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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injection series (J7323) in the right knee. 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 patients case, the options are limited. The patient has tried and failed NSAIDs, physical therapy and a home exercise program. However, she has not tried viscosupplementation. The medical evidence indicates that viscosupplementation is beneficial for chondromalacia of patella in light of the anti-inflammatory, analgesic, and chondroprotective action of hyaluronic acid. Furthermore, it has been shown to be safe and effective in the treatment of pain related to patellar chondropathy. Therefore, the requested Euflexxa injection series (J7323) in the right knee 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for acupuncture services. While conventional medicine has not yet developed effective treatments or clinical practice guidelines for the treatment of long COVID-19 due to the new and evolving nature of the condition and limited number of cases, current medical literature does support the use of acupuncture for the treatment of similar symptoms. Morehead and Salmon note that the efficacy of acupuncture has been proven for nausea and vomiting related to pregnancy, in patients receiving chemotherapy, and in postoperative, pediatric, and female patients. Streitberger reports that results from 26 trials showed that acupuncture-point stimulation was effective for both postoperative nausea and vomiting, concluding that there is good clinical evidence from more than 40 randomized controlled trials that acupuncture has some effect in preventing or attenuating nausea and vomiting. In this case, the patient underwent several therapies with limited relief of her symptoms including oral medication, patches, and vestibular therapy. Following five sessions of acupuncture, the patient reported significant improvement in sense of smell, dizziness, and nausea, allowing for a reduction in medication usage. In this clinical setting, given the patients benefits obtained with prior acupuncture care and the literature support for the use of acupuncture to treat nausea, the requested services are medically indicated. Therefore, acupuncture services are 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested reimbursement for an advanced lipoprotein test. Current medical literature does not demonstrate that advanced lipoprotein testing adds significant actionable information to what is already known from a basic fasting lipid profile. There is a lack of randomized trials showing that therapies to correct any novel lipoprotein abnormalities, such as lipoprotein(a), have any effect on cardiovascular outcomes such as myocardial infarction, stroke or death. In this clinical setting, there is insufficient evidence to support the use of the service at issue, particularly given this patients low-risk based on atherosclerotic cardiovascular disease (ASCVD) criteria. Therefore, advanced lipoprotein test 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 advanced lipoprotein test at issue was not likely to have been more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Hizentra 8 gm subcutaneously every week for one year. Selective antibody deficiency with normal serum immunoglobulin concentrations is a deficiency of specific antibody response to polysaccharide antigens with intact response to protein antigens and normal serum level of IgG and IgG subclass. Immunoglobulin replacement therapy with intravenous immunoglobulin (IVIG) or subcutaneous immunoglobulin preparations is a treatment option for this group of patients with recurrent infections that persist after immunizing and antibiotic treatment. Wasserman reports that immunoglobulin replacement therapy is the cornerstone of management for most primary immunodeficiency disease patients, and that immunoglobulin replacement therapy leads to significant decreases in the number of infections. In this case, the patient has normal levels of IgG and abnormal post-vaccination pneumococcal titers constituting an immunodeficiency with only a 57% response to vaccination, or 13 out of 23 serotypes showing protection. In this case, given that the patient meets the diagnostic criteria for specific antibody deficiency disorder based on a history of recurrent infections such as sinusitis and bronchitis, and poor antibody response to pneumococcal antibody, the requested services are medically indicated. Therefore, Hizentra 8 gm subcutaneously every week for one year 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 allergy and immunology 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 Positron Emission Tomography (PET) with concurrently acquired Computed Tomography (CT) Scan.Findings: Two out of three physician reviewers found that the current medical evidence does not support the requested service in this clinical setting. NCCN and ACR guidelines state that PET/CT is not useful in Stage 1 noninvasive parotid tumor follow up or initial stage imaging. PET/CT is more useful with invasive tumors that are T3/T4. These guidelines recommend follow up imaging in Stage 1 by CT and MRI. A study by researchers also describes the limited benefit of PET/CT in detecting head/neck cancer recurrence after initial treatment. This study also suggests that negative 3-month scans led to no significant differences in subsequent survival outcomes in patients whose recurrences were detected through PET/CT versus those with clinically detected recurrences. In this case, although there was some question of positive margins, the patients follow up radiation oncology consultation stated that the margins were close though negative. The patient also did not require radiation therapy due to her low staging. Her tumor pathology was low grade mucoepidermoid. Under these circumstances, NCCN and ACR guidelines indicate that further imaging with CT or MRI is more appropriate than PET/CT. PET/CT is more useful with invasive tumors that are T3/T4, though the patient does not fit this criterion. Accordingly, the requested Positron Emission Tomography (PET) with concurrently acquired Computed Tomography (CT) Scan is not likely to be more beneficial than any other available standard treatments for the patient's medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatments for the patient's medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer 1 is board certified in diagnostic radiology and is actively practicing. Physician reviewer 2 is board certified in diagnostic radiology, and interventional radiology and diagnostic radiology, and is actively practicing. Physician reviewer 3 is board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for peripheral nerve stimulation (PNS). One review on neurostimulation for neck pain and headache discussed two large randomized clinical trials with conflicting results (Hong, et al.). The authors noted that, Preliminary reports suggested that 60-80% of patients with chronic headache who have failed maximum medical therapy respond to PNS. The authors concluded however that the complications rates for PNS are high. This patient has responded well to treatment with trigger point injections in the upper back and neck, which is common for patients with myofascial pain syndrome. One systematic review and meta-analysis reviewed 11 studies evaluating the safety and efficacy of Botox for the treatment of patients with head and neck chronic myofascial pain syndrome (Khalifeh, et al.). The authors noted significant improvement at two to six months compared to the placebo group, but the results were nonsignificant at four to six weeks. The patients records do not report failure or a contraindication to treatment with Botox, or other standard options such as behavioral interventions, or duloxetine, which is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with chronic musculoskeletal pain. Therefore, the requested implantable PNS device is not likely to be more beneficial than any other available standard therapy to treat the patients condition.Findings: Two of the three physician reviewers found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation 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 anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for FoundationOne CDx genomic testing. Adenocarcinoma of the esophagus that has metastasized carries a poor prognosis. Next-generation sequencing (NGS) offers the opportunity to assess numerous mutations simultaneously, along with other molecular events such as amplification, deletions, tumor mutation burden, and microsatellite instability (MSI) status. The U.S. Food and Drug Administration (FDA) approves the use of several targeted therapeutic agents, including trastuzumab, pembrolizumab/nivolumab, for the treatment of esophageal and esophagogastric junction cancers. The National Comprehensive Cancer Network (NCCN) guidelines for esophageal and esophagogastric junction cancers recommend the use of NGS for locally advanced esophageal cancer. In this case, a pathology report reported that the patient is HER2 negative. In this clinical setting, the NCCN guidelines support the use of NGS comprehensive testing to look for targets for which newer treatments may be available and for evaluation for clinical trials. Therefore, FoundationOne CDx genomic testing is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested FoundationOne CDx genomic testing 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 service 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 internal medicine with sub-specialty certifications in medical oncology and in hematology 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 reimbursement for acute inpatient hospitalization services. In this case, the patient underwent appropriate inpatient testing and empiric treatments. Although no frank seizures were witnessed, and no evidence was found on electroencephalogram (EEG), empiric outpatient treatment with antiepileptics for a few months if indicated may be a reasonable and common practice.  In this case, continued hospitalization for ongoing inpatient diagnostic treatment was not indicated. The records indicated that further testing, such as screening for an ovarian teratoma causing encephalitis, was decided against due to the resolution of the patients white blood cell count on spinal tap. An empiric trial of intravenous immunoglobulin (IVIG) was not indicated as autoimmune encephalitis was not strongly suspected. The patients clinical status had improved, and an encephalitis panel was negative by the date of discharge. Given that this patient required only custodial care, and as further diagnostics and follow-up could have been performed on an outpatient basis, the services at issue were not medically indicated. Therefore, acute inpatient hospitalization services were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 neurology with sub-specialty 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 Rituxan (rituximab). This patients records document that the patient has been unable to tolerate standard therapy for systemic lupus erythematosus (SLE) with mycophenolate mofetil. In addition, the patient and provider are planning to avoid the use of cyclophosphamide due to the potential for the side effect of infertility. According to the American College of Rheumatology (ACR) guidelines for the screening, treatment, and management of patients with SLE, Rituxan is an appropriate therapy for the treatment of patients with SLE, especially given the patients plans childbearing age and desire to preserve fertility. On review of this patients records and the ACR guidelines, Rituxan is indicated for this patient as a third-line treatment option for the management of SLE, especially given the patients decision to avoid the risk of infertility associated with cyclophosphamide. Therefore, the requested Rituxan (rituximab) 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 internal medicine with subspecialty 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 continued skilled nursing level of care including physical therapy and wound care. At issue is whether the requested continued skilled nursing level of care including physical therapy and wound care is medically necessary for treatment of this patient. Acute heart failure has multiple potential etiologies, but typically occurs in the setting of decompensation of a pre-existing cardiomyopathy (Abdo). Statins are generally safe and highly effective pharmacotherapeutic tools used in the management of dyslipidemia to reduce cardiovascular morbidity. Statin-induced myopathy is the most common cause for discontinuation of this therapy (Ward, et al.; Vinci, et al.). Treatment in this clinical setting starts with statin discontinuation, consideration of re-challenge therapy with a different statin, and possible treatment with non-statin lipid lowering pharmaceuticals. In some cases, myopathy can persist despite statin discontinuation (Meyer, et al.). The patient in this case reportedly developed severe cardiomyopathy, most likely due to myocarditis. The patients ejection fraction was 15% initially and improved to only 20%. He also developed severe weakness in his left leg, attributed to statin-induced myopathy. The statin was discontinued, but there is a lack of documentation that the patient has experienced significant recovery of motor function in the affected limb. The patient has required a left knee and left ankle foot orthoses to stabilize his leg for standing and limited walking in the parallel bars. Overall, the patient has essentially maximized the amount of function he is expected to gain given his underlying impairments affecting his heart and his left lower limb. The patient is not expected to become a functional ambulator in the near term despite additional physical therapy. The patient will continue to require significant assistance to manage his lower body self-care. However, the records do not report ongoing skilled rehabilitation or skilled nursing needs requiring further SNF level care. For these reasons, the requested continued skilled nursing level of care including physical therapy and wound care 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 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 reimbursement and prospective authorization and coverage for functional medicine visits. The medical evidence does not support the requested services in this patients case. There are guidelines for the management of gastroesophageal reflux disease and dyspepsia, which recommend medical therapy followed by, if indicated, endoscopic evaluation. The request for the use of functional medicine evaluation and therapy is not supported by current medical literature. These treatments are not established in the medical community based on high-quality evidence for safety and efficacy. Such an approach may lead to missed diagnoses and ineffective or harmful therapy. All told, the functional medicine visits 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 internal medicine with subspecialty 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.