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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for anterior lumbar interbody fusion (ALIF) procedure to L5-S1 (CPT 22558 and 22853). Bydon and colleagues concluded that a trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy. These treatment options may include physical therapy, epidural steroid injections, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion. Resnick and colleagues noted that as a result of decompression, the inherent instability associated with the spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar fusion is considered appropriate to stabilize the spine and prevent delayed deterioration. This patient is being treated for degenerative disc disease at L5-S1, stenosis at L5-S1, left lumbar radiculopathy, and lumbago. The patients records document presentations of chronic low back and bilateral leg pain. The patients provider has recommended ALIF to L5-S1. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. The records include documentation of a recent bilateral transforaminal epidural steroid injection at L5 on 9/29/21 and right L5-S1 interlaminar epidural steroid injection on 8/31/21. Although the records document that the patient has undergone treatment with physical therapy, the available note was dated 9/24/20, without report of completion of recent physical therapy. Moreover, dynamic flexion and extension imaging studies were not provided for review to potentially assess the amount of instability at the requested surgical level. For these reasons, the requested ALIF procedure to L5-S1 (CPT 22558 and 22853) 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computer-assisted navigation during right knee replacement, such as the Mako Robotic Knee System. Medical literature concluded that when total knee arthroplasty was performed by an experienced provider, no significant difference was identified at five-year follow-up between patients who underwent computer-assisted versus manual total knee arthroplasty. Medical literature found that patient specific instrumentation for total knee arthroplasty has not reliably demonstrated improvement of postoperative limb or component alignment when compared with standard instrumentation. Researchers reported that patient specific instrumentation has not been shown to result in clinically meaningful improvement in alignment, better early patient-reported outcome measures, or reduction of operation time. This patient is being treated for right knee pain with a diagnosis of osteoarthritis. The patient has significant joint space narrowing medially and changes of the patellofemoral joint on x-rays. The patients provider has recommended total knee replacement with computer-assisted navigation, such as with the Mako Robotic System. However, there is a paucity of large volume, high quality clinical trials demonstrating that the clinical benefits of computer-assisted surgery over standard surgical approaches in total knee arthroplasty. Therefore, the requested computer-assisted navigation during right knee replacement, such as the Mako Robotic Knee System 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 computer-assisted navigation during right knee replacement, such as the Mako Robotic Knee System 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 orthopedic surgery 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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for Surestep supramalleolar orthosis (SMO) (HCPCS code L1907 x two). Lee and colleagues report that a custom molded ankle orthosis with hinged joints potentially offers better control over the subtalar joint and the ankle joint during lateral cutting movements, due to total contact design and increase in material strength. In this case, the records note that the patient has tried and failed an off-the-shelf model of orthotics. Given that current medical literature supports  custom-made orthosis as more effective than off-the-shelf models at controlling medial lateral movement of the ankle during gait, the requested equipment is medically indicated. Therefore, Surestep SMO (HCPCS code L1907 x two) is medically necessary for the treatment of 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for brand name medication, Wellbutrin XL (extended-release tablet). In a randomized clinical trial testing the bioequivalence and therapeutic equivalence of generic bupropion XL 300 mg to the brand product, researchers concluded that three bupropion XL 300 mg generic products were both bioequivalent and not therapeutically different from the brand drug and from each other. In this case, notes reported a diagnosis of major depressive disorder, treated with bupropion XL 150 mg daily. The patient reported a lack of improvement and no side effects. Notes reported that the patients dosage was increased to bupropion XL 300 mg daily. In an application for independent medical review, the patient reported having tried three different forms of generic Wellbutrin and experiencing side effects and a lack of improvement in symptoms. Despite being requested, the submitted records did not document if the patient underwent standard treatment with selective serotonin reuptake inhibitors (SSRI) as first-line therapy. In this case, given this patients sensitivity to medications and lack of remission, augmenting bupropion with a SSRI or switching therapy to a SSRI or serotonin and norepinephrine reuptake inhibitors (SNRI) would be recommended over the requested medication. Therefore, the brand name medication, Wellbutrin XL (extended-release tablet), is not likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested brand name medication, Wellbutrin XL (extended-release tablet) 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 medication is 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 reviewers 1 and 3 are board certified in psychiatry and are actively practicing. Physician reviewer 2 is board certified in psychiatry and in preventive medicine 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: The patient has requested authorization and coverage for Gammagard IVIG home infusion services. The records provided for review document that this patients work-up has included abnormal skin biopsy results with reduced epidermal nerve fiber density and a high titer of TS-HDS antibodies. The patient has been treated with gabapentin with partial improvement. The patients provider has recommended treatment with IVIG with home infusion services. The treatment of patients with SFPN is dependent on the underlying etiology, including associations with systemic autoimmune conditions. IVIG is considered a first-line treatment for patients with immune-mediated neuropathies. Liu and colleagues reported evidence suggesting that IVIG is safe and effective for rigorously selected SFPN patients with apparent autoimmune causality. In this case, the patient has SFPN with a positive TS-HDS antibody titer. Based on the support in the current peer-reviewed medical literature, patients with autoimmune SFPN may show clinical improvement with IVIG. Moreover, the medical records support an indication for home infusion services for administration of the Gammagard IVIG for this patient. A recent study by Perreault and colleagues concluded that transition from clinic based to home based IVIG infusion can be successfully done to decrease potential exposure during a pandemic in a high-risk immunosuppressed population, with no impact on patient satisfaction, adherence, or efficacy. For these reasons, the requested Gammagard IVIG home infusion services 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for hydrocodone-acetaminophen (ten 10-325 mg tablets, one to two tablets every six hours. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.  The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the records note chronic pain involving multiple sites related to a history of TMJ, lumbar radiculopathy, and a mechanical fall causing broken toes. The records document a history of previous opioid use disorder and the patients providers, including pain management providers, have not recommended or prescribed narcotic therapy. Given that this patient is being treated in a manner consistent with current medical literature regarding opioid therapy for non-cancer indications, the requested medication is not medically indicated. Therefore, hydrocodone-acetaminophen (ten 10-325 mg tablets, one to two tablets every six hours, are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cosentyx 300 mg injections administered every 28 days in the physicians office. This patients records document a history of plaque psoriasis as well as rheumatoid arthritis. The patients provider reported that treatment with methotrexate, topical corticosteroids, and Humira failed to adequately control the patients condition. The patient has started treatment with Cosentyx with good results. The U.S. Food and Drug Administration (FDA) approved Cosentyx for the treatment of patients with chronic plaque psoriasis. The records provided for review document that this patient with plaque psoriasis has been treated with conventional medications without substantial symptomatic improvement. There are data in the medical literature demonstrating that Cosentyx is safe and efficacious in the treatment of patients with plaque psoriasis. Augustin and colleagues concluded that, This meta-analysis strengthens existing evidence on the clinical effectiveness of secukinumab in patients with moderate-to-severe PsO [plaque psoriasis], demonstrating high drug survival rates, high levels of patient-reported outcomes, and good tolerance. However, the in-office injections are not medically necessary. Cosentyx is FDA approved for subcutaneous self-injection. The records do not demonstrate that the patient is unable to perform self-injections. Therefore, the requested Cosentyx 300 mg injections administered every 28 days are medically necessary for treatment of this patient, but the requested services of the physicians office are not medically necessary for the Cosentyx injection administration. Final Result: The reviewer determined that the requested medication, but not the requested services, is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: The patients parent has requested reimbursement and prospective authorization and coverage for Nutropin growth hormone therapy. The records provided for review document that this patients history, test results, and current presentation are consistent with inadequate growth hormone action. Based on the specific test results including Z-score, thyroid stimulating hormone (TSH), insulin like growth factor-1 (IGF-1), and magnetic resonance imaging (MRI), the patients condition is most likely related to pituitary hypoplasia. As noted in the medical literature, pituitary hypoplasia is a generally accepted indication for growth hormone therapy. Further, the patients predicted adult height by the Bayley-Pinneau method based on the height observed was significantly lower than the estimated mid-parental target height. Per the Pediatric Endocrine Society, this patient meets the criteria for treatment with growth hormone therapy (Grimberg, et al.). For these reasons, the Nutropin growth hormone therapy was and is medically necessary for treatment of this patient.Final Result: The reviewer determined that the medication at issue was and 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 pediatrics with subspecialty certification in pediatric endocrinology 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 reimbursement for DecisionDx-Melanoma genetic testing performed with Castle Biosciences Inc. Based on the patients American Joint Committee on Cancer (AJCC) stage alone, she had five-year and ten-year melanoma survival rates of 99% and 93%, respectively. The gene expression profiling (GEP) test was subsequently performed and yielded a Class 1a score. Based on the GEP score alone, the patients five-year melanoma specific survival would be as high as 100%, signifying a better prognosis for the patient. At this time, there is a lack of evidence indicating that this information can be used in a clinically meaningful way to benefit the patient, namely, how much less follow-up or screening would be safe for the patient given her current AJCC stage combined with GEP score. The National Comprehensive Cancer Network (NCCN) guidelines for cutaneous melanoma do not endorse the use of GEP testing at this time and it is not incorporated into the widely used treatment and management protocols. Therefore, DecisionDx-Melanoma genetic testing performed with Castle Biosciences Inc. was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma genetic testing performed with Castle Biosciences Inc. was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not 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 upheld. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for sacroiliac joint fusion surgery. As noted in the medical literature, sacroiliac joint block is the gold standard to establish a diagnosis of sacroiliac joint dysfunction (Zaidi, et al.). Simopoulos and colleagues performed a systematic evaluation of sacroiliac joint interventions. The authors commented that, The diagnosis and treatment of sacroiliac joint pain continues to be characterized by wide variability and a paucity of the literature. The authors concluded that, Based on present knowledge, a proper diagnosis can only be made using controlled diagnostic blocks. This patients records do not include documentation of response to sacroiliac joint block injections. In this clinical setting, SI fusion is not anticipated to produce a positive result. Therefore, the sacroiliac joint fusion surgery was not medically necessary for 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 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for transcatheter pulmonary valve implantation, percutaneous approach, including presenting of valve delivery site when performed (33477). In this case, the patient has a native dilated right ventricular outflow tract and severe pulmonary regurgitation that requires replacement to prevent right ventricular failure and further life threating arrhythmias. As the patients right ventricular outflow tract is too big to allow successful placement of a percutaneous pulmonary valve, such as a Melody valve, the only other percutaneous approach is with use of a Harmony valve, which has been shown in current medical literature as successful in larger right ventricular outflow tracts. Given that additional open-heart surgery in this clinical setting of a severely dilated right ventricle and arrhythmias is associated with significantly increased risk of adverse cardiac outcomes compared to percutaneous valve placement, the use of a Harmony valve is the only viable percutaneous option. Therefore, transcatheter pulmonary valve implantation, percutaneous approach, including presenting of valve delivery site when performed (33477), 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 transcatheter pulmonary valve implantation, percutaneous approach, including presenting of valve delivery site when performed (33477), 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 service 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.