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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for sodium hyaluronate/hyaluronan injection series (either a series of four Orthovisc injections or a series of three Gelsyn-3 injections) in both 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. 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 patients case, there is a history of lasting benefit from viscosupplementation of both knees. The injections helped to reduce his knee pain. Oral and topical medications were not effective. Therefore, the requested sodium hyaluronate/hyaluronan injection series (either a series of four Orthovisc injections or a series of three Gelsyn-3 injections) in both knees 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

Findings:  The physician reviewer found that The patient has requested reimbursement for transthoracic echocardiography. The available documentation supports that this patient presented with symptoms of left-sided chest pain, which worsened with deep inspiration and lying flat, as well as dyspnea. The patients symptoms reportedly started after the patient received COVID-19 vaccines. The patient underwent evaluation with a transthoracic echocardiography. Per the American College of Cardiology (ACC) appropriate use criteria for transthoracic echocardiography, the test is appropriate for patients with symptoms suggestive of  heart disease or dyspnea of uncertain cause (Doherty, et al.). In this case, the patients chest pain may have been due to pericarditis as it was increased with lying flat. The patient also reported associated dyspnea and the provider noted concern for cardiac disease. In this clinical setting, the patient meets the ACC criteria for transthoracic echocardiography. Myocarditis and pericarditis were also considerations, as the patient experienced symptom onset after receiving COVID-19 vaccines (Shay, et al.). Given these findings, the transthoracic echocardiography was medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
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 braces. Based on the available documentation, the providers submitted HLD score of 26 noted by the provider was overcalculated. The major discrepancy in the submitted HLD score and the records is in the scoring of the anterior-posterior (AP) spread. The provider submitted an 8 mm AP spread, which is not supported by the photographs provided for review, which supports an AP spread of 4 mm. Based on the records, the HLD index review included an overjet of 4 mm, overbite of 3 mm, anterior crowding for 5 points on the upper and 5 points on the lower, and an AP spread of 4 mm, for an HLD index score of 21. The records support a score of 21 on the HLD, which is below the required threshold to support a medical indication for the requested braces and associated orthodontic services. As with any malocclusion, orthodontic correction would aid in the patients ability to chew and tear food and aesthetics, so the requested treatment would benefit the patient functionally. However, there is a lack of evidence of a health condition caused by the current occlusion to support that the requested procedure is necessary for the patient to achieve adequate nutrition. The patients mother states that the patient bites cheek, has a lisp due to malocclusion, and has very crowded teeth. Overall, the records do not demonstrate that the patient has any significant health issues related to the requested orthodontic services to support the requested treatment with a HLD score below the threshold recommended for the requested orthodontic services. All told, the requested braces are not necessary to prevent disease and promote oral health, or restore oral structures to health and function.Final Result: The reviewer determined that the requested services are not 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 Besremi. The available records document that this patient has low-risk polycythemia vera. The patients provider has recommended treatment with Besremi. The U.S. Food and Drug Administration (FDA) has approved Besremi for the treatment of patients with polycythemia vera. Per the National Comprehensive Cancer Network (NCCN) guidelines, cytoreduction such as with hydroxyurea, is not recommended as initial therapy for this patient population. The NCCN guidelines support treatment with Besremi as category 2B for use in this patients clinical setting. Barbui and colleagues noted that supplementing phlebotomy with Besremi is supported as safe and effective in steadily maintaining haematocrit values on target in low-risk patients with polycythaemia vera. Gisslinger and colleagues found that Besremi demonstrated high durable hematological and molecular responses as well as good tolerability. The authors reported that Besremi offers a valuable and safe long-term treatment option with features distinct from hydroxyurea. The authors concluded that the addition of Besremi to phlebotomy led to a higher response rate compared to phlebotomy alone. Given these findings, the requested Besremi is medically necessary for 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 certifications in medical oncology and hematology 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 HopeSeq HemeComplete genetic testing (concurrent analysis of HopeSeq HemeMutations, HopeSeq HemeFusions and HopeSeq Expressions). Findings:  The physician reviewer found that patients with myeloproliferative neoplasms can present with diverse clinical manifestations including splenomegaly, leukocytosis coming polycythemia, thrombocythemia, or eosinophilia. Reiter and Gotlib report that eosinopenia is a common feature of the family of diseases generated by dysregulated fusion tyrosine kinase (TK) genes. Chronic eosinophilia can be a primary myeloproliferative neoplasm due to clonal mutations in hematopoietic progenitor cells. An analysis of distinct  mutations may show whether the patient has a primary eosinophilia rather than a secondary eosinophilia caused by a separate disorder such as lymphoma. Furthermore, this type of testing is consistent with National Comprehensive Cancer Network (NCCN)  guidelines for myeloid/lymphoid neoplasms with eosinophilia and TK fusion genes. Therefore, HopeSeq HemeComplete genetic testing (concurrent analysis of HopeSeq HemeMutations, HopeSeq HemeFusions and HopeSeq Expressions) is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested HopeSeq HemeComplete genetic testing (concurrent analysis of HopeSeq HemeMutations, HopeSeq HemeFusions and HopeSeq Expressions) 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. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology 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 Botox injections. This patient has a history of chronic migraines that have been resistant to treatment with several different classes of medications. The provider noted that treatment with Botox for migraines has successfully improved the patients quality of life with reduction in the intensity of the migraines. The provider has recommended continued treatment with Botox. The U.S. Food and Drug Administration (FDA) has approved Botox for the indication of treating and preventing chronic migraine headaches. In addition, there are large randomized controlled trials demonstrating clinically relevant benefit, which supports this patients reported response to therapy and continued treatment. Herd and colleagues performed a review of Botox injections in the treatment of patients with migraines. The authors found that Botox may reduce the number of migraine days per month in the chronic migraine population by 3.1 days. Frampton and Silberstein concluded that the data from current clinical trials indicates that Botox is an effective and generally well-tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. Given this support, the requested Botox injections 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 anesthesiology with subspecialty certification in pain 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the Intracept procedure (intraosseous ablation of the basivertebral nerve). The records document that this patient has a history of chronic low back pain that has persisted for several years. Treatment has included medications, physical therapy, and injection therapy without sustained benefit. The patients provider has recommended treatment with the Intracept procedure. Fischgrund and colleagues demonstrated that Intracept procedure is superior to continued conventional treatment with physical methods and injections for the treatment of patients with chronic back pain. Truumees and colleagues noted that the ideal candidate for the Intracept procedure has axial low back pain with Modic endplate changes on magnetic resonance imaging (MRI). In this case, the patient has ongoing low back pain with significant MRI changes. The peer-reviewed medical literature suggests that the Intracept procedure is superior to continued conservative care with data suggesting benefit beyond two years. Given this support, the requested Intracept procedure (intraosseous ablation of the 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 procedure (intraosseous ablation of the basivertebral nerve). 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Skyrizi 150 mg/mL pen. The records provided for review document that this patient presents with a two-year history of psoriasis with a BSA of 5% and disease involvement on the genitals and scalp. The patient has been treated with and failed to substantially improve with two IL-17 pathway inhibitors including ixekizumab and secukinumab. The patients provider has recommended treatment with Skyrizi. The systemic treatment of psoriasis is indicated when topical treatments are not tolerated or fail to achieve sufficient control of disease. Systemic therapies are particularly important to control psoriasis on the scalp, hands, and other areas that are difficult to treat with topical medications. There are several systemic options for the treatment of patients with psoriasis including non-biologics and biologics. Data suggests that biologics such as Skyrizi, which is an IL-23 inhibitor, have greater demonstrated efficacy when compared to non-biologic therapies (Armstrong, et al.; Menter, et al.). Given this patients failure of IL-17 agents, treatment with a less efficacious agent such as a tumor necrosis factor (TNF)-alpha inhibitor is not recommended. The medical literature and guidelines support treatment with an IL-23 inhibitor such as Skyrizi for treatment of this patients psoriasis. For these reasons, the requested Skyrizi 150 mg/mL pen 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 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 authorization and coverage for laparoscopic distal bypass. Findings:  The physician reviewer found that The available documentation indicates that this patient is a candidate for surgical intervention to lengthen the bypass limb. The patient is status post Roux-en-Y gastric bypass as well as revision surgery. However, the patient continues to be morbidly obese with a body mass index (BMI) over 50 kg/m2. Moreover, the patient has comorbidities including diabetes, hypertension, hyperlipidemia, and fatty liver. Given the patients BMI and comorbidities, the requested lengthening of the limb is likely to provide the patient with the best health outcome. El Ansari and Elhag noted that bariatric surgery remains effective and durable for treating obesity and ameliorating or resolving the obesity-related comorbidities. The authors commented that revision bariatric surgery is indicated to address surgical complications, weight regain or insufficient weight loss. In this patients clinical setting of weight regain after Roux-en-Y gastric bypass and revision, the requested laparoscopic distal bypass is likely to be more beneficial than other surgical approaches. All told, the requested laparoscopic distal bypass 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 laparoscopic distal bypass 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 reviewer 1 is board certified in general surgery and is actively practicing. Physician reviewer 2 is board certified in general surgery and is actively practicing. Physician reviewer 3 is board certified in general 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Letermovir 480 mg, 90 tablets for a 90-day supply. The medical records document that this patients clinical picture is consistent with cytomegalovirus (CMV)-related eye disease. The provider noted that the patient required a repeat corneal transplant while receiving valganciclovir prophylaxis, which suggests that valganciclovir may not be adequately suppressing the CMV. However, the recent clinical examination does not show evidence of active CMV infection or inflammation. Although there is evidence to support the use of letermovir for active CMV infection, there is a lack of documentation of active infection (Tsui, et al.). Overall, there is inadequate evidence to support that treatment with letermovir is likely to be more effective than valganciclovir for treatment of this patient. Therefore, the requested Letermovir 480 mg, 90 tablets for a 90-day supply 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 Letermovir 480 mg, 90 tablets for a 90-day supply 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 reviewer 1 is board certified in ophthalmology and is actively practicing. Physician reviewer 2 is board certified in ophthalmology and is actively practicing. Physician reviewer 3 is board certified in ophthalmology 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 patient has requested authorization and coverage for Xeljanz. The records provided for review document that this patient has symptoms consistent with alopecia totalis. The provider charted that the patient has failed to substantially respond to treatment with methotrexate, minoxidil, and clobetasol cream. The patients provider has recommended treatment with Xeljanz, which is a Janus kinase (JAK) inhibitor. Overall, there is adequate evidence that JAK inhibitors, in particular Xeljanz, is efficacious for the treatment of patients with alopecia totalis. Liu and colleagues concluded that Xeljanz should be considered for the treatment of severe AA [alopecia areata], alopecia totalis, and alopecia universalis. King and colleagues noted that baricitinib, another JAK inhibitor, has demonstrated efficacy in the treatment of patients with alopecia areata. Similarly, there are adequate large case series reports in the medical literature reporting the improvement of symptomatic alopecia with Xeljanz (Ibrahim, et al.). This patients records document failure to respond to other systemic medications including methotrexate, and topical treatments including steroids and minoxidil. Therefore, the requested Xeljanz 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.