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 cervical interlaminar epidural steroid injection at level C6-7. The updated American Society of Interventional Pain Physicians (ASIPP) guidelines state that the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness. The ASIPP guidelines also state that there is level 2 grade medical evidence to support use of these injections for patients with cervical stenosis conditions. In this case, the patient has cervical radiculopathy confirmed by physical examination and EMG study. In addition, the patients CT scan of the neck confirmed corresponding degenerative spine changes associated with neuroforaminal stenosis. The patients condition has not responded to three months of conservative care including medication management with NSAIDs, opiates, and neuromodulating agents. Moreover, the patient has been treated with a course of physical therapy and a home exercise program without adequate benefit. The next step in the treatment algorithm involves an epidural steroid injection. There is Level 1 and 2 evidence in the peer-reviewed medical literature demonstrating that this treatment can be effective for treatment of this patients cervical radiculopathy and stenosis. Given these findings, the requested cervical interlaminar epidural steroid injection at level C6-7 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Actemra solution prefilled syringe 162 mg/0.9 mL. The American College of Rheumatology guidelines for the treatment of rheumatoid arthritis recommend that patients who do not tolerate monotherapy with methotrexate try a tumor necrosis factor (TNF) inhibitor or any other non-TNF inhibitor biologic. Buckland reports that a phase IV study in patients with severe rheumatoid arthritis receiving tocilizumab (brand name Actemra) or adalimumab as monotherapy, without concomitant methotrexate, demonstrated that tocilizumab was superior to adalimumab for reducing the severity of disease in this setting. Given that current medical literature supports the efficacy and safety of Actemra in this clinical setting, the requested medications is medically indicated. Therefore, Actemra solution prefilled syringe 162 mg/0.9 mL 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 rheumatology 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 Nurtec 75 mg tablet every other day. Calcitonin generelated peptide (CGRP) monoclonal antibodies 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. Per the American Headache Society (AHS), this patient meets the criteria for treatment with a CGRP monoclonal antibody medication. In 2020, the U.S. Food and Drug Administration (FDA) approved Nurtec, an orally administered CGRP receptor antagonist, for the acute treatment of migraine with or without aura in adults and preventive treatment of episodic migraine in adults. The FDA approved Nurtec based on results of a randomized, double-blind, placebo-controlled trial published by Croop and colleagues. The authors noted that when taken every other day, Nurtec was effective for the preventive treatment of migraine. In this case, the patient has a history of migraines that have not responded to multiple preventative medications. The patients provider has recommended treatment with Nurtec, which is an alternative treatment approved by the FDA for the prevention of migraines in adults. Given this support, the requested Nurtec 75 mg tablet every other day 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 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for neuropsychological testing services including: (1 hour of 96132; 1.5 hours of 96133); (1 hour of 96116; 1 hour of 96121; 0.5 hour of 96136; 1 hour of 96137); (4 hours of 96137); (2 hours of 96137); (2 hours of 96133); (1 hour of 96133); and (1 hour of 96133). Neuropsychological testing is a key diagnostic tool for assessing patients with dementia and mild cognitive impairment, as well as other neurological conditions such as Parkinsons disease, stroke, multiple sclerosis, traumatic brain injury, and epilepsy. In the pediatric population, neuropsychologic assessments are used to evaluate developmental delays in addition to cognitive, behavioral, sensory-motor, perceptual, and socio-affective functioning skills. As noted in the medical literature ADHD, anxiety disorders, depression, and social disorder are clinical diagnoses that do not require confirmation via neuropsychological testing (Husser, et al.; Wolraich, et al.). According to the records provided for review, this patient was previously diagnosed with ADHD, inattentive presentation, in 2018. The provider noted that the patient was experiencing stressors, which contributed to his anxiety and depressive symptoms. In this clinical setting, a comprehensive psychiatric evaluation and utilization of various self, parent, and teacher rating scales would have been adequate for evaluation and treatment of this patient. For the reasons outlined, the neuropsychological testing services including: (1 hour of 96132; 1.5 hours of 96133); (1 hour of 96116; 1 hour of 96121; 0.5 hour of 96136; 1 hour of 96137); (4 hours of 96137); (2 hours of 96137); (2 hours of 96133); (1 hour of 96133); and (1 hour of 96133) were not medically necessary for this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry 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 IVIG infusions (J1568) (S9338) (99601) and (99602). Findings:  The physician reviewer found that Bonilla and colleagues note that immunodeficient patients are generally treated with prophylactic antibiotics. If there are still breakthrough infections, immunoglobulin replacement therapy may be considered. In this case, the records note a history of breakthrough infections, including two episodes of pneumonia, and recurrent sinopulmonary and gastrointestinal infections. Therefore, IVIG infusions (J1568) (S9338) (99601) and (99602) are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine and in allergy and immunology 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 acute rehabilitation facility services. The patient has a history of thoracic level myelopathy due to cord compression by metastatic disease. The patient underwent decompressive and stabilizing spinal surgery. The patient has experienced residual paraparesis, neurogenic bladder, and neurogenic bowel. The patient has received rehabilitation services at a skilled nursing facility. The records document that the patient made initial gains, but has largely functionally plateaued. The patient has required maximum assistance to stand and ambulate short distances with a walker. The patient's lower limb motor recovery has been limited. The primary goals of rehabilitation in this clinical setting are maximizing function given the impairments (Nas, et al.; Chay and Kirshblum). There is a lack of indication in the available documentation that the patient has the residual strength to participate and benefit from inpatient rehabilitation services. Given the available documentation, the patients primary rehabilitation goals should include maximizing function, as well as mobility and transfers at a wheelchair level, and self-management of neurogenic bladder and bowel. The patients current issues do not require the services of an acute rehabilitation facility. For these reasons, the requested acute rehabilitation facility services are 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Sonablate high intensity focused ultrasound (HIFU) (CPT 55880). Findings:  The physician reviewer found that patients records document a history of elevated prostate specific antigen (PSA) and Gleason 4+3 prostate cancer. The patients provider has recommended treatment with HIFU to address only the diseased portion of the prostate gland. However, HIFU for multifocal prostate cancer is not supported by adequate evidence as compared to radiation or prostatectomy to support its use in this patients clinical setting. Ahdoot and colleagues found that, Prostate cancer focal therapy is an attractive option for well-selected patients because of its low complication profile; however, long-term oncologic outcome is still lacking, and early recurrence rates are high, limiting the ability of most urologic associations from endorsing its routine use. All told, the requested Sonablate HIFU (CPT 55880) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in urology 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 authorization and coverage for continuous glucose monitor (CGM) Dexcom G6 and supplies. CGM systems are a recent technologic development that uses interstitial glucose monitoring to display glucose concentrations frequently throughout the day. This regular surveillance allows for determinations of glucose trends and immediate feedback while omitting numerous daily finger stick blood glucose tests (Condren, et al.). According to the American Diabetes Association (ADA) recommendations, glycemic variability, evaluated by a CGM system has an important role in assessing the effectiveness and safety of treatment in many patients with type 1 diabetes (Breyton, et al.). This patient is noted to have a diagnosis of type 1 diabetes. The patient reports that multiple finger sticks per day are required to maintain insulin. The provider noted that the patient has experienced episodes of nocturnal hypoglycemia. The patients provider has recommended treatment with the Dexcom G6 CGM system and related supplies. Based on the current medical literature, the requested Dexcom G6 CGM system is appropriate, given its capabilities to reduce episodes of nocturnal hypoglycemia. All told, the requested CGM Dexcom G6 and supplies are 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injections are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous Panzyga [140 grams over five consecutive days (20 gm/30 gm/30 gm/30 gm/30 gm) followed by 60 grams over two consecutive days (30 gm/30 gm) monthly for six cycles]. Hovaguimian and Gibbons note that management of small-fiber neuropathy depends on the underlying etiology with concurrent treatment of associated neuropathic pain, which can include several different classes of medications. Colleagues report that inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain. In an analysis of the efficacy and safety of IVIG for the treatment of autoimmune small-fiber polyneuropathy, Liu and colleagues report that IVIG is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy and is safe and effective for rigorously selected small-fiber polyneuropathy patients with apparent autoimmune causality. Oaklander reports that a review of various studies regarding immunotherapy for distal small fiber polyneuropathy provides a rationale for treating carefully selected patients with immunomodulatory therapies. The author further notes that candidates for treatment should have symptoms consistent with small fiber polyneuropathy, objective confirmation of diagnosis, exclusion of other causes, failure to improve with symptom management, and, ideally, serologic markers of immunity/inflammation. Novak and colleagues report that small-fiber polyneuropathy appears to be associated with post-treatment Lyme disease and may be responsible for certain sensory symptoms. In this case, the patient has chronic, painful paresthesias secondary to small fiber neuropathy presumed to be secondary to Lyme disease. His symptoms have not been controlled with conventional medical therapy. Given that current medical literature notes that patients with presumed autoimmune small fiber neuropathy may improve clinically with IVIG and that an autoimmune mechanism may be triggered in patients with small fiber neuropathy secondary to Lyme disease, the requested services are medically indicated. Therefore, intravenous Panzyga [140 grams over five consecutive days (20 gm/30 gm/30 gm/30 gm/30 gm) followed by 60 grams over two consecutive days (30 gm/30 gm) monthly for six cycles] is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for the 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
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for escalation frequency of Stelara 90 mg/mL x 1 injection every 28 days. The current peer-reviewed medical literature supports the requested dose escalation of Stelara from 90 mg/mL every eight weeks to every four weeks. One study found that Stelara dosing at 90 mg every four weeks can address inadequate disease control with a large proportion of patients able to maintain response with dose escalation to 90 mg every four weeks (Kopylov, et al.). Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks (Battat, et al.; Khorrami, et al.). The records provided for review document that this patient has failed conventional therapy including mesalamine, Remicade with azathioprine, and Xeljanz, which are recommended for the treatment of ulcerative colitis. The patient then experienced improvement with Stelara. The patient had a low Stelara level when dosed every eight weeks and reported urgency even on the higher dose of 90 mg every four weeks. As the patient demonstrated initial improvement on Stelara with but a low Stelara level, and then improvement but ongoing urgency on dosing every four weeks, continuation of Stelara 90 mg every four weeks is supported. Discontinuation of the current dose of  90 mg every four weeks or a change to another medication may be ineffective and may result in complications. For these reasons, the requested escalation frequency of Stelara 90 mg/mL x 1 injection every 28 days is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication dosage is 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 Orthovisc injections in both knees. 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 patient has a history of lasting benefit from prior viscosupplementation, which was documented to last over six months. Furthermore, the patients osteoarthritis is not severe enough to warrant bilateral total knee arthroplasties. Given these findings, the requested Orthovisc injections in both knees 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.