma history, symptoms of PTSD which have been unabated, and continued difficulty with functioning as well as motivation for psychotherapy, individual psychotherapy utilizing EMDR is an appropriate treatment approach. Moreover, the requested weekly psychotherapy with EMDR is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the requested weekly psychotherapy with EMDR is 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 psychiatry 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 cardiac catheterization procedure. Findings:  The physician reviewer found that Kannam and colleagues report that in patients with equivocal symptoms and stress testing abnormalities, coronary angiography is often medically reasonable to assess the significance of disease. The authors note that a diagnosis of chronic coronary syndrome can be confirmed by stress testing or, if that is ambivalent, by an invasive evaluation of the coronary circulation. The American College of Cardiology Foundations appropriate use criteria for diagnostic catheterization report that in symptomatic patients with abnormal findings on exercise testing, cardiac catheterization and coronary angiography are medically reasonable and necessary. In this case, the patient has chest symptoms and dyspnea, with significant baseline abnormality of her electrocardiogram (EKG) due to a left bundle branch block, which may be associated with significant coronary disease and be of negative prognostic significance. In this clinical setting, given the patients abnormal stress EKG findings with antero-septal hypokinesis, the requested service is medically indicated. Therefore, a cardiac catheterization procedure 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for SpaceOAR hydrogel procedure. This patient presents with Gleason 4+4 and Gleason 4+3 prostate cancer. His provider has recommended radiation therapy with the use of SpaceOAR hydrogel placement to minimize toxicity to surrounding normal tissue. SpaceOAR hydrogel has been demonstrated to minimize the risk for radiation-induced rectal, urinary, and sexual toxicity per high quality prospective randomized clinical trial outcomes published in the peer-reviewed medical literature. SpaceOAR is widely utilized throughout the radiation oncology community for patients with a clinical presentation similar to this patient. Moreover, SpaceOAR is supported by the National Comprehensive Cancer Network (NCCN) guideline for the management of prostate cancer. All told, the requested SpaceOAR hydrogel procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested SpaceOAR hydrogel procedure 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz oral tablets 5 mg. Current medical literature supports the safety and efficacy of tofacitinib (brand name Xeljanz) in treating severe alopecia areata. Tofacitinib, a systemic medication often prescribed to patients with rheumatoid arthritis, has been documented to result in clinical improvements in patients with alopecia areata. Researchers concluded that based on a retrospective study of patients aged 18 years or older with alopecia areata, with at least 40% scalp hair loss, tofacitinib should be considered for the treatment of severe alopecia areata, alopecia totalis, and alopecia universalis. Researchers report that Janus kinase (JAK) inhibitors, such as tofacitinib, are a therapeutic option that is safe and effective for the treatment of severe alopecia areata. Researchers make the definitive statement that JAK inhibitors are the ideal choice of systemic therapy in adults. In this case, the patients alopecia areata is not controlled by standard steroid or calcineurin inhibitor regimens. Her symptoms have progressed to eyelash loss, which may negatively affect her vision due to an increased risk of eye irritation. In this clinical setting, given that patient has tried and failed conventional therapies, there is no question that tofacitinib would be a safe and effective alternative systemic therapy. Therefore, Xeljanz oral tablets 5 mg are likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Xeljanz oral tablets 5 mg are 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 medication is 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 dermatology 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 endocrinology services at a tertiary level of care. Polycystic ovarian syndrome (PCOS) is an endocrine disorder that has been associated with infertility, menstrual disorders, insulin resistance, obesity, and cardiovascular problems (Patel). Although data gained in recent years has improved understanding of the pathogenesis, diagnosis, and clinical manifestations, there are limited data directing therapeutic interventions (Aversa, et al.). Recent studies have demonstrated that due to the complexity of the condition, a multidisciplinary treatment approach to PCOS is an effective strategy that enables the coordination of care and serves as an innovative platform for research (Wolf, et al.). For these reasons, the requested endocrinology services at a tertiary level of care 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 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 radiofrequency ablation of the L3-4, L4-5 and L5-S1 bilateral lumbar facet. Findings:  The physician reviewer found that current guidelines for interventional techniques from the American Society of Interventional Pain Physicians states that, The evidence for therapeutic facet joint interventions is good for conventional radiofrequency. A systemic review by Manchikanti and colleagues reported Level II evidence supporting the long-term safety and efficacy of radiofrequency ablation for treatment of chronic pain in the lumbar spine. Similarly, Lee and colleagues found a reduction in pain at 12 months post procedure for patients with facet joint disease of the lumbar spine. In this case, the patient has chronic low back pain and underwent a diagnostic lumbar facet joint injection, which provided 80% relief of the pain along with functional improvements for one week. The patient has also undergone radiofrequency procedures in the past, most recently in 2019, with reported approximately eight months of relief. This outcome with lumbar radiofrequency ablation and the patients positive response to the diagnostic injection support an indication for repeat radiofrequency ablation of three lumbar facet joint levels. Moreover, this treatment plan is consistent with the current recommendations from the pain management national guidelines and evidence-based medical literature. For these reasons, the requested radiofrequency ablation of the L3-4, L4-5 and L5-S1 bilateral lumbar facet is medically necessary for 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 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.