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 Erleada (apalutamide) 60 mg tablets. Findings:  The physician reviewer found that Current medical literature does not support the safety and efficacy of Erleada in patients with metastatic castration-resistant prostate cancer. Randomized placebo-controlled clinical trials of apalutamide (TITAN and SPARTAN trials) only included patients with non-metastatic castration-resistant and metastatic castration-sensitive prostate cancer. They did not include patients with metastatic castration-resistant prostate cancer. In addition, current medical literature supporting the efficacy of apalutamide in patients with failed similar drug Xtandi, abiraterone and Taxotere is largely unknown, and as such not considered a generally accepted and clinically appropriate standard. NCCN guidelines mention multiple options for patients who have had prior failure to first-line abiraterone or enzalutamide. These include docetaxel, Sipuleucel-T, olaparib, pembrolizumab, radium223, cabazitaxel, fine particles abiraterone or other secondary hormone therapy (ketoconazole, ketoconazole plus hydrocortisone, plus generation antiandrogen, corticosteroids, DES, antiandrogen withdrawal). In this case, the patient has metastatic castration-resistant prostate cancer and has failed Xtandi, abiraterone and Taxotere. Accordingly, the requested medication, Erleada (apalutamide) 60 mg tablets, is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for 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: An enrollee has requested reimbursement for the Gelsyn-3 injections in both knees. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to 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 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 patients options were limited. The patient had tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. As such, Gelsyn-3 injections in both knees were medically necessary for treatment of the patients medical condition.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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Inogen One G5 Portable Oxygen concentrator. The records provided for review document the presence of fibrotic lung disease, which supports an indication for treatment with supplemental oxygen. Use of supplemental oxygen should be adequate to meet a patients needs, while still promoting ambulation, mobility, and an active lifestyle. This patients current portable oxygenator is no longer under warranty. The device is heavy and not suitable to supporting an active and mobile lifestyle. Given the critical importance of protecting the functional status in patients with fibrotic lung disease, the requested Inogen One G5 portable oxygen concentrator is appropriate for this patient. Therefore, the requested Inogen One G5 Portable Oxygen concentrator is medically necessary for 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 board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injection series (CPT J7324) in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the options are limited based on the available documentation. The patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties. For these reasons, the requested Orthovisc injection series (CPT J7324) in both knees is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an otolaryngology office visit at a tertiary care facility.At issue is whether the requested referral for an otolaryngology office visit at a tertiary care facility is medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.There is sufficient support for the requested services in this clinical setting. Audiometry follow-up and evaluation of the tympanic membrane after myringotomy and tube placement is part of the standard of care in caring for patients with tubes. In this case, the patient presents with a significant speech delay. He had bilateral tubes placed in 2019. On late 2020, the patient had a vocabulary of 50 words. The plan was for the patient to return in three months. Per the submitted documentation, speech delay is the primary problem in this case. A tertiary care facility is the most appropriate site for follow-up evaluation, which would include speech, audiology, otolaryngology, and pediatric neurology evaluations. Therefore, the requested otolaryngology office visit at a tertiary care facility is medically necessary to prevent disease, disability, and other health conditions or their progression.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 otolaryngology 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 pain relief injection. Findings:  The physician reviewer found that vidence based on one high-quality randomized controlled trials in each category the evidence is Level III to II for fluoroscopically-guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically-guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness. ASIPP further reported that epidural injections have been shown to be effective in managing lumbar spinal stenosis in multiple randomized controlled trials and systematic reviews. A systemic review by Lee and colleagues concluded that lumbar epidural steroid injections were more effective injections than those without steroid for improved pain relief and function for patients with lumbar back pain. This patients records document a history of chronic low back with radiation into the lower extremities. Based on her history and current presentation, the patient has signs and symptoms consistent with neurogenic claudication. An MRI from March 2020 confirmed the presence of moderate-to-severe canal stenosis at L4-5 with an anterior-posterior diameter of 6 mm due to secondary canal changes. She has tried and failed medication management with non-steroidal anti-inflammatory drugs (NSAIDs), opioid medications, and neuromodulating agents. Moreover, she did not obtain adequate relief with physical therapy. Her treating provider has recommended a trial of lumbar epidural steroid injections as a next step in her treatment plan before consideration of surgical options. The current guidelines from ASIPP endorse the use of epidural steroid injections in the treatment of patients with spinal stenosis who have exhausted conservative modalities. Based on these findings, the requested pain relief injection is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 physical therapy. Findings:  The physician reviewer found that there is no one surgical technique or protocol that has been established to address each combination of prognostic factors for recovery following rotator cuff repair surgery. Coda and colleagues found that although certain rehabilitation components are common, such as duration of passive range of motion and sling or immobilizer use, a large degree of variation remains among published rehabilitation protocols after rotator cuff repair. Post-operative physical therapy can be beneficial. The goal of physical therapy is to transition to an independent home exercise program without continued dependence on supervised therapy. The records provided for review document that this patient has undergone prior extensive physical therapy. The patient has been educated in a home exercise program and has requested additional physical therapy. However, the patients expected rehabilitation potential is not significant in relation to the extent and duration of the physical therapy services requested. The specialized skill of a qualified therapist is not required to establish, design or deliver a maintenance program to maintain the patients current condition or to prevent or slow further deterioration. The patient can continue her home exercise program and follow up with her provider for further evaluation and management of her symptoms. All told, the requested physical therapy is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services. Findings:  The physician reviewer found that documentation fails to demonstrate the medical necessity of the requested services. There is some support for an acupuncture trial of six sessions to treat shoulder pain. However, passive care (acupuncture) should be combined with active care (e.g. conditioning-aerobic-stretching exercise program). Indications for care discontinuation should be followed and include resolution, intolerance, lack of measurable improvements or non-compliance, including non-compliance with aerobic and strengthening exercises. In this case, the records fail to adequately document the clinical findings, including the deficits (motor-sensory-functional) to be addressed by the care requested. Therefore, the goals to be obtained with the acupuncture are unclear. Additionally, there is no documentation indicating whether the patient is currently undergoing an independent exercise program or other active care, which is recommended by the peer-reviewed literature. Therefore, the requested acupuncture services are not medically necessary to treat the patients medical condition.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 oriental 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5 mg tablet daily. Findings:  The physician reviewer found that the most recent published guidelines, the treatment of alopecia areata includes methotrexate and contact sensitization. Few treatment methods have been evaluated by randomized control trials to determine the most efficacious modalities to treat alopecia areata. While the Janus kinase (JAK) inhibitors, such as Xeljanz, show excellent promise in treating extensive alopecia, there is a paucity of peer-reviewed medical literature showing that Xeljanz is superior to standard therapies. According to the Alopecia Areata Consensus of Experts, there is agreement on the effectiveness of monotherapy with oral corticosteroids, cyclosporine, and JAK inhibition therapy as well as combination therapy of oral corticosteroids together with cyclosporine or methotrexate when used as steroid-sparing agents. This patients records document alopecia areata that has failed to improve with steroids. However, there is a lack of evidence that the patient has failed standard therapies to support an indication for treatment with Xeljanz. There is a lack of data that Xeljanz is likely to be more effective and well-tolerated as compared to standard treatments like methotrexate, cyclosporine or contact sensitization. Therefore, the requested Xeljanz 5 mg tablet daily is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Xeljanz 5 mg tablet daily 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 medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. 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 Descovy. In a meta-analysis on the efficacy, safety, and tolerability of tenofovir alafenamide (TAF-Descovy), a study found TAF regimens were non-inferior to tenofovir disoproxil fumarate (TDF-Truvada) regimens and noted advantages in renal function, bone parameters, and lipid profile. Another study found TAF had a similar tolerability, safety, and effectiveness to TDF and probably less adverse events related to renal and bone density outcomes in the treatment of naive and experienced patients with HIV-1. Given that current medical literature does not show that differences between TAF and TDF regimens are clinically significant, the requested medication is medically indicated. Therefore, Descovy 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 infectious 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 reimbursement for an adalimumab assay (CPT 80145) provided by Lab Corporation of America. In this case, the records noted that the patient had been diagnosed with Crohns disease, was status post ileocecal resection, and was asymptomatic postoperatively. The records noted a recurrence, and the patient started Humira. He then developed a neck abscess of unclear etiology and stopped Humira therapy. The records noted that the patient was reluctant to resume Humira during the COVID-19 outbreak. Due to the reported side effects and the noted reluctance to continue on Humira during the pandemic, it was unlikely that the patient would continue on Humira.  In this clinical setting, given that the provider was likely switching the patient to a medication of another class with a better side effect/adverse effect profile that would not be as immunosuppressive, the testing at issue was not likely to alter this patients outcomes. The documentation does not show that the service at issue provided a safer or more effective evaluation than a standard clinical assessment to make medical therapy changes as part of conventional disease management. Therefore, the adalimumab assay (CPT 80145) provided by Lab Corporation of America 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 adalimumab assay (CPT 80145) provided by Lab Corporation of America 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 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 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.