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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a heart surgery, a patent foramen ovale (PFO) closure (using a Cardioform percutaneous device). Nietlispach and Meier advocate for the use of percutaneous PFO closure for primary stroke prevention in high-risk populations, which includes patients who are suffering from a disease associated with PFO. In a review of patient-pooled analysis, Desai and colleagues found that PFO closure for the treatment of migraine, both with and without aura, was safe and reduced the average number of monthly migraine days and attacks compared with medical therapy. In this case, the records note a history of migraines and that the patient is anticipating in-vitro fertilization (IVF) treatment that is likely to exacerbate her already existing hypercoagulable state due to Factor V Leiden and MTHFR gene mutation. In this clinical setting,  PFO closure will reduce the potential for a paradoxical embolism and stroke without the bleeding risk associated with systemic anticoagulant therapy.  Therefore, heart surgery, a PFO closure (using a Cardioform percutaneous device), 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 heart surgery, a patent foramen ovale (PFO) closure (using a Cardioform percutaneous device), 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 certification in cardiovascular disease and are actively practicing. Physician reviewer 2 is board certified internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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 Dupixent. Findings: The U.S. Food and Drug Administration (FDA) approves the use of Dupixent, an interleukin-4 receptor alpha antagonist, for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. There are very few treatments approved for this condition, and Dupixent is the preferred therapeutic option by dermatologists in the community. A study notes that the data supporting the safety and efficacy of the use of dupilumab (brand name Dupixent) in moderate-to-severe atopic dermatitis is substantial. In this case, given that the patient has a diagnosis of atopic dermatitis with an IGA score of 4, indicating severe disease, the requested medication is medically indicated. Therefore, Dupixent 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 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

Findings:  The physician reviewer found that The patient has requested reimbursement for services provided at a medical center. Cecconi and colleagues noted that, The World Health Assembly and WHO made sepsis a global health priority in 2017 and have adopted a resolution to improve the prevention, diagnosis, and management of sepsis. In 2016, a new definition of sepsis (Sepsis-3) was developed. Sepsis is now defined as infection with organ dysfunction. The patients blood culture reportedly showed gram-positive cocci as an outpatient, and was started on antibiotics. However, the patient did not require admission for management of her symptoms. The patient did not have documented evidence of sepsis when hospitalized (Iwashyna, et al.). A full admission for sepsis requires evidence of serious infection with report of signs or symptoms such as high fever, impaired renal function, and confusion. The patient had none of the expected corollaries of sepsis. Therefore, the services at issue were 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for a weekly injection of Humira 40 mg. The America College of Rheumatology (ACR) guidelines recommend the following for the treatment of active of psoriatic arthritis (PsA) in treatment-naive patients: Treatment with a tumor necrosis factor inhibitor (TNFi) biologic agent is recommended over an oral small molecule (OSM) as a first- line option. OSMs may be used instead of a TNFi biologic in patients without severe PsA and without severe psoriasis, those who prefer an oral drug instead of parenteral therapy, or those with contraindications to TNFi treatment, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. For treatment-naive patients with active PsA, the use of a TNFi biologic or OSM is recommended over an interleukin (IL) 17 inhibitor or IL-12/23i biologic. An IL-17i or IL-12/23i biologic may be used instead of TNFi biologics in patients with severe psoriasis or contraindications to TNFi biologics and may be used instead of OSMs in patients with severe psoriasis or severe PsA. Methotrexate is recommended over non-steroidal anti-inflammatory drugs (NSAIDs) in treatment-naive patients with active PsA.  NSAIDs may be used instead of methotrexate after consideration of possible contraindications and side effect profile in patients without evidence of severe PsA or severe psoriasis and in those at risk for liver toxicity. An IL-17i biologic is recommended over an IL-12/23i biologic.  IL-12/23i biologics may be used in patients who have concomitant inflammatory bowel disease or who desire less frequent drug administration. In this case, the patient has evidence of active PsA. While current medical literature supports the use of a TNFi, such as Humira, as first line therapy for the treatment of active PsA, there is a lack of evidence or data demonstrating the efficacy and safety of accelerated dosing of a TNFi for the treatment of PsA. Given the lack of support in current guidelines recommending increased dosing of TNFi for the treatment of PsA, the requested medication regimen is not medically indicated. Therefore, a weekly injection of Humira 40 mg is not medically necessary for the treatment of this patient..Final Result: The reviewer determined that the requested medication regimen 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for proton beam radiation therapy (PBRT). This patients treating provider has supplied the results of a PBRT versus photon beam radiation therapy plan comparison, which shows that the photon-based IMRT plan results in excessive exposure to the patients contralateral salivary tissues and oral cavity. If delivered, the photon based plan would lead to an unacceptable risk for xerostomia and dysphagia. The PBRT plan is able to significantly reduce the exposure to the contralateral salivary tissues and oral cavity, thereby minimizing the risk for chronic radiation-induced toxicity. In addition, the requested PBRT for this patient is supported by the American Society of Radiation Oncology (ASTRO), which recommends coverage for unresectable head and neck malignancies and for patients who cannot be treated safely with photon-based treatment techniques. The records provided for review document that this patients disease could not be resected to negative margins. Furthermore, there are numerous high quality prospective clinical outcomes published in the peer-reviewed medical literature demonstrating the safety and efficacy of PBRT for management of head and neck malignancies. Given this support, the requested PBRT 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 reimbursement for Gelsyn-3 injections to 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. 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 patients options were limited. She was unable to take cortisone injections due to cardiac complications and had tried and failed physical therapy, restriction of activities, and NSAIDs. Therefore, Gelsyn-3 injections to the left knee were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: A patient has requested authorization and coverage for a Monovisc injection in the right 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. 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 enrollee has failed NSAIDs, arthroscopic surgery, and physical therapy. The right knee remains swollen and painful. The osteoarthritis is considered mild, and the patient is not a candidate for joint replacement surgery. There is sufficient support for the requested service in this clinical setting. Therefore, the requested Monovisc injection in the right knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 inpatient admission services. The records provided for review document that this patient presented to the emergency department with complaints of an erythematous rash that covered most of their body. The patient reported that they noticed symptoms following receipt of their second dose of the COVID-19 vaccine. The provider noted that the patient was afebrile due to treatment with Tylenol. The patient does not have a reported history of allergic reaction to vaccine or injectable. Overall, the patients presentation was concerning for delayed hypersensitivity reaction to the COVID-19 vaccine, which required evaluation and treatment at the inpatient level of care. The Centers for Disease Control and Prevention (CDC) recommend that patients with a history of an immediate allergic reaction to a vaccine or injectable or any history of anaphylaxis be observed for 30 minutes after COVID-19 vaccination while all other individuals should be observed for 15 minutes (Banerji, et al.). However, as noted by Sokolowska and colleagues, as is the case for any medication, anaphylaxis may occur after vaccination in the absence of a history of allergic disease. Considering the potential severity of some of this patients possible diagnoses and the need for treatment with IV steroids, the inpatient admission services were appropriate. Given this support, the inpatient admission services were medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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: An enrollee has requested authorization and coverage for Aimovig 70 mg/ml auto-injector. Aimovig (erenumab) is a calcitonin gene-related peptide monoclonal antibody (CGRP mAb). CGRP mAbs are biologic agents that have demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3 randomized, placebocontrolled trials. Medical literature shows a phase 2 randomized, double-blind placebo-controlled study of erenumab for adults aged 18-65 years with chronic migraines. Medical literature shows that erenumab 70 mg and 140 mg reduced the number of monthly migraine days, with a safety profile similar to placebo. Medical literature shows, Clinical judgment may result in an emerging treatment being added to one or more established treatments. If initiating treatment with an antiCGRP mAb in a patient already on a preventive treatment, since the risk of drugmAb interactions is minimal or nonexistent, it is appropriate to add the mAb to the existing regimen and make no other changes until the effectiveness of the mAb is determined. In this case, the patient has a history of chronic migraines that have not responded to oral preventive medications. In this setting, it is appropriate to initiate treatment with an antiCGRP mAb. Therefore, Aimovig 70 mg/ml auto-injector, 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 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 Wegovy. The submitted documentation supports the medical necessity of the requested medication. 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. Currently, several pharmacologic therapies are available for weight management. Wegovy (semaglutide) is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs. These medications improve glycemic control, reduce body weight and decrease cardiovascular risk. Multiple studies have demonstrated this medications ability to promote weight loss. Therefore, Wegovy 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: A patient has requested reimbursement for Intensive Care Unit (ICU) services. Findings:  The physician reviewer found that the submitted records partially support that the services at issue were medically necessary. In this case, the patient presented with a submassive pulmonary embolism, for which he underwent catheter-directed thrombolysis treatment with EKOS. This treatment option was reasonable based on the current medical evidence and clinical practice guidelines. This treatment necessitated ICU level care on the first date of service, given the presence of pulmonary artery catheters, which required close monitoring and strict positioning of the patient flat in bed. The catheters were removed on the first date of service, after which time the patient would have been safe to transfer to the floor, given his lower acuity needs. Thus, by the second date of service, ICU-level services were no longer medically necessary. Accordingly, while ICU services provided on the first date of service were medically necessary to treat the patients medical condition, ICU services provided on the second date of service were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were partially medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in pulmonary disease and critical care 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for apolipoprotein test (CPT 82172). The records provided for review document that this patient has a history of elevated lipoprotein levels. The patients provider has recommended additional evaluation with apolipoprotein testing. However, there is a paucity of support for the requested apolipoprotein testing for further evaluation of this patients cardiovascular risk. The available medical literature has not shown that strategies to correct the residual risk potentially identified by apolipoprotein testing will further reduce a patients cardiovascular risk (Robinson). Current clinical trial data do not support the superiority of treatment strategies based on novel apolipoprotein testing as requested for use in this patients evaluation and treatment. Therefore, the requested apolipoprotein test (CPT 82172) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested apolipoprotein test (CPT 82172) is not likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.