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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for conversion of gastric bypass revision surgery. In a comparison of revisional and primary bariatric surgery, Fulton and colleagues note that complications were significantly more frequent in revision patients than primary patients. Due to its risks, current medical literature does not support revisional bariatric surgery as the primary intervention to address weight regain after gastric bypass given the availability of less invasive, lower-risk endoscopic nonsurgical options for patients in this clinical setting. Dhindsa and colleagues note that transoral outlet reduction (TORe) is an endoscopic procedure that is safe and technically feasible for patients with weight gain post Roux-en-Y gastric bypass. Thompson and colleagues report that TORe is one approach to avoid weight regain. In this case, the patient has had weight regain following Roux-en-Y gastric bypass and has failed medications and other noninvasive measures to address weight regain. However, the records note that the patients provider does not recommend the patient as a candidate for surgical revision due to immediate risks. Given that surgical revision is significantly more invasive than endoscopic intervention, with a higher complication rate than primary bariatric surgery, the requested service is not medically indicated. Therefore, gastric bypass revision surgery is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 authorization and coverage for Ocrevus infusions. On review of the available documentation, this patient presents with a history of relapsing remitting multiple sclerosis. As noted in the medical literature, multiple sclerosis is an immune-mediated inflammatory demyelinating disease of the central nervous system. The patients provider has recommended treatment with Ocrevus. Ocrevus is an anti B cell monoclonal antibody indicated for the treatment of patients with relapsing forms of multiple sclerosis including relapsing remitting multiple sclerosis. Ocrevus is a U.S. Food and Drug Administration (FDA) approved therapy with robust evidence supporting its efficacy and safety in multiple sclerosis. Hauser and colleagues reported on two identical controlled trials with randomization of 821 and 835 patients with relapsing multiple sclerosis to receive Ocrevus or interferon beta-1a. The authors reported that the patient treated with Ocrevus showed lower rates of disease activity and progression. The authors concluded that Ocrevus is an effective medication in the management of multiple sclerosis. Given this support, the requested Ocrevus infusions 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. Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the administration of the Rituxan 500 mg/50 mL medication at a hospital outpatient setting. Neuromyelitis optica is an immune-mediated chronic inflammatory disease of the central nervous system. It presents with optic neuritis and myelitis, which can cause blindness and paralysis, respectively. Medical literatures note that therapy for neuromyelitis optica should be initiated early, and that rituximab is regarded as an established first-line treatment with long-term efficacy and an acceptable safety profile. However, rituximab is also a high risk therapy with multiple potential adverse side effects. Researchers report that while rituximab is a standard treatment for neuromyelitis optica, there is the risk of infusion-related reactions. The U.S. Food and Drug Administration (FDA) prescribing information notes that rituximab administration may result in serious, including fatal, infusion-related reactions, tumor lysis syndrome, severe mucocutaneous reactions, and progressive multifocal leukoencephalopathy. The FDA notes that fatal infusion reactions within 24-hours of infusion may occur and advises that patients be monitored for severe reactions. In this case, the records note that the patient experienced a rash shortly after receiving infusion in the past. In a letter, the provider reports that the patient is high risk for anaphylaxis. In this clinical setting, given the recommendations for close monitoring of patients while receiving therapy, the requested service is medically indicated. Therefore, the administration of the Rituxan 500 mg/50 mL medication at a hospital outpatient setting 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continuous passive motion (CPM) machine (E0935). Hill and colleagues found that the results of their study suggest that the use of CPM in the immediate postoperative period following the treatment of intra-articular fractures offers no benefit with regard to knee motion at six months and is not tolerated by all patients. Schulz and colleagues concluded that controlled active motion (CAM) therapies and CPM lead to significant improvements after total knee arthroplasty, but CAM showed better results in term of flexion, pain and quality of life. Harvey and colleagues reported that CPM does not have clinically important effects on active knee flexion range of motion, pain, function or quality of life to support its routine use. This patient is status post left total knee replacement. The patient was treated in a skilled rehabilitation facility for one week following the surgery. While in the rehabilitation facility, she utilized a CPM machine. The provider recommended use of a CPM machine to be used at home. However, there is a paucity of large-scale, peer-reviewed medical literature demonstrating that use of a CPM device in this patients clinical setting is effective in improving patient health outcomes. In addition, there is a lack of documentation in the patients records that CPM use is required in lieu of physical therapy to address any significant postoperative deficits in range of motion. Moreover, detailed documentation is not evident regarding any significant improvements in the patients range of motion with the use of the CPM machine while in the rehabilitation facility. All told, the requested CPM machine (E0935) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device 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 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 Strensiq (asfotase alpha) 80 mg/0.8 mL vials = 9.6 mL (12 vials) x 28 days, and Strensiq (asfotase alpha) 80 mg/0.45 mL vials = 5.4 mL (12 vials) x 28 days. Findings:  The physician reviewer found that submitted documentation does not support the medical necessity of the requested medication, which is used to stabilize skeletal abnormalities, and is not indicated for chronic pain. The records did not demonstrate clinical signs and/or symptoms of hypophosphatasia, such as skeletal deformities or juvenile onset, or a diagnosis confirmed by the presence of a known pathological mutation in the ALPL gene, or of skeletal abnormalities demonstrated on radiographic imaging. In this case, while the patient has chronic pain, the records do not document a history of juvenile onset or of recurrent fracture. Therefore, Strensiq (asfotase alpha) 80 mg/0.8 mL vials = 9.6 mL (12 vials) x 28 days, and Strensiq (asfotase alpha) 80 mg/0.45 mL vials = 5.4 mL (12 vials) x 28 days are not medically necessary for the treatment of this patientFinal 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 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: 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 series 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. 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 benefitted from viscosupplementation. Furthermore, he has tried and failed NSAIDs. He is a diabetic and cannot take corticosteroid injections. There is sufficient support for the requested services in this patients case. Therefore, the requested Synvisc-One injection series 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 Orencia. This patients provider has recommended treatment with Orencia to address diagnosis of systemic lupus erythematosus (SLE) with secondary antiphospholipid antibody syndrome. The reviewed records indicate that the patients SLE is stable, but there is concern for persistently elevated lupus anticoagulant and anticardiolipin. Steroid sparing therapy with Orencia is not indicated for the treatment of positive lupus anticoagulant and anticardiolipin. Although arthralgias and myalgia is reported, on physical examination there were no synovitis or joint tenderness noted to specifically support the use of Orencia. Medical literature shows that Orencia failed to meet its primary endpoint, time to complete response, in a phase II/III trial as an adjunct treatment for class III or IV lupus nephritis. There are several standard medications recommended for the treatment of patients with SLE that serve as steroid sparing agents including azathioprine, CellCept, Benlysta, and Saphnelo. The medical records do not document that this patient has been treated with and failed to improve with the recommended agents that have been demonstrated to be safe and effective in the peer-reviewed medical literature. In conclusion, the requested Orencia 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 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 internal medicine with subspecialty certification in rheumatology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in rheumatology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in rheumatology 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 reimbursement and prospective authorization and coverage for Supartz injections. 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 is status post lateral meniscus transplantation and articular cartilage paste grafting of the lateral tibial plateau, and status post chondroplasty of the lateral femoral condyle. Magnetic resonance imaging (MRI) showed grade III chondromalacia of the medial femoral condyle and grade IV chondromalacia of the posterior medial tibial plateau. The provider reported that Supartz was administered to supplement the synovial fluid in the osteoarthritic knee and to help the elastoviscosity in the joint, thereby alleviating the symptoms. In this clinical setting, the options were limited, and a corticosteroid injection was not an option as it would have harmed the transplanted tissue. Given the patients limited options and based on the current medical literature, the services at issue were and are medically indicated. Therefore, Supartz injections were and are 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Supartz injection series 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 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 records document osteoarthritis of the left knee following two ACL reconstructions and two meniscal surgeries. The patient reports chronic pain along with mechanical symptoms of catching and locking. The patient has tried and failed other conservative treatments, including physical therapy. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Supartz injection series in the left knee 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for testosterone gel. Findings: Male hypogonadism may present with multiple symptoms, including diminished libido and erectile dysfunction, fatigue, irritability, increased body fat, decreased muscle mass and osteoporosis. A study notes that testosterone treatment is indicated for men with symptomatic testosterone deficiency. Another study notes that there are several possible administration routes for testosterone treatment. The authors state, Although new developments are promising, it seems that among the available treatments, only transdermal gel delivery and long-acting injectable testosterone undecanoate provide pharmacokinetic behavior that gives a steady state level within a physiological range. Therefore, testosterone gel is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ozempic pen. Findings: A study notes that while lifestyle modification is recommended as the cornerstone of obesity management, as many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss, there are currently multiple pharmacologic therapies which are available for weight management. Another study reports that glucagon-like peptide-1 (GLP-1) analogs, such as Ozempic, improve glycemic control, reduce body weight, and decrease cardiovascular risk. Cornell notes that GLP-1 receptor agonists have an established efficacy and safety profile. Given that current medical literature supports the use of the Ozempic in promoting weight loss and the low likelihood of health risks associated with this medication, the requested medication is medically indicated. Therefore, Ozempic pen is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.