Persius/hicric huggingface dataset:
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 Omnitrope solution cartridge 10 mg/1.5 mL. In this case, the patient has mild central precocious puberty. The records document that the patients height is within the normal range for North American adult men. While a standard evaluation of pediatric short stature includes direct measurements of parental heights due to inaccuracy from self-reported heights, in this case, it is unlikely that direct measurements would change the mid-parental target height (MPTH) below the normal range for North American adult men. Given that the patients predicted adult height is within the normal range for North American adult men and also consistent with his family MPTH, the requested medication is not medically indicated. Therefore, Omnitrope solution cartridge 10 mg/1.5 mL is not medically necessary for the 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 patients parent has requested reimbursement for vitamin D testing (CPT 82306). The American Academy of Pediatrics (AAP) has published guidelines on vitamin D supplementation and testing to optimize bone health in children and adolescents (Golden, et al.). The AAP guidelines include updated allowances for calcium and vitamin D, along with recommendations for supplementation and weight-bearing activities. The AAP currently endorses the higher recommended dietary allowances for vitamin D advised by the Institute of Medicine and supports testing for vitamin D deficiency in children and adolescents with conditions associated with increased bone fragility. Further, the AAP noted that, Universal screening for vitamin D deficiency is not routinely recommended in healthy children. This patients records document that the patient presented with abdominal pain and diarrhea. The patients provider recommended laboratory testing including vitamin D assessment. However, the records provided for review do not document that the patient was at risk for vitamin D deficiency to meet an indication for testing. Therefore, the vitamin D testing (CPT 82306) was not medically necessary for evaluation of 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for intravenous ketamine infusions. Cohen and colleagues report, Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. The authors further note that for CRPS, There is moderate evidence supporting ketamine infusions to provide improvements in pain for up to 12 weeks, and that, In terms of duration of benefit, patient expectations and satisfaction should be considered, but based on the cumulative risks and costs of treatment, greater than three weeks following a single outpatient infusion and greater than six weeks following an inpatient or series of infusions are a reasonable designation. The authors recommended that, A consecutive series of infusions should not be administered by rote, but rather tailored to patient response. Considering the risks of long-term ketamine treatment, limiting these to no more than six to twelve treatments per year is reasonable. In a systematic review of 14 studies on the use of ketamine infusion therapy for the treatment of CRPS, Chitneni and colleagues found that in 13 of the studies, ketamine infusion resulted in a decrease in pain scores and relief of symptoms. The authors concluded, Patients who received ketamine infusion for treatment-resistant CRPS self-reported adequate pain relief with treatment. This suggests that ketamine infusion may be a useful form of treatment for patients with no significant pain relief with other conservative measures. In this case, the patient has a diagnosis of CRPS that has been refractory to standard treatments, including non-pharmacological approaches and medication management with multiple different drug classes. The records note successful prior treatment with ketamine infusions, leading to improvements in pain levels and functionality. Given that current medical literature suggests that ketamine infusions may be a useful form of treatment for patients with treatment-resistant CRPS without significant pain relief with other conservative measures, the services at issue were and are medically indicated. Therefore, intravenous ketamine infusions were and are medically necessary for the treatment of this patientFinal Result: The reviewer determined that the services at issue were and 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 sub-specialty 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for a custom fabricated right knee brace. Steadman and colleagues note that there is clinical evidence supporting brace use as improving pain and functional ability in patients with unicompartmental knee osteoarthritis. In a meta-analysis of randomized trials involving valgus bracing for knee osteoarthritis, Moyer and colleagues did not note a significant difference between custom and off-the-shelf bracing. In this case, given that the submitted records do not document a trial of off-the-shelf bracing, the requested custom brace is not medically indicated. Therefore, a custom fabricated right knee brace is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is 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 Repatha SureClick Auto-Injector. Findings: The clinical indication for PCSK9 inhibitors such as Repatha includes patients with clinical atherosclerotic cardiovascular disease and those with familial hypercholesterolemia who are on maximally tolerated statin therapy and require greater reduction in LDL cholesterol levels to reach their goal. The indication has also been extended to such patients with statin intolerance, generally due to myalgias and/or myopathy secondary to statin drugs with significant LDL cholesterol elevations. This patients records do not include any documentation of vascular disease or diabetes. The provider noted that the patient experienced possible joint pain and myalgias with rosuvastatin. However, the records do not indicate that treatment with another statin was attempted. Additionally, without a statin, the patients LDL cholesterol was 95 mg/dL on ezetimibe alone, which is within the published guidelines for a patient with a family history of coronary artery disease as the primary risk factor. Given these findings, the requested Repatha SureClick Auto-Injector 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 internal medicine with subspecialty certification in cardiology 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 Tepezza (initial dose of 10 mg/kg followed by 20 mg/kg every three weeks for seven additional infusions). Treatment with teprotumumab (Tepezza) for the patients exophthalmos is medically necessary based on medical records supporting a diagnosis of dysthyroid orbitopathy with associated diplopia and documented failure of surgical treatment. There is no reported contraindication for use of Tepezza in patients with previous surgery. Markham noted that Tepezza is a monoclonal antibody insulin-like growth factor-I receptor (IGF-IR) antagonist developed for the treatment of thyroid eye disease (Graves ophthalmopathy/orbitopathy, thyroid-associated ophthalmopathy). Douglas and colleagues concluded that, Among patients with active thyroid eye disease, teprotumumab resulted in better outcomes with respect to proptosis, Clinical Activity Score, diplopia, and quality of life than placebo. Overall, Tepezza has been shown to be beneficial and safe for patients with acute and active orbital inflammation related to dysthyroid orbital disease. Given these findings, the requested Tepezza (initial dose of 10 mg/kg followed by 20 mg/kg every three weeks for seven additional infusions) 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for (1) Synvisc-One (hyaluronan) knee injection and (2) Synvisc-One (hyaluronan) injection in the left knee. 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 six months of relief from prior injections received, which allowed her to walk again. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, (1) Synvisc-One (hyaluronan) knee injection and (2) Synvisc-One (hyaluronan) injection in the left knee was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 Xeljanz 10 mg tablets (two times a day). Conventional treatment options for alopecia areata include immunosuppressants that are administered either locally or systemically, with the most common approach involving the use of intralesional and topical steroids. Given the potential for side effects, these therapies are only recommended for short-term use. Other immunosuppressive agents used in the treatment of patients with alopecia areata include methotrexate, cyclosporine, and azathioprine, which lack adequate randomized controlled clinical trial supporting their safety and tend to require close patient follow-up. Current studies have demonstrated the effectiveness of monotherapy with oral corticosteroids, cyclosporine, and JAK inhibition therapy for the treatment of alopecia areata. The records provided for review document that this patient has widespread long-term disease. Moreover, there is adequate report that the patient has failed conventional treatment with oral steroids. For these reasons, the requested Xeljanz 10 mg tablets (two times a day) 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Taltz. There is a lack of documentation regarding the extent of this patients psoriasis in terms of body surface area (BSA) involvement or prior disease severity to support an indication for treatment with Taltz. The medical records state that the patients psoriasis is well controlled while on Taltz. However, biologic medications including Taltz are not recommended for mild disease in the absence of extenuating factors such as difficult to treat areas. The U.S. Food and Drug Administration (FDA) has approved Taltz for the treatment of patients with moderate-to-severe plaque psoriasis, as defined by a BSA greater than 3%, or a psoriasis area and severity index (PASI) greater than 10 (Menter, et al.; Gordon, et al.). Similarly, the peer-reviewed medical literature recommends treatment with Taltz for patients with moderate-to-severe plaque psoriasis, which is not reported in the records provided for review. All told, the requested Taltz 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 dermatology with subspecialty certification in dermatopathology 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 magnetic resonance imaging (MRI) of the lumbar spine (CPT code 72148) and/or MRI of the thoracic spine (CPT code 72146).Findings:  The physician reviewer found that records document a history of back pain with diagnoses of lumbago with sciatica. The patient has undergone treatment with medications and diclofenac gel. Prior MRI demonstrated chronic L1 compression fracture deformity with decreased in vertebral height with stable findings compared to previous imaging. The patients provider has recommended additional imaging with MRI of the lumbar and thoracic spine. According to American College of Radiology (ACR) guidelines, Imaging is usually not appropriate for the initial imaging of patients with subacute or chronic low back pain with or without radiculopathy, no red flags, and no prior management. This patients records do not include documentation of any neurological deficits, or red flag signs or symptoms to support an indication or the requested MRI scans of the lumbar and thoracic spine. There is a lack of evidence of failure of conservative therapies or surgical interventions reported in the available records. Therefore, the requested MRI of the lumbar spine (CPT code 72148) and MRI of the thoracic spine (CPT code 72146) are not medically necessary for this patient. Final Result: The reviewer determined that the requested services are 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 radiology with subspecialty certification 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc-One injection in both knees. Findings: 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 tried and failed other conservative treatments, including oral and topical nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections. The records document that relief from radiofrequency ablation of genicular nerves, expected to last six months to a year, only lasted for three months. The alternative to viscosupplementation is bilateral total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc-One injection in both knees is 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Stretta procedure. In a systematic review to evaluate the efficacy of Stretta for the management of gastroesophageal reflux disease (GERD), Lipka and colleagues reported no evidence of significant changes, compared with sham therapy, in physiologic parameters, including time spent at a pH less than 4, lower esophageal sphincter pressure, ability to stop proton pump inhibitors, or health-related quality of life. Thosani and colleagues noted adverse events from the Stretta procedure included aspiration pneumonia, permanent gastroparesis, esophageal perforation, cardiac arrest, and four deaths. Nabi and colleagues reported that long-term follow-up studies and randomized comparison with anti-reflux surgery were required for a clear understanding of the endoscopic modalities in treating GERD. Katz and colleagues noted in guidelines for the management of GERD that endoscopic therapies have not demonstrated long-term efficacy. Fass reported that with the Stretta procedure, up to 42% of patients experienced recurrence of GERD symptoms. In this clinical setting, current medical literature does not support the use of Stretta as likely to be more beneficial than standard treatments for GERD. Therefore, the Stretta procedure is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Stretta procedure 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 service 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 internal medicine with sub-specialty certification in gastroenterology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Tyrvaya nasal solution (0.03 mg/actuation). The U.S. Food and Drug Administration (FDA) approves the use of Tyrvaya (generic name varenicline solution) for the treatment of the signs and symptoms of dry eye disease. Wirta and colleagues report that OC-01 (varenicline) nasal spray is well tolerated and has a clinically meaningful effect on signs and symptoms of dry eye disease. Likewise, Quiroz-Mercado and colleagues report that OC-01 (varenicline solution) nasal spray improved tear production in patients with dry eye disease over a long-term (12-week) period. In this case, given that this patient with dry eye syndrome has tried multiple therapies including anti-inflammatory medications without significant improvement and experienced symptomatic relief with Tyrvaya, the requested medication is medically indicated. Therefore, Tyrvaya nasal solution (0.03 mg/actuation) 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.