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 Botox (onabotulinumtoxin A). Findings: The records provided for review document that this patient presents with blepharospasm and hemifacial spasm. The patients provider has recommended treatment with Botox injections. A study noted that, Blepharospasm is a focal dystonia characterized by involuntary, repetitive eye closure. The American Academy of Neurology (AAN) guidelines on the treatment of blepharospasm state that Botox injections are supported by Level B evidence as probably safe and effective in the management of this blepharospasm. The AAN guideline noted that Botox is considered the first-line treatment of blepharospasm by most movement disorder specialists. Based on the current medical literature, the requested Botox injections are likely to be effective for symptomatic relief of the patients facial spasm and twitching. Therefore, the requested Botox (onabotulinumtoxinA) is medically necessary for 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 ophthalmology 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 Dupixent. Findings: The guidelines of care for patients with eczema include treatment with measures such as avoidance of triggers, emollients and treatment of superficial colonization or infection of the skin. First-line topical calcineurin inhibitors, UVB phototherapy, and topical corticosteroids have also been shown to be effective. In this case, the patient does not have documentation of failure of the recommended first-line treatment options to support an indication for Dupixent. Specifically, the records do not document that the patient has received adequate treatment with topical calcineurin inhibitors like tacrolimus or pimecrolimus. Given the limited body surface area affected, the patient should receive treatment with these topical agents prior to starting systemic treatment with a biologic like Dupixent. Given these findings, the requested Dupixent is not medically necessary for 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for VenaSeal closure system procedure. Findings:  The physician reviewer found that patient presents with symptomatic chronic venous insufficiency. The patients venous duplex revealed significant reflux in the right anterior accessory vein, right and left GSV, and left SSV. The patients provider has recommended treatment with VenaSeal, which is an accepted venous ablation technique that has been demonstrated in the peer-reviewed medical literature to be equivalent in efficacy when compared to radiofrequency ablation (Gibson, et al.; Hirsch). However, this patients medical records fail to document the current location of reflux in the left and right GSV, including whether the distribution of reflux is above or below the knee. In this clinical setting, VenaSeal is not likely to confer substantial additional benefit to treatment with radiofrequency ablation in the treatment of this patients symptomatic chronic venous insufficiency. Accordingly, the requested VenaSeal closure system procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested VenaSeal closure system procedure 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 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 reviewers 1, 2, and 3 are board certified in general surgery with subspecialty certification in vascular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Durolane injection in the left knee. 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 has tried and failed other conservative treatments, including only four weeks of relief from a cortisone injection, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Durolane injection in the left knee 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 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 reimbursement for inpatient hospitalization. Findings:  The physician reviewer found that Encephalopathy describes any diffuse disease of the brain that alters brain function or structure, and its hallmark is an altered mental state. When a patient presents to the emergency department with altered mental status, three broad categories of diagnosis should be considered: delirium, coma, and dementia. Altered mental status fundamentally involves changes in a persons alertness, attention, memory, and/or awareness, and its etiology may consist of five broad categories including infections, metabolic or toxic encephalopathies, neurologic causes, cardiopulmonary causes, and drug-related causes. Treatment of altered mental status is targeted at the underlying cause. Altered mental status has a relatively high mortality rate, and the disposition for most patients from the emergency room is admission to the hospital for further evaluation and management. Only patients with readily reversible causes of mental status changes, a clear cause of the episode that is treated and reversed, appropriate home care and physician follow-up, and who are back to baseline mental status may be discharged safely. Chen and colleagues note that some stroke types can present with encephalopathy or even bilateral deficits. Kernan and colleagues note that guidelines for the management of acute stroke recommend hospitalization for a work-up and treatment of underlying causes. In this case, the patient presented with confusion and acute encephalopathy. An initial work-up showed multiple metabolic abnormalities and a subsequent work-up showed multiple bilateral acute strokes. In this clinical setting, given that hospital admission was indicated for evaluation and management of the patient's condition, the services at issue were medically indicated. Therefore, inpatient hospitalization provided was medically necessary for the treatment of this patient.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 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 Synvisc-One, to be injected in the left knee, every six months. 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, while there is no history of prior viscosupplementation. The patient reported that a corticosteroid injection was effective for only a couple months and a recent crepitus in the joint indicated worsening symptoms. Based upon the moderate degree of this patients osteoarthritis, a total knee arthroplasty would not be indicated. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc-One, to be injected in the left knee, every six months, 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:  An enrollee has requested authorization and coverage for Stelara syringe 90 mg/ml, every 8 weeks.Stelara (ustekinumab) is approved by the U.S. Food and Drug Administration for treatment of Crohns disease. A large randomized controlled trial by Sandborn and colleagues demonstrated safety and efficacy of ustekinumab for induction and maintenance of remission in patients with moderate-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. A study by Kopylov and colleagues showed that subcutaneous ustekinumab showed a 73.7% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. Moreover, American Gastroenterological Association guidelines for the treatment of Crohns disease recommend ustekinumab in patients with failure of an anti-tumor necrosis factor medication, such as Remicade. In this case, the patient has Crohns disease, which is currently controlled by Stelara. The use of Stelara for the patients medical condition is supported by the medical literature. Moreover, the records indicate the patient has already initiated Stelara, with some benefit. As such, continuation of therapy is more appropriate than discontinuation and change to alternative therapy. Therefore, the requested Stelara syringe 90 mg/ml, every 8 weeks is 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: The patient has requested authorization and coverage for a consultation for proton beam radiation therapy. The National Comprehensive Cancer Network (NCCN) guidelines on the treatment of breast cancer  do not endorse the routine use of proton therapy. Per the medical literature, there is a lack of clinical data suggesting that proton beam radiation therapy is associated with a clinical benefit in the treatment of breast cancer. In a majority of cases, an acceptable cardiac and lung dose may be achieved using intensity modulated radiation or three-dimensional conformal techniques, along with the use of deep inspiratory breath holds during treatment, moving the heart away from the chest wall. Therefore, a consultation for proton beam radiation therapy 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 radiation 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 a Panasol 3D Ultraviolet (UV) Device for home use. Vitiligo is a medical illness that can cause severe psychosocial distress to patients. Narrow band ultraviolet phototherapy (NB-UVB) is a well-accepted and effective therapy for generalized vitiligo as it leads to some degree of repigmentation and is supported by high quality evidence in the medical literature. For generalized lesions, many providers consider NB-UVB for first-line therapy. In-office treatment requires multiple treatments per week. Patients who are unable to receive in-office treatment may be good candidates for a home-based unit and protocol. One randomized controlled trial found that a home device can be as effective as in-office therapy, with better compliance rates. In this case, the patient has demonstrated response to in-office NB-UVB therapy, and it is reasonable to suspect continued therapy at home would be beneficial. The patient is unable to attend in-office treatment sessions due to graduate school commitments. Given these findings, the requested Panasol 3D Ultraviolet (UV) Device for home use is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for prostatic artery embolization. There is a lack of clinical experience or peer-reviewed medical literature to support the routine use of prostatic artery embolization in the treatment of patients with benign prostatic hyperplasia outside of a clinical trial. However, prostatic artery embolization is appropriate to manage this patients symptomatic benign prostatic hyperplasia as less invasive to open simple prostatectomy or staged transurethral resection of prostate (TURP) given the likelihood for symptomatic relief (Malling, et al.). This patients prostate is large and measures 140 cc, which limits his surgical options. Wang and colleagues found that, The clinical and imaging outcomes of prostatic artery embolization were better in patients with larger prostate glands than medium-sized ones. Moreover, treatment with prostatic artery embolization will not prevent future treatment with open surgery if prostatic artery embolization fails. Given these findings, the requested prostatic artery embolization 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 urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Privigen immune globulin (IVIG), intravenous, nonlyophilized, 500 mg (HCPCS J1459).Findings: Two out of three physician reviewers found that Privigen immune globulin (IVIG), intravenous, nonlyophilized, 500 mg (HCPCS J1459) is likely to be more beneficial for the enrollee than any available standard therapy.Liu and colleagues state, Small fiber polyneuropathy (SFPN) has various underlying causes, including associations with systemic autoimmune conditions. In a retrospective study by Liu and colleagues, 55 patients with objectively confirmed SFPN attributed to autoimmunity received IVIG for more than three months. The authors concluded that the results provide Class IV evidence suggesting that IVIG is safe and effective for rigorously selected SFPN patients with apparent autoimmune causality. Further, Oaklander reviewed various studies regarding immunotherapy for distal SFPN. The author notes, These reports provide a rationale for treating carefully selected patients with immunomodulatory therapies. Candidates should have symptoms consistent with SFPN, objective confirmation of diagnosis, exclusion of other causes, failure to improve with symptom management, and, ideally, serologic markers of immunity/inflammation. In this case, the patient has been diagnosed with small fiber neuropathy. Currently, there is no good standard of care to treat these patients. However, IVIG is the most frequently used treatment. According to medical literature, IVIG is safe and effective for SFPN patients with apparent autoimmune causality. Treatment with IVIG is indicated as there are no other good options to treat this patients condition. Therefore, Privigen immune globulin (IVIG), intravenous, nonlyophilized, 500 mg (HCPCS J1459) is likely to be more beneficial than any available standard therapy for the patients medical condition.Final Result: The reviewers determined that the requested service is likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in neurology. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocodone-acetaminophen 10-325 mg (60 tablets per 30 days).Dowell and colleagues state, Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. The Federation of State Medical Boards guidelines indicate that providers should use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. The guidelines recommend that providers maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. Moreover, Manchikanti and colleagues state that prescribing of opioids less than 40 morphine milligram equivalents a day is consider low-dose therapy.In this case, the patient has chronic back and pelvic neuropathic pain due to previous surgeries in both areas. She has tried and failed multiple conservative non-pharmacological therapies. The patient been prescribed low-dose opioid therapy to manage her neuropathic pain without issues. There is no documentation expressing concerns that the patient has shown any aberrant or drug seeking behavior. The patient has stated that the medications are managing her pain and allowing for the performance of her activities of daily living. Additionally, there is no documentation showing that there has been any irregularities in the CURES report, and there has not been any inconsistent urine drug screens documented. Therefore, the requested hydrocodone-acetaminophen 10-325 mg (60 tablets per 30 days) is 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.