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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hereditary spastic paraplegia panel. Primary lateral sclerosis is a disorder of progressive spinobulbar spasticity with a mostly spinal and occasionally bulbar region onset. Hereditary spastic paraparesis is a clinically and genetically heterogeneous group of disorders characterized by a slowly progressive spastic paraparesis. In patients with an apparently sporadic adult-onset upper motor neuron syndrome, clinical differentiation between primary lateral sclerosis and hereditary spastic paraparesis can be problematic. Genetic testing is the recommended method to differentiate hereditary spastic paraparesis from primary lateral sclerosis in patients with apparently sporadic adult-onset upper motor neuron syndromes, at least for those who have symptom onset in the legs. In this case, the patient presents with progressive gait instability and upper motor neuron findings in the lower extremities on examination. An extensive work-up has been unremarkable. Genetic testing will help differentiate between primary lateral sclerosis and hereditary spastic paraparesis, which is important for treatment planning. Therefore, the requested hereditary spastic paraplegia panel is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested hereditary spastic paraplegia panel is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation 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 neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gammaplex, or in the alternative, Octagam. Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic progressive or relapsing and remitting disease that usually causes weakness and sensory loss. This patient has chronic immune sensory polyradiculopathy (CISP), a sensory variant of CIDP, that is progressive and more debilitating. CISP is a condition that presents with sensory neuropathy, ataxia, and normal nerve conduction from selective sensory nerve root inflammatory demyelination. According to the evidence-based guideline by the American Academy of Neurology, IVIG is effective and should be offered in the long-term treatment of this patients medical condition. Thus, the requested Gammaplex is 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 Gammaplex is 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 neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for robotic-assisted right knee arthroplasty. This patient is indicated for right total knee arthroplasty given her history of bilateral knee osteoarthritis. The patients provider has recommended robotic-assisted right total knee arthroplasty. The patient previously underwent left total knee arthroplasty, which required early manipulation under anesthesia and revision surgery due to tibial loosening. The patient has severe bone-on-bone right knee osteoarthritis with varus alignment. Current evidence-based medical literature does not support the routine use of robotic-assisted total knee arthroplasty in lieu of conventional total knee arthroplasty. However, there are data that robotic-assisted arthroplasty can reduce the overall rate of revision due to loosening in patients under 65 years of age (Young, et al.; Beal, et al.). Given this patients complex surgical history and experience with her left total knee arthroplasty, her anatomic alignment issues, this request for robotic-assisted right knee arthroplasty is considered an accepted standard of care. For these reasons, the requested robotic-assisted right knee arthroplasty is 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 robotic-assisted right knee arthroplasty is 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 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 orthopedic surgery 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: Upheld Decision of Health Plan

: An enrollee has requested authorization and coverage for a C-Stim Unit neuromuscular stimulator (CPT code E0745).Kroeling and colleagues conducted a systematic review of randomized controlled trials (RCTs) and concluded that electrical muscle stimulation did not reduce pain or disability for patient with neck pain. They indicated that future trials on these interventions should have larger patient samples, include more precise standardization, and detail treatment characteristics. Alrwaily and colleagues conducted a randomized controlled trial to investigate the clinical benefit of using neuromuscular electrical stimulation as a supplement to stabilization exercises in patients with chronic low back pain. They concluded that supplementing stabilization exercises with neuromuscular electrical stimulation did not offer any additional clinical benefit for the trials chronic low back pain patients.In this case, the patient presents with a history of chronic, constant neck pain. Records include radiographic evidence of degenerative disc disease at C5-6 with right neuroforaminal stenosis and 3 mm degenerative retrolisthesis. The patients treatments have included medications, physical therapy, acupuncture, and chiropractic treatment, and a neuromuscular electrical stimulator (CPT code E0745) has been prescribed for diagnoses of cervical disc degeneration and spondylosis. Current evidence based medical literature, however, does not support the use of electrical muscle stimulation for patients with chronic neck pain. Therefore, the requested C-Stim Unit neuromuscular stimulator (CPT code E0745) is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested device is not medically necessary to treat the patient's 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 Gammagard. The records provided for review document that this patient has total immunoglobulin G (IgG) and subclasses 1 and 2 deficiency. The patient has experienced a multitude of sinus and lung infections. Treatment has included several courses of antibiotics and sinus surgeries without substantial improvement. The patients provider has recommended treatment with immunoglobulin therapy. Current data supports the safety and efficacy of immunoglobulin therapy in this clinical setting. Researchers reported immunoglobulin therapy has a positive impact on the frequency of sinusitis and pulmonary infections in patients with common variable immunodeficiency (CVID) and specific antibody deficiency. Given this support, the requested Gammagard 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gammaCore Sapphire non-invasive vagus nerve stimulator (VNS). Findings:  The physician reviewer found that integrating new migraine treatments into clinical practice states that, neuromodulation may be appropriate for preventive and acute treatment, depending on the needs of individual patients. Neuromodulation may be useful for patients who prefer nondrug therapies or who respond poorly, cannot tolerate, or have contraindications to pharmacotherapy. Non-invasive neuromodulation, which alters neural activity through the stimulation of nerves or neural tissue, includes the gammaCore system. The FDA approved gammaCore for the acute treatment of migraine and episodic cluster headache. Mwamburi and colleagues reviewed the evidence of noninvasive VNS for treatment of migraine. The authors concluded that, patients with migraine who experience two or more headache days per month and remain dissatisfied with their current treatment are the best candidates to try gammaCore. In this case, the patient has migraine headaches that have increased in frequency despite treatment with multiple abortive and preventative medications. She is planning to become pregnant which affects her choice and intake of migraine medications. She has tried gammaCore in the past which resulted in improvement in migraine frequency. Based on the AHS position statement and current studies, gammaCore is likely to be more beneficial for the treatment of this patients migraines than available standard therapies. All told, the requested gammaCore Sapphire non-invasive VNS is 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 gammaCore Sapphire non-invasive VNS is 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 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 neurology 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 consultation at the tertiary level of care. Mylotte and colleagues note that clinical guidelines recommend specialized care for patients with adult congenital heart disease (ACHD), and that referral for specialized ACHD care was associated with a significant mortality reduction. The American Heart Association and American College of Cardiology (AHA/ACC) guideline for the management of ACHD  notes the need for specialized care for patients with ACHD. In this case, the patient has complex ACHD. The records document comprehensive congenital care at the tertiary medical center by providers who are specialized congenital heart disease interventionalists. Given the high level of specific experience of the multidisciplinary team dedicated to the ongoing treatment of patients with ACHD, and current medical guidelines recommended specialized care for patients with ACHD, the requested service is medically indicated. Therefore, a consultation at the tertiary level of care 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zulresso IV infusion treatment.The submitted records do not support that the requested medication is medically necessary. In treating postpartum depression, current literature recommends that add-on pharmacotherapy such as a second-generation antipsychotic, lithium, or triiodothyronine be added. For patients who are refractory to these sequential medication trials, ECT is recommended. In this case, while the patient has a diagnosis of postpartum depression, she has not had a trial of add-on pharmacotherapy such as a second-generation antipsychotic, lithium, or triiodothyronine. She has also declined electroconvulsive therapy (ECT). In addition, Zulresso (brexanolone) has only been studied for use in patients who are within 6 months of delivery, while the patient is now 12 months postpartum and would not be eligible for treatment with this medication. Under these circumstances, the requested Zulresso IV infusion treatment is not medically necessary to treat the patients medical condition, postpartum depression.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Remicade 5 mg/kg given as an intravenous induction regimen followed by a maintenance regimen. In a systemic review on medical therapies for inflammatory bowel disease, it was found that tumor necrosis factor (TNF) inhibitors, such as infliximab, are strongly recommended based on their efficacy at inducing remission in patients with moderate to severely active symptoms. The American Gastroenterological Associations guidelines for initial treatment of Crohns disease recommend using anti-TNF- drugs, such as infliximab, to induce remission in patients with moderately severe Crohns disease that is refractory to other therapies. The guidelines further recommended anti-TNF monotherapy over no therapy or thiopurine monotherapy, and the continued use of anti-TNF  drugs to maintain remission. Alternatives to anti-TNF therapy, such as immunosuppressants, aminosalicylates, corticosteroids, and antibiotics, were not recommended. In this case, the patient has Crohns disease and has already failed therapy on 6-mercaptopurine. Without treatment, the patient is at risk for complications from Crohns disease, such as fistula, stricture, hospitalization, and need for surgery. Given the current medical literature, the requested medication regimen is medically indicated in this setting. Therefore, Remicade is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 patients parent has requested authorization and coverage for a Dupixent pen auto injector 300 mg/2 mL. In a systemic literature review, Seger and colleagues concluded that for severe atopic dermatitis refractory to topical therapies, the strongest evidence currently existed for dupilumab and cyclosporine at improving clinical disease severity. Paller and colleagues found that dupilumab and topical corticosteroids were effective and well tolerated in children aged 6-11 with severe atopic dermatitis, significantly improving symptoms and quality of life. In this case, the patient has tried and failed topical therapies and emollients. Given that current  medical literature reports that Dupixent is safe, well tolerated and effective in treating children with atopic dermatitis, the requested medication is medically indicated. Therefore, a Dupixent pen auto injector 300 mg/2 mL is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trulance. Findings: The U.S. Food and Drug Administration (FDA) has approved the use of Trulance, a guanylate cyclase-C agonist, for chronic idiopathic constipation (CIC). A study noted that plecanatide significantly improved constipation and its related symptoms with a low rate of adverse events, and may be a useful treatment option in the management of CIC. The most recent guidelines for the treatment of constipation recommend the use of osmotic and then stimulant laxatives before advanced agents such as Trulance and note, A newer agent should be considered when symptoms do not respond to laxatives.  In this case, while the patient has chronic constipation, the documentation does not show a failure of laxative alternatives prior to treatment with an agent such as Trulance. Therefore, Trulance 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 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 conversion of Roux-en-Y gastric bypass to the duodenal switch. Mechanick and colleagues note that bariatric procedures are a safe and effective intervention for higher-risk patients with obesity, but that a team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues. In a systematic review on reoperative bariatric surgery, Brethauer and colleagues concluded that while current evidence supports additional treatment for persistent obesity, comorbid disease, and complications, the indications and outcomes for reoperative bariatric surgery are procedure-specific. In this case, the patient has persistent morbid obesity. The records document a comprehensive multidisciplinary evaluation, including a dietary evaluation. In this clinical setting, the requested service is medically indicated. Therefore, conversion of Roux-en-Y gastric bypass to the duodenal switch 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 surgery with expertise in bariatric 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.