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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pulsed radiofrequency nerve ablation (destruction of neurolytic agent, unlisted procedure, nervous system;  fluouroscopic guidance and localization of needle; and moderate sedation services).Findings:  Two out of three physician reviewers found that this patient reported a history of tailbone area pain since a fall in 2005. The medical literature on pulsed radiofrequency nerve ablation is limited. Most studies are retrospective and non-controlled. A 2018 study by Usmani and colleagues concluded that the requested services (pulsed radiofrequency) were inferior to conventional radiofrequency ablation. An evidence-based review by Chen and colleagues also found that patients who underwent conventional (vs pulsed radiofrequency treatment) and who received prognostic blocks were more likely to experience a positive outcome. Accordingly, pulsed radiofrequency nerve ablation (destruction of neurolytic agent; unlisted procedure, nervous system; fluouroscopic guidance and localization of needle; and  moderate sedation services) is not likely to be more beneficial than any other available standard treatments for this patients medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatments for this patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for laboratory services for hyperlipidemia. Findings:  The physician reviewer found that the enrollee indicates she needed the labs to check her cholesterol level. Results of the testing revealed LDL-cholesterol 90, HDL cholesterol 53, non-HDL cholesterol 119, total cholesterol 172, triglycerides 191, apolipoprotein B 78, lipoprotein (a) 474, LDL particle number 1007 with peak size 219.2 and pattern A. This enrollee does not relate a history of cardiovascular disease and records submitted indicate that Cardio IQ testing was performed six times over the last few years. According to the medical literature there is no benefit recommendation for lipoprotein and apolipoprotein assessments, citing absence of evidence that these measurements provide additional productive value beyond that obtained by measuring the standard fasting lipid panel. This testing does not have support from the national cardiovascular societies. There is insufficient evidence in the record supporting the benefit of this testing for this enrollee over the standard fasting lipid profile. Moreover, treatment of hyperlipidemia is based on the standard lipid profile. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Cardiology and are actively practicing.  All three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Lyrica 50 mg. for the treatment of idiopathic peripheral neuropathy. Findings:  The physician reviewer found that the requested medication is not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be upheld. Researchers concluded that Lyrica has strong evidence to support its use for post-herpetic neuralgia, diabetic neuropathy and post-traumatic neuropathic pain. The authors did not find strong evidence to support its use in the treatment of idiopathic peripheral neuropathy. Further, the U.S. Food and Drug Administration (FDA) has not approved Lyrica for treatment of idiopathic peripheral neuropathy. National Institute for Health and Care Excellence (NICE) Guidelines recommend that if one of the first-line agents fails to provide relief, to consider another agent, such as Duloxetine or a tricyclic acid. This enrollee has complaints of numbness involving the bilateral legs and feet. A nerve conduction study demonstrated findings of mild peripheral neuropathy. The enrollee's physical examination findings are notable for an unsteady gait and a positive Rombergs test. The enrollees sensory and motor examinations have documented as normal. A lumbar MRI demonstrated findings of lumbar degenerative disc disease without significant canal or foraminal stenosis. The enrollee has tried Gabapentin for the neuropathic pain, which was ineffective. The enrollee reported that treatment with Lyrica was beneficial. The medical records do not document a failed trial of Duloxetine or a tricyclic acid. Currently, there is no evidence in the medical literature to suggest that Lyrica is superior to Duloxetine or a tricyclic acid for treating idiopathic neuropathic pain. Therefore, Lyrica 50 mg is not medically necessary for treatment of this enrollee.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the enrollees 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 patients parent has requested authorization and coverage for Exondys 51. Findings:  The physician reviewer found that Exondys 51 is an exon 51 skipping agent that has been demonstrated to increase dystrophin in muscle and increased muscle strength. Exondys 51 received U.S. Food and Drug Administration (FDA) approved for the treatment of patients with Duchenne muscular dystrophy (DMD) who have a confirmed mutation of the dystrophin gene amenable to exon 51 skipping. The FDA does not require the ability to ambulate as a requirement for treatment. In this case, the patient has preserved strength in the bilateral upper extremities. In addition, his cardiac and pulmonary function are preserved. He would benefit from Exondys 51 to increase muscle dystrophin, delay upper extremity progression and slow the decline of cardiac and pulmonary function. Exondys 51 may also delay the use of pulmonary support. Therefore, Exondys 51 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 with subspecialty certification in neuromuscular medicine and expertise in pediatric neuromuscular 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 a positron emission tomography (PET) scan with fluciclovine F-18. PET with computed tomography (CT) attenuation is a valuable imaging modality in evaluating patients with prostate cancer. Findings: the physician reviewer found that the primary role for PET is the restaging of patients with biochemical recurrence after radical prostatectomy or external beam radiotherapy. Gleason score and PSA values, doubling time, and velocity can influence the positivity of PET. Fluciclovine PET has a high positivity rate (PR) for detection of prostate cancer recurrence and correlates with increasing PSA levels. For extraprostatic disease, the PR increases with higher Gleason scores. Savir-Baruch and colleagues noted that, fluciclovine PET/CT has a high PR for detection of prostate cancer recurrence and is positively correlated with increasing PSA levels. Therefore, the requested PET scan with fluciclovine F-18 is medically necessary for evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 authorization and coverage for psychiatric residential treatment center (RTC) services. Findings:  The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patient presents a composite score of 16, which correlates with intensive outpatient program (IOP) services. Therefore, the requested psychiatric RTC services are not medically necessary for treatment of this patients behavioral health issues. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon dilation Eustachian tuboplasty. Eustachian tube dysfunction (ETD) is a disorder for which there are limited medical and surgical treatments. Data suggests that Eustachian tube balloon dilation is one potential intervention, which may have a positive effect on objective and subjective indicators for chronic dilatory ETD in adult patients (Satmis and van der Torn). A prospective, multicenter, randomized, controlled study demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter and medical management compared to medical management alone to treat dilatory ETD in adults. However, there is insufficient evidence in the peer-reviewed literature demonstrating the long-term safety and efficacy of this procedure. Therefore, the requested Eustachian tube dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested Eustachian tube dilation is 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 requested Eustachian tube dilation is 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 otolaryngology 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 parent of an enrollee has requested authorization and coverage for Norditropin FlexPro 15 mg/1.5 mL. This patient has evidence of growth hormone deficiency based on a history of poor growth velocity and a height which was 2.2 standard deviation below the mean prior to therapy. There is evidence of growth hormone deficiency based on failed stimulation tests with two agents. The records document good response to growth hormone therapy based on the growth chart provided. The patient has open epiphyses. The medical evidence supports growth hormone therapy in this clinical setting. Therefore, Norditropin FlexPro 15 mg/1.5 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 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 enrollee is requesting reimbursement for the medication, Aimovig for chronic migraines. Findings: The physician reviewer found that the requested service is not medically necessary for the treatment of the enrollees medical condition.  At a neurology visit for evaluation of migraine headaches refractory to treatment, her headaches are described as a throbbing pain associated with photophobia, phonophobia, and nausea. She tried various prophylactic medications without significant improvement and was receiving Botox injections every three months. For breakthrough migraines she took Maxalt, Toradol injections, or rectal Dilaudid. Examination was notable for bilateral occipital point tenderness. Her Botox protocol was continued and she was told to try magnesium taurate supplements. Headaches were noted to be responsive to Botox injections she was receiving every 10-11 weeks and she had recently started treatment with Aimovig. She had failed a trial of Botox every 12 weeks. She was to continue with Botox and Aimovig 70mg injection monthly. Subsequently, continued severe headache breakthroughs around the time of her Botox or Aimovig injections are noted. The plan was to continue with Botox every 10-11 weeks and increase Aimovig to 240mg monthly. According to the current peer-reviewed medical literature, Aimovig is FDA-approved as a calcitonin gene-related peptide receptor antagonist indicated for the preventive treatment of migraine in adults. However, review of the record provides insufficient information regarding the average number of headaches days per month, which is necessary to determine the necessity for preventative therapy. Additionally, there are no details of prior trials of oral therapies for chronic migraine.  Although there is a reference in the record to prior trial failure, it is not documented which of those therapies was attempted.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurology and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting the medication, Dupixent. Findings: The physician reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The enrollee has a diagnosis of atopic dermatitis. He was seen in a dermatology office for eczema and dermatitis on his legs and upper body and Clobetasol cream was prescribed. Examination revealed atopic dermatitis with excoriated scaly plaques of the right arm, left supraclavicular, and right chest. Clobetasol with Cerave cream was continued and a prior authorization for Dupixent was requested. He was seen in follow up and atopic dermatitis on his full body with failed treatment with Doxycycline and Bactrim DS. Culture of the right leg showed heavy growth of Staphylococcus aureus with sensitivity to Bactrim and Augmentin. Resistance to most antibiotics, including Doxycycline, and allergy to Bactrim is noted. Examination revealed red, hot, excoriated scaly plaques of the right anterior tibia and scaly, red, plaque with satellite pustules of the upper lip. He was diagnosed with atopic dermatitis, cellulitis, and impetigo of the right tibia and Mupirocin was prescribed. Nystatin was prescribed for his lip.  Dupixent injections were prescribed. The enrollees advocate indicates he is not a candidate for traditional immune suppressing treatments, such as methotrexate or Acitretin because the risks outweigh the benefits. Review of the record fails to provide sufficient evidence demonstrating the need for Dupixent. There is no documentation of trial and failure of alternative therapies, such as a topical calcineurin inhibitor, systemic medications including methotrexate, cyclosporine, or azathioprine.  These medications have proven safety and efficacy in the treatment of atopic dermatitis. A history of impetiginization is not an absolute contraindication to any of these medications. This enrollee has no noted history of immunodeficiency, contraindications or allergies to any of these medications.  According to the medical literature, cyclosporine, methotrexate, mycophenolate mofetil, and azathioprine are used for cases with severe, difficult-to-manage symptoms. A trial of cyclosporine is commonly administered first; if that is not successful, then treatment with the others can be attempted.Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for residential treatment center (RTC) level of care.  The enrollee has a history of anxiety and substance abuse with alcohol, marijuana, cocaine, and methamphetamines. Findings:  The physician reviewer found that criteria indicate residential treatment is a medically necessary treatment when there is a need for opioid treatment services (Level 5), and/or withdrawal management services (Level 6).  The composite score required for level 5 is 23  27 and the required composite score for level 6 would be 28 or more.Review of the record indicates a composite score of 23, which, supports residential level of care.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Orthovisc injections. This patient has chronic left knee pain and imaging evidence of advanced patellofemoral arthritis and mild tibiofemoral arthritis. A review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit.  Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence does not support viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. In this patients case, her options are limited. She has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Therefore, Orthovisc injections 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.