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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Lyrica 150 mg capsules. In the medical literature, van den Beukel and colleagues performed a systematic review of abdominal pain treatment options in patients with adhesions-related chronic abdominal and pelvic pain after surgery. The authors concluded that in a trial of 18 patients, Lyrica tended to have benefit over placebo improving pain at three months. Silverman and colleagues performed a double-blind, placebo-controlled trial to evaluate the efficacy of Lyrica on pain modulation in patients with prior abdominal surgery and documented adhesion. The authors concluded that Lyrica significantly reduced patient-documented pain scores compared with placebo in our small cohort of patients with abdominal adhesion pain. In this case, the patient has chronic abdominal pain due to initial gunshot wound status post small bowel resection with multiple abdominal surgeries complicated by recent hospitalization for small bowel obstruction. The provider reports that the patient has been stable on Lyrica, which is being using in combination with Norco for pain relief. The patient has not reported any side effects or adverse drug reactions. Moreover, the patient indicated that this treatment regimen improves fatigue and ability to function. The patient has previously been treated with numerous other medications from different drug classes without substantial benefit. The patient has expressed an interest in weaning off  chronic opioid therapy which has been ineffective, and the provider has recommended a trial of increased dose of Lyrica. In this clinical setting, there is adequate data to support an increased dose of Lyrica for this patient to address the patient's ongoing abdominal pain. Based on the medical records and current literature, the requested Lyrica 150 mg capsules are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy (semaglutide). Findings:  The physician reviewer found that Gadde and colleagues note that obesity remains a continuing global health concern, as it is associated with increased risk of numerous chronic diseases, including type 2 diabetes, hypertension, and cardiovascular disease. The authors further note that while lifestyle modification is recommended as the cornerstone of obesity management, as 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. Knudsen and Lau report that glucagon-like peptide-1 (GLP-1) analogs, such as Wegovy, improve glycemic control, reduce body weight, and decrease cardiovascular risk. Cornell notes that GLP-1 receptor agonists have an established efficacy and safety profile. Given that current medical literature supports the use of the Wegovy in promoting weight loss and the low likelihood of health risks associated with this medication, the requested medication is medically indicated. Therefore, Wegovy (semaglutide) 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mobile cardiac outpatient telemetry. Findings:  The physician reviewer found that  clinical condition, age, and cardiac risk factors, this patient was predicted to be at low risk for life-threatening arrhythmias. In this clinical setting, immediate telemetered data, such as provided by a mobile cardiac outpatient telemetry monitor, was not likely to be more beneficial for the evaluation of this patient than other devices, such as a standard patient-activated or auto-activated event monitor. Therefore, mobile cardiac outpatient telemetry was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the mobile cardiac outpatient telemetry at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the equipment 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 reviewer 1 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease and is actively practicing. Physician reviewer 3 are board certified board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 patients parent has requested authorization and coverage for custom orthotics. Biomechanical changes of a foot that cause abnormal motion and pain should be corrected. In this case, the patient presented with chronic bilateral arch pain. His diagnoses included plantar fasciitis, posterior tibial insufficiency, and hallux limitus. An examination showed over pronation with hypermobility of the first metatarsal, and posterior tibial insufficiency that placed undue and increased pressure to the posterior tibial tendon and on the plantar fascia, biomechanical abnormalities that can cause significant pain. In this clinical setting, given that custom functional firm orthotics may be used to keep the patients foot in neutral position, reducing not only first metatarsal elevation but also abnormal pull and strain on the posterior tibial tendon, the requested equipment is medically indicated. Therefore, custom orthotics 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.Credentials/Qualifications: The reviewer is a licensed D.P.M., board certified in podiatry 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 reimbursement for magnetic resonance imaging (MRI) of the left arm. Cho and colleagues explain that neurogenic thoracic outlet syndrome is produced by compression of neurovascular structures exiting the thoracic outlet. The thoracic outlet is an anatomical area in the lower neck defined as a group of three spaces between the clavicle and the first rib through which several important neurovascular structures pass. Jones and colleagues report that MRI can evaluate the anatomy of the thoracic outlet, the soft tissue structures causing compression, and allow direct visualization of brachial plexus compression. Given that anatomical abnormalities or defects, such as prominent cervical ribs, fracture calluses, or compressive tumors are commonly demonstrated on imaging and may support a history and physical examination consistent with thoracic outlet syndrome, the service at issue was medically indicated. Therefore, MRI of the left arm was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was 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 with sub-specialty certification in vascular 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Dexcom G6 continuous glucose sensor and transmitter. Olczuk and Priefer note that self-monitoring of glucose allows patients with diabetes mellitus to take control of their disease and thus directly affect the outcomes related to it. The authors further note that continuous glucose monitor (CGM) systems have recently been refined and improved for home use. Zheng and colleagues report that CGM systems may be clinically valuable due to their accuracy and convenience and may promote glycemic and weight control, helping to reduce the risk of hypoglycemia and hyperglycemia. Given that current medical literature supports the safety and accuracy of CGM systems, such as the Dexcom G6, for home monitoring of glucose levels, the requested equipment is medically indicated. Therefore, Dexcom G6 continuous glucose sensor and transmitter 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for platelet rich plasma (PRP) injections. There is a lack of evidence in current medical literature supporting the use of PRP in meniscal repair. In an evaluation specifically addressing the effect of PRP augmentation after meniscal surgery, Griffin and colleagues concluded that no difference in outcomes were seen with the use of PRP augmented meniscal repair. Pourcho and colleagues report that future investigations and high-quality randomized controlled trials are needed to optimize PRP treatment methods. Therefore, PRP injections were not and are not 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 PRP injections at issue were not and are 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 and 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery 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 Stelara. Findings: Current medical literature supports dose escalation of Stelara to 90 mg every four weeks in this case. One study reports in a double-blind, placebo-controlled trial of ustekinumab as induction and maintenance therapy for ulcerative colitis that a single intravenous dose of Stelara induced clinical remission in a significantly greater proportion of patients than placebo did, as measured by both clinical response and endoscopic response. Another study notes that dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. 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. Another study reports that while ustekinumab is effective for the treatment of ulcerative colitis, over 40% of patients have suboptimal clinical response after induction and maintenance dosing every eight weeks, and that many of these patients undergo empiric dose intensification. In this case, the patient has moderate-to-severe ulcerative colitis and has failed multiple conventional therapies. The patient had initial improvement on Stelara but laboratory testing showed a low Stelara level when dosed every eight weeks, with active disease symptoms. Continuation of dosing at every eight weeks or discontinuation of Stelara may result in loss of toxic megacolon, dysplasia leading to colorectal cancer, flare, hospitalization, need for surgery, or other complications. Therefore, Stelara 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 internal medicine with sub-specialty certification in gastroenterology 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 Ultram (tramadol) tablets (50 mg by mouth four times a day as needed). At issue is whether the requested Ultram (tramadol) tablets (50 mg by mouth four times a day as needed) is medically necessary for treatment of this patient. 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 (Dowell, et al.). The CDC noted that, 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. The FSMB state that, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. In this case, the patient has chronic knee pain due to advanced osteoarthritis. However, the records document that the patient was combining benzodiazepines with alcohol, which prompted one of the providers to discontinue benzodiazepine therapy and refer the patient to addiction medicine. The patients orthopedic specialist has advised against opioid therapy and suggested treatment with NSAIDs along with steroid injections in the knee, and possible  future joint replacement. Overall, the records indicate that the risk-to-benefit ratio is unfavorable and that the patient is not considered an ideal candidate for chronic opioid therapy. Given these findings, the requested Ultram (tramadol) tablets (50 mg by mouth four times a day as needed) 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcatheter pulmonary valve replacement with a Sapien 3 valve. The patients clinical picture includes complex heart disease with symptoms that are partially attributable to high volume moderate-to-severe pulmonary regurgitation. The patients provider has recommended treatment with transcatheter pulmonary valve replacement with use of a Sapien 3 valve. Chatterjee and colleagues noted that, Transcatheter pulmonary valve implantation is approved for the treatment of dysfunctional right ventricle to pulmonary artery conduits. The authors concluded that of the 1,044 patients who underwent transcatheter pulmonary valve replacement, the success rate of the procedure was 96.2%. As noted in the medical records provided for review, the patients right ventricle outflow tract (RVOT) conduit is more than 16 mm, the present valve is 29 mm, and her pulmonary regurgitation is at least moderate. In addition, the patients right ventricle was enlarged on imaging with low normal function. Correction of the patients pulmonary regurgitation via a transcatheter pulmonary valve should help prevent further right ventricle dysfunction and decrease the recurrence of atrial fibrillation. Moreover, the documentation supports that this patient meets the American Heart Association (AHA) and American College of Cardiology (ACC) criteria for the requested transcatheter pulmonary valve replacement with a Sapien 3 valve (Stout, et al.). Given these findings, the requested transcatheter pulmonary valve replacement with a Sapien 3 valve is medically necessary for 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 with subspecialty certifications in cardiovascular disease and adult congenital heart disease 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 positron emission tomography scan with concurrently acquired computed tomography for attenuation (PET/CT) from skull base to midthigh (CPT 78815). Findings:  The physician reviewer found that PET/CT is a nuclear medicine study that has been demonstrated to be effective in the accurate staging of patients with certain malignancies. However, there is a paucity of data demonstrating the efficacy of PET/CT in the evaluation of this patients pancreatic cancer. As noted by the American College of Radiology (ACR), CT is considered usually appropriate for assessing primary pancreatic malignancy and metastatic disease, while PET/CT may be appropriate to serve as a supplemental imaging modality. Per the American Joint Committee on Cancer (AJCC), PET/CT provides limited diagnostic value for local disease assessment compared to CT or MRI in patients with pancreatic cancer (Amin, et al.). The AJCC noted that PET/CT is primarily recommended for initial staging to assess nodal and distant metastatic disease. Wartski and Sauvanet noted that PET/CT is useful to obtain critical parameters at initial staging to determine treatment in patients with distant metastases. This patient has already undergone evaluation with extensive imaging. All told, the requested PET/CT from skull base to midthigh (CPT 78815) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested PET/CT from skull base to midthigh (CPT 78815) 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. Credentials/Qualifications: Physician reviewer 1 is board certified in diagnostic radiology and is actively practicing. Physician reviewer 2 is board certified in diagnostic radiology and is actively practicing. Physician reviewer 3 is board certified in neuroradiology with subspecialty certification in diagnostic radiology 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.