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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Afrezza (insulin human). Findings:  The physician reviewer found that Afrezza is an ultra-rapid-acting inhaled insulin used to improve postprandial glycemic control in adults with diabetes mellitus. Afrezza has been approved by the U.S. Food and Drug Administration. The medical literature has demonstrated comparable glycemic control between people using inhaled versus conventional insulin therapy, and the safety profile is similar. In this case, the patient has stated that she can no longer take injectable insulin due to swelling, burning, and pain. Since this patient has been unable to tolerate frequent insulin injections, she may be an ideal candidate for inhaled insulin. There is sufficient support for the requested medication in this clinical setting. Therefore, Afrezza (insulin human) is 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 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: An enrollee has requested authorization and coverage for Gammagard infusions.Multiple sclerosis is a progressive immune disease affecting the central nervous system (CNS), causing neurological dysfunction. Multifocal inflammation of the CNS characterizes the disease and causes impaired nerve conduction. Multiple sclerosis is not a curable pathology; however, there are several medications that are approved by the U.S. Food and Drug Administration (FDA) and indicated for management. There is some evidence to suggest the possibility of benefit with the use of IVIG. When compared with a placebo, IVIG has been associated with disability improvement after one year. However, there is an absence of statistically significant improvement noted after two years. Furthermore, there is a lack of evidence that immunoglobulins can reduce the progression of multiple sclerosis. Despite some testable benefit, IVIG is not endorsed by national neurological groups, including the American Academy of Neurology. Guidelines only support the use of IVIG if conventional immunomodulatory medications are poorly tolerated or ineffective. There is limited evidence supporting the efficacy of Gammagard infusions in this clinical setting. In this case, the patient has been diagnosed with multiple sclerosis. The submitted documentation does not show a poorly tolerated or ineffective response to conventional immunomodulatory medications. There is a lack of support for the requested services in this clinical setting. Thus, Gammagard infusions are not medically necessary for the treatment of the patients medical condition.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 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: An enrollee has requested authorization and coverage for Repatha SureClick 140 mg injector.Plaque stabilization, prevention of progression or occasional plaque regression can be seen with aggressive lipid lowering therapy. Generally, statin therapy would be recommended as standard of care. In this case, the patient has been diagnosed with hyperlipidemia. With intensive lifestyle modifications, nutritional supplements and ezetimibe, he has been able to decrease his LDL to 94. Based on current risk profile, he has a 10-year cardiovascular event risk of 6.7%, and recommendations would be for moderate dose statin therapy to lower his LDL to 70 or below. The risk is further enhanced given the established coronary disease noted on the 2019 CTA. Unfortunately, he is intolerant to low doses statin medications (rosuvastatin 10 mg and simvastatin 20 mg). As he is not at goal and is intolerant of recommended statin medication, the use of an alternative lipid-lowering agent (Repatha PCSK9 inhibitor) is medically appropriate. Thus, the requested Repatha SureClick 140 mg injector is 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for blood glucose testing four (4) times a day from December 2020 and forward utilizing True Metrix strips and lancets.Self-monitoring of blood glucose (SMBG) is recommended as an integral component of diabetes therapy.  Studies have shown that its use is linked to better clinical outcomes and more effective control of blood glucose levels, reducing the risk of diabetes-related complications. Current recommendations state that for individuals injecting insulin more than two times per day, SMBG should be done at least three times per day. However, there is insufficient evidence on the number of times SMBG needs to be done in individuals who are taking oral antidiabetic agents, rather than insulin. According to medical literature, some studies have demonstrated that once daily SMBG is helpful to maintain glycemic control in non-insulin-treated type 2 diabetes. In this case, the patient has been diagnosed with type 2 diabetes. Records show that the patient is taking glipizide, which is an anti-diabetic medication. As such, there is insufficient evidence supporting blood glucose testing four times per day in this case. Thus, blood glucose testing four (4) times a day from December 2020 and forward utilizing True Metrix strips and lancets was not and is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the equipment 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 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: An enrollee has requested authorization and coverage for Dupixent.Findings: Dupixent is FDA approved for the treatment of moderate-to-severe atopic dermatitis. It is not approved nor recommended for alopecia areata. The recommended dosing schedule for atopic dermatitis is 300 mg every other week (14 days). There was a 300 mg weekly dose studied in the original clinical trials, but it consistently failed to demonstrate any superiority over the 300 mg every other week schedule. Moreover, there are no well-regarded existing consensus/treatment guidelines that advocate for increasing the dose of Dupixent to try to achieve greater clinical benefit in this setting.In this case, the patient has a history of atopic dermatitis that has been treated with Dupixent. The patient has had breakthrough flares with the conventional, recommended dosing schedule of 300 mg subcutaneous every 14 days and has requested an increase in the frequency of dosing. However, as noted above, when weekly dosing was studied in the original clinical trials it consistently failed to demonstrate any superiority over the 300 mg every other week schedule. There are also no well-regarded existing consensus/treatment guidelines that advocate for increasing the dose of Dupixent to try to achieve greater clinical benefit in this setting. Therefore, the requested medication, Dupixent, is not medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for this patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in dermatology, with subspecialty certification in dermatopathology, 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 diclofenac sodium 3%. In the medical literature, a study assessed the benefits of various topical anti-inflammatory medications. The authors concluded that topical non-steroidal anti-inflammatory drugs (NSAIDs) provide good levels of pain relief in acute conditions such as sprains, strains and overuse injuries, probably similar to that provided by oral NSAIDs. Specifically, the authors noted that, certain formulations, mainly gel formulations of diclofenac, ibuprofen, and ketoprofen, provide the best results. In addition, researchers reported that, There is good evidence that some formulations of topical diclofenac and ketoprofen are useful in acute pain conditions such as sprains or strains. In this case, the patient has chronic knee pain with a recent episode of falling on his right knee after it buckled. The records document that he has been treated with steroid injections in the past with good effect and ibuprofen 600 mg to manage his knee pain. The patients provider has also recommended topical diclofenac gel 3% to apply to the knee given his acute on chronic episode of pain. Given this support, the requested diclofenac sodium 3% 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections in the left knee.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 options are limited. The patient has tried and failed other conservative treatments. Intraarticular corticosteroid injections are contraindicated because of diabetes mellitus and the chronic right foot ulcer, with the alternative being a total knee arthroplasty. Thus, Euflexxa injections in the left knee 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right knee arthroscopy (partial meniscectomy and limited synovectomy). Researchers concluded that there is a paucity of evidence that operative approaches are superior to conservative measures as the first-line treatment of older patients with knee pain and meniscal tears. From the available data, a trial of conservative therapy is recommended for the treatment of degenerative meniscal tears in older patients in the absence of mechanical symptoms, such as knee locking. Researchers performed a systematic review of the role for arthroscopic meniscectomy in patients with degenerative knee changes. The authors reported that two randomized controlled trials showed a benefit of arthroscopic surgery in patients with limited degenerative joint disease compared with conservative treatment. A study concluded that positive McMurray sign suggests good postoperative outcomes for patients with meniscal tears associated with osteoarthritis. This patient is being treated for primary osteoarthritis of the right knee. MRI demonstrated grade 4 cartilage fissuring seated within the patellar articular surface in the midline femoral trochlea, grade 2 cartilage thinning in the medial compartment, and subtle fraying at the inner inferior surface of the body of the medial meniscus and small effusion within the knee. X-rays showed small patellar osteophytes. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. The provider recommended treatment with diclofenac and the patient presented for follow-up, representing a trial of the medication for approximately one month. There is a lack of documentation that the patient has exhausted conservative options, including physical therapy. Furthermore, significant mechanical symptoms are not evident based on the available records. For these reasons, the requested right knee arthroscopy (partial meniscectomy and limited synovectomy) is 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 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 Synvisc One injections in both knees. 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 severe osteoarthritis of both knees with chronic pain. The patient has tried and failed other conservative treatments, including bilateral intra-articular corticosteroid injections, icing, and nonsteroidal anti-inflammatory drugs, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc One injections in both knees 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: An enrollee has requested authorization and coverage for Otezla 30 mg tablets.Otezla has been approved by the U.S. Food and Drug Administration and is indicated for the treatment of moderate-to-severe psoriasis. Based on the psoriasis treatment guidelines put forth by the American Academy of Dermatology-National Psoriasis Foundation, patients who have psoriasis affecting between 3-10% (defined as moderate) and greater than 10% (defined as severe) of their body surface area are candidates for phototherapy and systemic medical therapy. There are no step therapy guidelines recommended in this context, and the choice of therapy should be made at the discretion of the treating provider with attention paid to patient comorbidities. In this case, the patient has psoriasis affecting greater than 30% of body surface area. In this clinical setting, it is medically appropriate to continue therapy with Otezla. Thus, Otezla 30 mg 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for inpatient care services at Providence St. Joseph Medical Center. In this case, the patient presented with gastroparesis and malnutrition. She had a gastrojejunostomy tube with appropriate placement confirmed on computed tomography (CT) scans, with stable neurologic and hemodynamic statuses. Her future treatment options included deep brain stimulation surgery. The patients chronic pain was managed with a medication regimen. Given that the patient was medically stable, without advanced procedures or monitoring, and without complications or unstable comorbidities, the services at issue were not and are not medically indicated. Therefore, inpatient care services at Providence St. Joseph Medical Center were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are 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 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.