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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for customized oral mouthpiece device/appliance. As noted by the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM), an oral appliance is indicated for the treatment of patients with mild-to-moderate obstructive sleep apnea (OSA) as first-line treatment, or as alternative therapy when a patient fails continuous positive airway pressure (CPAP) therapy (Patil, et al.). The available records report that this patient was diagnosed with mild OSA with an apnea/hypopnea index (AHI) of 10.4 episodes per hour on home sleep study, which can underestimate the severity of a patients OSA. The patients AHI did not substantially improve despite treatment with an oral appliance. The provider noted that the oral appliance failed to control the patients OSA symptoms, as evidenced by minimal improvement in AHI. In this clinical setting, a custom oral appliance is not likely to add substantial benefit since the patients OSA symptoms did not respond to the first oral appliance. A prior dental examination confirmed that the patient was not a good candidate for a second oral appliance due to dentition not being able to support the appliance. Per the current guidelines and recommendations, treatment with CPAP is recommended for management of this patients mild OSA symptoms. The records do not adequately document failure of treatment with CPAP. For these reasons, the requested customized oral mouthpiece device/appliance is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device 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 internal medicine with subspecialty certification in sleep 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco (30 tablets per month). The Centers for Disease Control and Prevention (CDC) guidelines state that, 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. Per the CDC guidelines, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Federation of State Medical Boards (FSMB) guidelines recommend opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. In this case, the patient has chronic neck and back pain attributed to a remote motor vehicle accident, which resulted in cervical and thoracic fractures that were managed non-operatively. The patient has been treated with physical therapy for refractory muscle spasms of the trapezius muscles. The provider recommended participation in an integrative pain management program and tapering off Norco. The provider noted that continued opioid therapy for chronic pain management is not indicated. Per the CDC guidelines and current medical literature recommendations, the patients condition should be managed with non-pharmacological treatment modalities. Therefore, the requested Norco (30 tablets per month) is not medically necessary for 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 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 Cosentyx 300 mg solution auto injection 150 mg/mL. Systemic treatment of psoriasis is indicated when topical treatments fail or do not achieve sufficient control of the disease. While the U.S. Food and Drug Administration (FDA) has approved several systemic options for the treatment of psoriasis including non-biologics such as methotrexate, cyclosporine, acitretin, cyclosporine, and apremilast, and biologics such as tumor necrosis factor (TNF)-alpha inhibitors, interleukin (IL)-17 pathway inhibitors like Cosentyx, IL-12/23 inhibitors, and IL-23 inhibitors, some of these medications carry severe potential side effects. For example, cyclosporine is contraindicated in those with hypertension and kidney impairment, is immunosuppressive and associated with increased infection risk, and often results in psoriasis flares after being discontinued as it may not be used in the long-term due to toxicities. Kridin and colleagues report that the use of oral methotrexate was associated with increased odds of COVID-associated hospitalization, whereas the use of biologic drugs was not associated with worse outcomes of COVID-19 among patients with psoriasis. Menter and colleagues note that topical therapies alone or combined with phototherapy may be insufficient for patients with moderate-to-severe psoriasis, and that biologic agents, as monotherapy or combined with other topical or systemic medications, have a high benefit-to-risk ratio. In this case, given that the patient has tried and failed treatment with narrowband ultraviolet B (UVB) and topical steroids including triamcinolone and clobetasol, treatment with a systemic biologic agent, such as Cosentyx. is medically indicated. Therefore, Cosentyx 300 mg solution auto injection 150 mg/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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mavenclad (six tablets/five day dosing regimen). The U.S. Food and Drug Administration (FDA) approves the use of Mavenclad for the treatment of patients with relapsing forms of MS, including relapsing-remitting MS and active secondary progressive MS, and is generally recommended for patients who have had an inadequate response to, or are unable to tolerate, an alternate drug indicated for the treatment of MS. The American Academy of Neurology (AAN) practice guideline recommendations for disease-modifying therapies (DMTs) for adults with MS include (1) offering DMTs to patients with relapsing forms of MS with recent clinical relapses or MRI activity, (2) discussing a switch to a DMT with a lower PML risk for patients taking Tysabri who are or become JC-virus antibodypositive, especially with an index of above 0.9 while on therapy, and (3) as multiple DMTs are available, discussing switching DMT therapies for patients who experience adverse effects or complications with a DMT, including changing to non-injectable or less frequently injectable DMTs in patients who report intolerable discomfort with the injections or injection fatigue. In this case, the patient has a diagnosis of relapsing remitting multiple sclerosis. The records noted that the patient was being treated with Tysabri with a recent JC-virus antibody index of 2.26. The records noted that Gilenya was not considered due to an increased risk of PML, and that Extavia was not considered because the patient did not desire an injectable therapy. In this clinical setting, given that the AAN practice guidelines support switching the patient to another DMT, the requested medication regimen is medically indicated. Therefore, Mavenclad (six tablets/five day dosing regimen) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 patient has requested reimbursement for 30 treatments (two hours per treatment) of hyperbaric oxygen therapy (HBOT) in a multi chamber. The records provided for review document that this patient underwent a body contouring procedure with grafting of 2500 cc of fat to the flanks and buttocks. Postoperative evaluations performed after the procedure showed normal postoperative healing with swelling, tenderness, and ecchymosis. There was no report of findings indicating compromised healing of the liposuction or the fat grafted areas. There is no evidence of threatened or compromised surgical grafts. The patient underwent treatment with HBOT. However, there is a paucity of evidence in the medical literature to support the clinical utility of HBOT in free fat grafting by increasing the partial pressure of oxygen in the recipient tissue. Researchers noted that HBOT is ineffective when it is provided to patients who could heal without it. Medical literature shows that, HBOT is used on occasion to treat compromised flaps and grafts, where there is decreased perfusion or hypoxia, a practice supported also by the Guidelines from UHMS [Undersea and Hyperbaric Medical Society]. In addition, the authors noted that, HBOT can help maximize the viability of the compromised tissue hereby reducing the need for re-grafting or repeat flap procedures. Overall, there is a lack of peer-reviewed clinical literature documenting the benefit of HBOT in injectable fat grafting. This patient has no evidence of threatened or compromised surgical grafts, and the use of HBOT in injectable fat grafting is not supported by the medical literature. HBOT treatment to treat postoperative threatened or compromised surgical grafts status post body contouring procedure was not medically necessary in this patient. Thus, the 30 treatments (two hours per treatment) of HBOT in a multi chamber were not medically necessary for this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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 oxycodone-acetaminophen (Percocet) 10 mg/325 mg. The Centers for Disease Control and Prevention (CDC) guidelines state that, 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. Per the CDC guidelines, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. In this case, the patient has a history of liver cirrhosis, esophageal cancer, and back pain. The patient has been treated with Percocet for chronic pain related to her previous cancer pain and chronic lower back pain. The records document that the patient has undergone testing with multiple urine drug screens, which detected the presence of alcohol metabolites. On 1/25/22, the provider charted that chronic opioid therapy is not indicated when considering the risk-to-benefit ratio for Percocet was no longer favorable. The provider also expressed concern over the patients cirrhosis and the potential harm caused by the acetaminophen in Percocet. Given these findings, the requested oxycodone-acetaminophen (Percocet) 10 mg/325 mg is not medically necessary for 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 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 Orthovisc injection series of left knee. Findings:  The physician reviewer found that 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, various conservative options have been attempted, including weeks of physical therapy and a corticosteroid injection without substantial benefit. The only other alternative is a total knee arthroplasty. As such, the provider has recommended treatment with viscosupplementation for pain relief and to delay the patients need for total knee arthroplasty. Given this support, the requested Orthovisc injection series of left 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. 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 lumbar fusion-single level (CPT 22558) and/or thoracic spine computed tomography (CT) (CPT 72128). Findings:  The physician reviewer found that Lumbar spinal fusion may be used for a variety of measures, including for the treatment of refractory radiculopathy in certain clinical circumstances (Wang, et al.; Watters, et al.). Lumbar fusion should be considered in patients with degenerative spinal issues after exhaustion of conservative measures, and only when such fusion is likely to result in pain relief. In this case, the patient has undergone and failed conservative measures. However, there is a lack of support for the requested single level spinal fusion procedure for treatment of this patients low back pain. The available documentation does not support that the patients condition is likely to improve with single level spinal fusion. Moreover, the records do not establish a current indication for further evaluation of the patients thoracic spine with the requested CT imaging. All told, the requested lumbar fusion-single level (CPT 22558) and thoracic spine CT (CPT 72128) are not medically necessary for evaluation and 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 neurological 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 LORETA neurofeedback therapy two to three times per week for six months. The records provided for review document that this patient has a history of traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) with problems in memory, concentration, and hyperarousal symptoms due to traumatic cues associated with his assault. The patient has a complex psychiatric and neurological presentation. He has been treated with various psychotherapeutic  and psychopharmacological approaches without substantial improvement. The best outcome for the patients psychiatric and neurological symptoms has been from LORETA neurofeedback. As noted in the medical literature, one of the best indicators for future benefit in a patient is past positive response to a treatment modality. In addition, systematic reviews report low risk and high value patient health outcomes with neurofeedback in the treatment of patients with TBI and PTSD (Reiter, et al.; Panisch and Hai). For these reasons, the requested LORETA neurofeedback therapy two to three times per week for six months 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 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 Euflexxa 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 excellent benefit from prior viscosupplementation with Euflexxa injections. Furthermore, the patient is a diabetic and is unable to tolerate corticosteroid injections due to the effect on her blood sugar levels. For these reasons, the requested Euflexxa 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for IVIG Octagam 2 gm/kg (125 gm total dose) over five days repeated monthly. Treatment of severe and refractory calcinosis cutis and scleroderma must be individualized based on clinical findings and presentation. In this case, the patients presentation is advanced and rare, and current medical literature draws mainly from case reports and findings from similar immune-mediated conditions that may cause severe calcinosis cutis. Waldman and colleagues note that the best supporting data for the use of IVIG in refractory calcinosis cutis is in the setting of dermatomyositis, which shares many similarities to scleroderma in terms of management. In this case, the records document findings consistent with severe and refractory calcinosis cutis and worsening scleroderma. The patient has tried and failed treatment with hydroxychloroquine and mupirocin. Fagni and colleagues note that with the COVID-19 pandemic, treatment with immunosuppressives, such as cyclophosphamide, are associated with increased hospitalization if a patient is infected with COVID-19 and may result in significant morbidity and mortality. Therefore, IVIG Octagam 2 gm/kg (125 gm total dose) over five days repeated monthly 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.