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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 270 sterile gauze pads per month and 270 urinary catheters per month.The requested supply of 270 catheters per month implies a catheterization frequency of at least 7 times per day and possibly more. Sterile gauze pads for an established surgical site (catheterizable stoma) or to grasp intermittent catheters would prove no safer than clean gauzes for both purposes. The patients circumstances are complicated, but increasing the frequency of catheterization to the requested frequency does not solve her underlying issues of bladder storage and her clinically incompetent catheterizable channel. At this time, there is no literature or clinical support for the requested frequency of catheterization and hence the number of catheters and sterile gauze pads that have been requested. Accordingly, the requested 270 sterile gauze pads per month are not medically necessary to treat the patients medical condition. In addition, the requested 270 urinary catheters per month are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested supplies are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an Optune device (E0766).  Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved the use of Optune, a portable medical device that produces alternating electrical fields called tumor treatment fields (TTFields), to treat  recurrent glioblastoma. Stupp and colleagues found in an analysis of 315 patients with glioblastoma who had completed standard chemoradiation therapy, that adding TTFields to maintenance temozolomide chemotherapy significantly prolonged progression-free and overall survival. The authors also found that TTFields therapy was associated with lower toxicity and improved quality of life. The National Comprehensive Cancer Network (NCCN) Guidelines for treatment of central nervous system cancers recommend including alternating electric field therapy as adjuvant therapy in combination with concurrent temozolomide and adjuvant temozolomide. In this case, the patient had a diagnosis of glioblastoma, which was progressing. Given the current medical literature, the device at issue was medically indicated. Therefore, an Optune device (E0766) was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the device 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 internal medicine with sub-specialty certification in medical oncology 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 Botox injection. The American Headache Society (AHS) recommends preventive treatment when migraine attacks significantly interfere with a patients daily routine despite acute treatment, a patient has four or more attacks per month, or a patient has contraindication to, failure, or overuse of acute treatment. OnabotulinumtoxinA (Botox) is U.S. Food and Drug Administration (FDA) approved for chronic migraine. Per the American Academy of Neurology (AAN), Botox is recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. The AAN noted that Botox has been demonstrated to be effective in increasing headache-free days and should be considered to improve health-related quality of life in patients with chronic migraine. The records provided for review support that this patient has a history of chronic migraines, which have not responded to multiple oral abortive and preventative medications. The provider documented that the patients symptoms have persisted despite treatment with Tizanidine, Baclofen, Imitrex, and nortriptyline. Based on the AHS and AAN recommendations, this patient is a candidate for prophylactic treatment with Botox therapy. Given these findings, the requested Botox injection is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Tepezza 10 mg/kg infusion and authorization and coverage for Tepezza 20 mg/kg infusions every 3 weeks for seven (7) additional doses.Findings: Three out of three physician reviewers found that the Tepezza 10 mg/kg infusion at issue and the requested Tepezza 20 mg/kg infusions every 3 weeks for seven (7) additional doses were, and are, likely to be more beneficial than any other available standard treatments for the patients medical condition.Thyroid eye disease is an autoimmune disorder that is associated with hyperthyroidism and causes substantial morbidity, including orbital disfigurement, double vision, and visual loss. Management is guided by its activity and severity status, and treatment options until recently have been limited to smoking cessation, control of hyperthyroidism, local eye measures, glucocorticoids, selenium, orbital radiotherapy, and surgery. Newer targeted biologic therapies have recently become available which have shown promise, including Tepezza (teprotumumab), an IGF-1 receptor antagonist. Tepezza appears to substantially reduce proptosis associated with Graves Ophthalmopathy. This medication has demonstrated impressive reductions in disease activity and severity of Graves Ophthalmopathy. Thus, the Tepezza 10 mg/kg infusion at issue was likely to have been more beneficial than any other available standard treatments for the patients medical condition. Furthermore, the requested Tepezza 20 mg/kg infusions every 3 weeks for seven (7) additional doses are likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism, 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 a Synvisc-One injection in the left knee. 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 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 left knee pain. She has tried and failed other conservative treatments, including a corticosteroid injection, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, a Synvisc-One injection in the left knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 reimbursement for DecisionDx-Melanoma testing. While gene expression profile (GEP) testing has been shown to accurately identify risk of metastasis for patients with cutaneous melanoma, there is a lack of  consensus on how this affects the treatment plan for patients. GEP testing is not considered routine standard of care and is not currently recommended under National Comprehensive Cancer Network (NCCN) guidelines. There is a lack of medical literature supporting its use for the evaluation of patients with thin melanomas. In this case, the course of treatment for this patient would not change based on the results of the GEP testing, as the recommended course of treatment would still be a wide local excision with follow-up skin surveillance and possible sentinel lymph node biopsy. Therefore, the DecisionDx-Melanoma testing was not likely to have been more beneficial than any other available standard therapy for the patients medical condition.Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma testing 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 service at issue was 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 dermatology 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 Xeljanz XR. Findings: Guidelines for the treatment of rheumatoid arthritis state that compared to tumornecrosis factor inhibitor (TNFi) monotherapy, TNFi therapy has superior efficacy when used in combination with methotrexate, based on high quality evidence. The guidelines do not specify an order in choosing the next drug to be added to traditional diseasemodifying antirheumatic drug (DMARDs). Researchers found in comparing the efficacy of tofacitinib monotherapy, tofacitinib plus methotrexate, and adalimumab plus methotrexate, tofacitinib and methotrexate combination therapy was non-inferior to adalimumab and methotrexate combination therapy in the treatment of rheumatoid arthritis in patients with an inadequate response to methotrexate in this trial. In this case, the patient continued to have rheumatoid arthritis disease activity despite DMARD monotherapy with methotrexate. The provider added Xeljanz to methotrexate to optimize disease control. The records show that the patient achieved improved disease control using Xeljanz and methotrexate. Given the medical literature, the requested medication is medically indicated in this clinical setting. Therefore, Xeljanz XR is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for tolerance induction program. As noted in recent review articles, oral immunotherapy treatment is in the early stages of development and further studies are necessary to optimize the protocols and improve safety. The potential therapeutic benefits of oral immunotherapy need to be considered in terms of significant oropharyngeal, respiratory, and gastrointestinal symptoms that have led to cessation of therapy in an estimated 10-15% of treated patients. Oral immunotherapy has not been recommended for the treatment of patients with food allergies by the AAAAI due to uncertainty whether therapeutic benefit outweighs risk of treatment. According to the AAAAI, the interventions and endpoints used in clinical trials vary widely. As a result, neither safety nor efficacy have been established a tolerance induction program as superior to allergen avoidance. This patient has a history of allergies to foods including peanuts, which supports treatment with food avoidance and use of an epinephrine autoinjector as needed. Given these findings, the requested tolerance induction program is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested tolerance induction program 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 services 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 reviewer 1 is board certified in allergy and  immunology with subspecialty certification in pediatrics and is actively practicing. Physician reviewer 2 is board certified in allergy and  immunology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in allergy and immunology 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 patient has requested authorization and coverage for Xeljanz tablets. Findings: The records provided for review document that this patients symptoms of alopecia were present for one year before they presented to their provider for treatment. The patient underwent evaluation and skin biopsy, which support a diagnosis of alopecia totalis given the facial involvement. During the past year, they have been treated with intralesional Kenalog, intramuscular steroids, as well as anthralin and squaric acid without sustained improvement. They have experienced recurrences in areas after initial response to treatment. The patients provider has recommended treatment with Xeljanz. In the medical literature, a study reported that Xeljanz was more effective than immunotherapy including squaric and anthralin, as well as traditional systemic therapy with a lower risk profile. Given that this patient has undergone treatment with intralesional and intramuscular steroids in addition to immunotherapy, and still has persistent disease diagnosed as alopecia totalis, Xeljanz is appropriate. Further studies support Xeljanz as safe and effective a treatment for alopecia areata, especially in cases that are not responding to typical treatments. For these reasons, the requested Xeljanz tablets are 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 a stress echocardiogram. Findings:  The physician reviewer found that Stress echocardiography is appropriate for patients with symptoms suggesting the possibility of coronary ischemia. Stress echocardiography may also aid in evaluating additional possible causes of exertional dyspnea, such as left ventricular dysfunction, occult valvular disease and diastolic dysfunction. In this case, the patient has multiple coronary risk factors and reports significant exertional dyspnea, suggesting possible ischemia. The provider has recommended further evaluation with stress testing, which is considered standard practice. Therefore, a stress echocardiogram is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service 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 cardiovascular 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Linzess capsules. Findings: A study noted that Linzess has a novel mechanism of action, resulting in accelerated intestinal transit and is indicated for treatment of constipation-predominant irritable bowel syndrome (IBS-C). Another study noted that linaclotide may be recommended for step-up management of IBS-C. Guidelines recommend linaclotide for overall symptom improvement in IBS-C patients. In this case, the patient has a diagnosis of IBS-C. The records show that the patient has used Linzess previously, with good results. Therefore, Linzess capsules are 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a sleep study with continuous positive airway pressure. The  American Academy of Sleep Medicine (AASM) clinical practice guidelines for the treatment of adult OSA with positive airway pressure (PAP), recommend that PAP therapy be initiated using either automatic PAP at home or in-laboratory PAP titration in adults with OSA and no significant comorbidities. The guidelines note, The choice of PAP initiation in the home or lab should be based on access, cost-effectiveness, patient preference, sleep clinician judgement, and other factors. In this case, the patient was diagnosed with mild OSA and did not have significant comorbidities. Her provider recommended an in-laboratory CPAP titration study. There is sufficient support for the service at issue in this clinical setting. Therefore, the sleep study with continuous positive airway pressure 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 otolaryngology with sleep-study 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.