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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for 25-hydroxy vitamin D screening test (procedure code 82306) rendered by Quest Diagnostics in Philadelphia. It is standard practice for evaluations of unusual pediatric fractures to include an assessment of vitamin D status to exclude vitamin D deficiency, which may be a common risk factor for fracture or an indication of treatable nutritional deficiency, and to exclude disorders of calcium metabolism. In a study on vitamin D insufficiency and fracture risk, Thompson and colleagues report that higher fracture incidence is associated with serum 25-hydroxy vitamin D insufficiency and that consideration should be given to routine assessment of vitamin D in fractured children. Scully and colleagues note that patellar stress fractures are exceptionally rare in the pediatric population and necessitate a diligent workup. Reinhardt and colleagues report that the prevalence of vitamin D insufficiency/deficiency of operative patella fractures suggest that these patients likely have abnormal vitamin D levels and should undergo a metabolic bone work-up. In this case, given the patients medical condition of multiple non-trivial fractures, including a patellar fracture and failure to thrive, the service at issue was medically indicated. Therefore, the 25-hydroxy vitamin D screening test (procedure code 82306) rendered by Quest Diagnostics in Philadelphia was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Imvexxy vaginal insert 4 mcg. The U.S. Food and Drug Administration (FDA) approves the use Imvexxy, a vaginal estradiol insert,  for the treatment of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy, due to menopause. Archer and colleagues report that vaginal estradiol softgel capsules result in negligible to very low systemic absorption of estradiol and provide local benefits with limited systemic exposure. In this case, the records document that the risk/benefit profile regarding systemic absorption of estrogen in the setting of this patients breast cancer history was discussed with an oncologist. Given that the one of the vaginal estrogen preparations with the lowest systemic absorption is a standard regimen of the 4 mcg estradiol tablets such as Imvexxy, the requested medication is medically indicated. Therefore, Imvexxy vaginal insert 4 mcg 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 obstetrics and gynecology 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 gene expression test. There is a lack of evidence from randomized controlled trials in current medical literature that the results from gene expression profiling (GEP) tests may be used in a clinically meaningful way for the benefit of the patient. The results from the GEP test, combined with the patients American Joint Committee on Cancer (AJCC) stage, do not answer questions how much less or more follow-up, screening, or treatment would be beneficial for this patient. 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, the DecisionDx-Melanoma gene expression test was not likely to have been more beneficial for evaluation of the patients 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ozempic. Findings:  The physician reviewer found that the patients records document a history of obesity, prediabetes, and hyperlipidemia. As part of his treatment regimen, the provider has recommended treatment with Ozempic. While lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. There are currently multiple pharmacologic therapies which are available for weight management (Gadde, et al.). Ozempic is a member of a class of medications known as glucagon like peptide 1 (GLP-1) analogs, which have been demonstrated to improve glycemic control as well as reduce body weight and decrease cardiovascular risk (Knudson and Lau). Multiple studies have shown that Ozempic is a safe and effective agent used to promote weight loss, via reduced appetite and energy intake, and delayed gastric emptying (Cornell). In this clinical setting, this patient is an appropriate candidate for treatment with Ozempic. Given these findings, the requested Ozempic 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. This patients records document a history of malignant melanoma, superficial spreading type, with a maximum tumor thickness of at least 0.5 mm, with peripheral margin involved by melanoma in situ. A sample of the patients tumor was submitted for analysis with DecisionDx-Melanoma testing. The data available from the peer-reviewed medical literature does not support the routine use of the DecisionDx-Melanoma test after sentinel lymph node biopsy (Gerami, et al.). In addition, the National Comprehensive Cancer Network (NCCN) does not recommend the DecisionDx-Melanoma assay for the evaluation and treatment planning of patients with melanoma. The two prospective studies discussed within the NCCN guidelines indicate that the patients analyzed were a high risk cohort. There has also been a lack of consistency between various genes being used as biomarkers. Given these findings, the DecisionDx-Melanoma genetic testing was 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 DecisionDx-Melanoma genetic testing was 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 sacroiliac joint fusion (CPT 27279). Findings:  The physician reviewer found that In addition, the authors found sacroiliac joint fusion to be more effective than nonsurgical treatment modalities. Polly and colleagues noted that, In this Level 1 multicenter prospective randomized controlled trial, minimally invasive sacroiliac joint fusion with triangular titanium implants provided larger improvements in pain, disability and quality of life compared to nonsurgical management. In this case, the patient has undergone maximal nonsurgical treatment with injections that have localized the pain to the sacroiliac joint. While there is adjacent level degenerative disc disease on imaging next to the prior lumbar fusion, it is remote from the pain site anatomically. Therefore, the requested sacroiliac joint fusion (CPT 27279) 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 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 Vicodin 5 mg to be taken twice daily. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The guidelines further advise, 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. Manchikanti and colleague state to establish medical necessity for opioid therapy, it is essential to have a physical diagnosis and information on inadequacy of multiple modalities of treatments including non-controlled substance therapy, physical modalities, behavioral interventions, interventional pain management techniques, and any other alternatives. In this case, the records note that the patient is managed on Norco. Both Vicodin and Norco contain hydrocodone as the active opioid agent, with the main difference being that Vicodin is formulated with a higher dose of acetaminophen compared to the Norco, and there is a lack of evidence that one medication is superior to the other in terms of clinical efficacy in the treatment of pain. Given the lack of evidence in current medical literature showing that any one opioid is superior to another, and a lack of documentation reporting that any specific allergy or adverse drug reactions to Norco, the requested medication is not medically indicated. Therefore, Vicodin 5 mg to be taken twice daily 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 anesthesiology with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet rich plasma (PRP) treatment (CPT 0232T). Findings:  The physician reviewer found that This patient is being treated for osteoarthritis of the left ankle. The patient previously underwent left ankle arthrodesis peroneus longus and brevis tenolysis in 2019 with hardware removal in 2021. The patient presents with continued complaints of foot pain that is persistent and noted to be in the heel rated at 4/10 in the posterior aspect. The provider noted that the patient has been treated with physical therapy. The provider has recommended treatment with PRP injections. On review of the peer-reviewed medical literature, the data on PRP injections remains mixed with regard to efficacy in the treatment of patients with ankle arthritis. Fukawa and colleagues concluded that intra-articular PRP injections resulted in no serious adverse effects, while it reduced pain in the patients with ankle osteoarthritis. Paget and colleagues concluded among patients with ankle osteoarthritis, intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks. However, there is a paucity of large-scale, peer-reviewed literature demonstrating the long-term safety and efficacy of PRP injection in the treatment of patients with ankle osteoarthritis. For these reasons, the requested PRP treatment (CPT 0232T) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested PRP treatment (CPT 0232T) is not likely to be more beneficial for treatment of the patients 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 patient has requested authorization and coverage for Synvisc One injection to the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients available treatment options are limited. The patients right knee pain has not responded treatment with corticosteroid injections, NSAIDs, or arthroscopic surgery. The provider has recommended treatment with a Synvisc One injection for the right knee, which is consistent with the current AAOS guidelines and medical literature. For these reasons, the requested Synvisc One injection to the right knee 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trulicity (dulaglutide). Findings:  The physician reviewer found that Trujillo reports that glucagon-like peptide-1 receptor agonists (GLP-1 RAs), such as Trulicity, have been incorporated into type 2 diabetes clinical guidelines. GLP1 RAs promote glucose control through mimicking GLP1 and activating GLP1 receptor mechanisms, thus increasing glucosedependent insulin secretion, inhibiting glucagon secretion, and decreasing gastric emptying. Iorga and colleagues note that GLP1 RAs associated with a significant reduction of cardiovascular and all-cause mortality. Given that current medical literature supports the use of GLP-1 RAs to improve glycemic control and aid weight loss, and as carrying a lower risk of hypoglycemia compared with other glucoselowering treatments, the requested medication is medically indicated. Therefore, Trulicity (dulaglutide) 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gelsyn injections x 3 to the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the options are limited. The enrollee is unable to have corticosteroid injections due to facial flushing. The osteoarthritis of the left knee is mild, and she is not a candidate for total knee arthroplasty. All told, the requested Gelsyn injections x 3 to the left knee 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 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 minimally invasive lumbar decompression (MILD) procedure. The records provided for review document that this patient presents with pain secondary to lumbar spinal stenosis. Treatment has included transforaminal steroid injections. The patients provider has recommended treatment with the MILD procedure. In the multicenter a study found patients demonstrated a statistically significant reduction of pain and statistically significant improvement in physical function and mobility from baseline through two years with the MILD procedure. In addition, no major device or procedural complications were reported. Researchers found that the MILD procedure provided significant improvement from baseline at all follow-up intervals over two years. According to the authors, the MILD procedure resulted in lower re-operation rates, less morbidity and greater safety when compared to the broad range of lumbar spine interventions including spacers, surgical decompression, and spinal fusion. Given these findings, the requested MILD procedure 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 MILD 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 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.