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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for teeth implants (CDT-D6010) for teeth 4, 7, 10, and 12 provided on 12/18/20. Findings:  The physician reviewer found that many studies, support the use of complete dentures for rehabilitation of the edentulous maxilla. Placement of implants for an implant retained prosthesis can improve masticatory performance, reduce size of the prosthesis and improve phonetics and occlusion. High levels of patient satisfaction have been reported with implant supported prosthesis, especially for those patients who are dissatisfied with complete dentures. In this case, the patient does have an edentulous maxilla and it is known that this can result in decreased masticatory efficiency among other issues. On 12/23/20, the patient had his dentures relined. The patient underwent implant placement indicating a level of dissatisfaction with his conventional denture. Additionally, treating complete denture wearers with implants to support their denture has been shown to improve their chewing efficiency, increases maximum bite force and improves satisfaction. The placement of implants for a maxillary overdenture is consistent with the patients diagnosis of edentulous maxilla. Therefore, teeth implants (CDT-D6010) for teeth 4, 7, 10, and 12 provided on 12/18/20 were medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were 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 oral and maxillofacial 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 series of Ocrevus intravenous (IV) infusions. The U.S. Food and Drug Administration (FDA) approves the use of ocrelizumab (brand name Ocrevus) for the treatment of patients with relapsing or primary progressive forms of multiple sclerosis. The American Academy of Neurology practice guideline recommendations for disease-modifying therapies (DMTs) for adults with multiple sclerosis include offering DMTs to patients with relapsing forms of MS with recent clinical relapses or MRI activity. Hauser and colleagues note that in two phase III trials among patients with relapsing multiple sclerosis, ocrelizumab was associated with lower rates of disease activity and progression than interferon beta-1a over a period of 96 weeks. McCool and colleagues note that the results of a systemic literature search suggested that ocrelizumab has an efficacy superior to or comparable with all other currently approved DMTs across all endpoints analyzed, and a similar safety profile, indicating that it offers a valuable package for the treatment of patients with relapsing multiple sclerosis. In this case, the patient has a diagnosis of relapsing remitting multiple sclerosis, presenting with several relapses and active lesions on MRI. In this clinical setting, given that treatment with DMT is indicated and as current medical literature shows ocrelizumab has an efficacy superior to or comparable with all other currently approved DMTs, the requested service is medically indicated. Therefore, a series of Ocrevus IV infusions 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computer-assisted navigation for the authorized right reverse total shoulder arthroplasty. There is a lack of mid-term to long-term quality data in current medical literature involving computer-assisted reverse shoulder surgery. Researchers note that while accurate positioning of the glenoidal baseplate in the axial scapular plane may be improved using 3D C-arm navigation for reversed shoulder arthroplasty, computer navigation may not improve the inferior tilt of the component or the position in the inferior glenoid to avoid scapular notching, and that further studies are required to confirm these findings in the clinical setting. Given that long-term clinical studies are needed to determine if preoperative planning and navigation with more precise and accurate glenoid component positioning leads to improved clinical outcomes, functional outcomes, or implant survival, there is a lack of support for the durable clinical benefit of navigated reverse shoulder replacement. Therefore, computer-assisted navigation for the authorized right reverse total shoulder arthroplasty is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested computer-assisted navigation for the authorized right reverse total shoulder arthroplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for delivery of baby with midwife at a birth center that offers a water birth. The management of labor pain is a primary goal of intrapartum care and consists of pharmacologic and nonpharmacologic approaches (Jones, et al.; Chaillet, et al.). Nonpharmacologic techniques for management of labor pain can be combined or used sequentially to increase their effectiveness. Water birth has been advocated as a non-pharmacologic technique. However, the available data regarding the efficacy of water birth are limited to a few trials including small numbers of patients with wide variations in patient populations and study design. A committee opinion from the American College of Obstetricians and Gynecologists (ACOG) concluded that underwater delivery only should be performed within the context of an appropriately designed clinical trial. Current studies report that an underwater birth may cause respiratory problems in the neonate and there are reports of increased infection rates to the mother and fetus (Vanderlaan, et al.). All told, the requested delivery of baby with midwife at a birth center that offers a water birth is not medically necessary for 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 obstetrics and gynecology with subspecialty certification in reproductive endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lumakras tablet 120 mg. Blair describes sotorasib (brand name Lumakras) as a RAS GTPase family inhibitor developed to treat solid tumors with KRAS mutations, including non-small cell lung cancer (NSCLC) and colorectal cancer. The author further notes that the U.S. Food and Drug Administration (FDA) approves the use of sotorasib for the treatment of adult patients with KRAS G12C-mutated locally advanced or metastatic NSCLC who have received at least one prior systemic therapy. Hong and colleagues note that the KRAS G12C  mutation occurs in 13% of NSCLCs and in 1% to 3% of colorectal and other cancers. The authors noted that in a study of the efficacy of sotorasib on a subgroup of 42 patients with colorectal cancer, 7.1% (or 3 patients) had a confirmed response, and 73.8% (or 31 patients) had disease control. While studies are ongoing, a response rate of 7% does not suggest a significant clinical response to sotorasib in the context of colorectal cancer. Therefore, Lumakras tablet 120 mg is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Lumakras tablet 120 mg 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 reviewers 1 and 2 are board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology and are actively practicing. Physician reviewer 3 is board certified internal medicine with sub-specialty certification in medical oncology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vascepa 1 gm and/or Lovaza 1 gm. Rosenson and Eckel note that Vascepa is more than 95 percent icosapent ethyl and that in a small trial of patients with very high fasting triglyceride levels, reduced triglyceride levels up to 45 percent, but did not significantly affect low-density lipoprotein cholesterol (LDL-C) levels. The authors note that Lovaza is a prescription preparation of omega-3 ethyl esters that is 85 percent omega-3 fatty acids, and in patients with severe hypertriglyceridemia, omega-3 ethyl esters (4 gm daily) reduced triglyceride levels by 45 percent but raised LDL-C levels by 31 percent. In this clinical setting, given that the submitted documentation did not include a diagnosis of hypertriglyceridemia, the results of a lipid profile, a reason why the patient was unable to take fibrates, or if the patient was refractory to other medications, the requested medication is not medically indicated. Therefore, Vascepa 1 gm and/or Lovaza 1 gm are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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 cancer vaccine.Findings: Two out of three physician reviewers found that the requested cancer vaccine is not likely to be more beneficial for you than any available standard therapy.This patient has advanced neuroblastoma. There is insufficient evidence demonstrating the efficacy and safety of neuroblastoma vaccine for the treatment of advanced neuroblastoma. The current National Cancer Institute (NCI) guidelines do not support the use of a neuroblastoma vaccine as an accepted treatment option for advanced neuroblastoma. The current literature indicates that further studies are still needed to establish the efficacy and safety of the vaccine. Therefore, the requested cancer vaccine is not likely to be more beneficial than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in internal medicine with sub-specialty certification in medical oncology. All reviewers 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for 56 hours per week (eight hours per day) of home skilled nursing services. Findings:  The physician reviewer found that patient presents with congenital myasthenia gravis, hypoxic ischemic encephalopathy, severe dysphagia, and ventricular septal defect. As noted in the medical literature, the congenital myasthenic syndromes include a group of diverse genetic disorders that result in dysfunctional neuromuscular junction transmission. Clinical manifestations include weakness of the ocular and other cranial muscles, fatiguability on exertion, limb weakness, and generalized weakness. Based on the available documentation, this patient requires supervision due to safety and intermittent physical assistance for some tasks that can be provided by a caregiver or a trained aide such as placing him on and off of his ventilator, respiratory tract hygiene, and gastrostomy tube feeding/medication administration. His skilled nursing needs including caregiver training, tracheostomy changes, changes in his ventilator settings, and gastrostomy tube changes can be met with intermittent home nursing visits. The patient is placed onto his ventilator via his tracheostomy around midnight, which is placed on pressure control mode without supplemental oxygen, and he stays on this until about 5:30 in the morning. Occasionally, he receives interventions for respiratory tract hygiene. His tracheostomy tube is changed once a week. He is also receiving feedings, fluid boluses and medications through his gastrostomy tube chronically, due to his severe dysphagia with oral intake restrictions. His respiratory and dysphagia conditions are chronic and stable. The available records do not support the medical necessity of eight hours per day of skilled nursing services for this patient. All told, the 56 hours per week (eight hours per day) of home skilled nursing services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 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 extracorporeal shockwave therapy (ESWT). The documentation reviewed states that this patient has a history of left heel pain 15 years prior that was treated successfully with conservative care and orthotics. Recently, the patient underwent conservative care over four months for plantar fasciitis. The treating provider noted that the patients left heel pain was almost resolved, which suggests that conservative treatment has been at least partially effective. The patients provider has recommended treatment with ESWT. However, the current research to support ESWT has been inconclusive. Gollwitzer and colleagues assessed 246 patients who received either ESWT or placebo. The authors noted 69.2% improvement with ESWT compared to 34.5% improvement with placebo, with only minor complications. The authors concluded that further studies should focus on resolution of inconsistencies in treatment protocols. All told, the requested ESWT is not likely to be more beneficial for the treatment of the patients medical condition then available standard therapy.Findings:  Two of the three physician reviewers found the requested ESWT is not likely to be more beneficial for the treatment of the patients medical condition then 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 a licensed D.P.M., board certified in podiatry and is actively practicing. Physician reviewer 2 is a licensed D.P.M., board certified in podiatry and is actively practicing. Physician reviewer 3 is a licensed D.P.M., board certified in podiatry 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:  An enrollee has requested authorization and coverage for Dificid 200 mg tablets.According to Infectious Diseases Society of America (IDSA) guidelines, Dificid (fidaxomicin) is recommended for the treatment of Clostridium difficile diarrhea at the dose of 200 mg twice daily for 10 days, either as initial treatment of the infection or as treatment after failure of vancomycin. American College of Gastroenterology guidelines concur that, Oral fidaxomicin 200 mg twice daily for 10 days be used for an initial episode of non-severe Clostridium difficile infection. Fidaxomicin has demonstrated safety and efficacy for the treatment of Clostridium difficile infection. In this case, the patient has confirmed Clostridium difficile infection, and has not responded to vancomycin, which is evidenced by ongoing bloody bowel movements with mucus. Therefore, the requested Dificid 200 mg tablets are medically necessary for treatment of the patients medical condition.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for immunotherapy combination of nivolumab (Opdivo) and ipilimumab (Yervoy).Per the National Comprehensive Cancer Network, for patients who experience disease control (complete response, partial response, or stable disease) and have no residual toxicity, but subsequently experience disease progression/relapse greater than three months after treatment discontinuation, re-induction with the same agent or same class of agents may be considered. In addition, although some studies show benefit of ipilimumab rechallenge, it is limited to those with an initial response. In this case, the patient had progression of disease on nivolumab and pembrolizumab. This patient does not fit criteria for rechallenge. Therefore, immunotherapy combination of nivolumab (Opdivo) and ipilimumab (Yervoy) is not medically necessary for treatment of the patients medical condition.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 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 thyroid radiofrequency ablation (CPT 60699). Findings:  The physician reviewer found that records provided for review document that this patient has a history of an enlarging thyroid nodule. The nodule has grown compared to previous ultrasound. One of the patients providers has recommended treatment with radiofrequency ablation. Per Chung and colleagues, radiofrequency ablation is a safe treatment of benign thyroid nodules and recurrent thyroid cancers. Feroci and colleagues reported that radiofrequency ablation of thyroid nodules has been found to be safe and effective in reducing the size of a thyroid nodule without the need for open surgery in a majority of patients with low complication rates. Given this support, the requested thyroid radiofrequency ablation (CPT 60699) 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 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.