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 a lumbar total disc arthroplasty (CPT codes 63077, 63078, 22857 and 0163T). The submitted documentation supports the medical necessity of the requested service. The U.S. Food and Drug Administration (FDA) has approved ProDisc-L total disc replacement for spinal arthroplasty in skeletally mature patients with degenerative disc disease. The FDA further notes that the patient should have no more than grade 1 spondylolisthesis at the involved level and have failed at least six months of conservative treatment. The FDA notes that contraindications include active systemic or site infection, osteopenia or osteoporosis, bony lumbar spinal stenosis, isolated radicular compression syndromes especially due to disc herniation, and pars defect. The 2020 updated FDA guidance now provides for multilevel (2) disc replacement in the setting of degenerative disc disease. In a follow-up at the five-year mark of 236 patients who underwent either ProDisc-L total disc replacement (TDR) or fusions, Zigler and colleagues noted that the TDR group had significantly better improvement on some scales, and while TDR patients avoid the stiffness of fusion and are more satisfied than fusion patients, both fusion and TDR were reasonable surgical options in this specific patient population. In this case, the patient is being treated for lumbar arthralgia and lumbar radiculopathy and reports persistent and ongoing pain. Diagnostic imaging corroborates multilevel degenerative changes with plausible pain generators. Given the current FDA guidance, the requested service is medically indicated in this clinical setting of multilevel degenerative disc disease. Therefore, a lumbar total disc arthroplasty (CPT codes 63077, 63078, 22857 and 0163T) 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 authorization and coverage for bilateral Gel One injections. Findings:  The physician reviewer found that patient presents with chronic bilateral knee pain due to osteoarthritis. She has failed conservative treatment with long term use of non-steroidal anti-inflammatory drugs (NSAIDs), long-term use of acetaminophen, physical therapy, and corticosteroid injections. She also failed arthroscopic surgery on both knees. Her provider has recommended treatment with viscosupplementation with Gel One injections of both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients remaining treatment options are limited. The patient has tried and failed conservative treatments as well as arthroscopies, with the alternative being bilateral total knee arthroplasties. All told, the requested bilateral Gel One injections are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xanax 1 mg two to three tablets daily as needed (dispense 70 tablets/30 day supply). Findings:  The physician reviewer found that he patient has a history of anxiety and the records suggest that the patient may benefit from psychiatric evaluation and treatment. He has been off Xanax for over a year, and is not currently managed on any benzodiazepines, given their contraindication to opioid treatment. The patients current medication regimen includes prescriptions for pain management medications such as Cymbalta, Wellbutrin, hydroxyzine, and gabapentin, which may also be utilized for the treatment of anxiety. In this clinical setting, while there is room for adjustment of the patients psychotropic medication regimen to target anxiety symptoms, given that benzodiazepines are contraindicated alongside high dose opioid therapy, restarting the requested medication is not medically indicated. In this patients case, Xanax 1 mg two to three tablets daily as needed (dispense 70 tablets/30 day supply) is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medication is not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested medication is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, Xanax 1 mg two to three tablets daily as needed (dispense 70 tablets/30 day supply) 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 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 Trulicity. This patient presents with a history of type 2 diabetes. Patient has struggled with control of the condition with use of metformin, insulin, and sulfonylurea. The patients provider has recommended treatment with Trulicity, which is a member of the GLP-1 analogues, a class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. As noted in the medical literature, GLP-1 analogues such as Trulicity have been demonstrated to provide significant improvements in glycemic control and weight loss as well as provide potential improvement in cardiovascular risk factors (Verges, et al.). Another important benefit of Trulicity relates to potential improvements in beta cell function, which is likely to halt or slow the progression of diabetes (Vilsboll and Garber). One recent study reported that Trulicity is associated with a substantial reduction in the risk of a major adverse cardiac events (Scott). Given this support, the requested Trulicity 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 diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation with a pain management specialist. Findings:  The physician reviewer found that guidelines for prescribing opioids for non-cancer pain state that Nonpharmacologic therapy and nonopioid 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 nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The American Society of Interventional Pain Physicians (ASIPP) guidelines state that if there is any indication of abuse, misuse, lack of analgesia, lack of activity, adverse effects, or aberrant behavior, the physician must taper the drug therapy and discontinue. In this case, the patient has chronic back pain with a history of previous fusion. He has been treated by pain management providers in the past, but he has a history of more than one inconsistent urine drug screen. The provider documented that the patient has been managed on high-dose opioid therapy as a temporary measure. The CDC guidelines recommend tapering opioid therapy in patients who have demonstrated non-compliance with their opioid agreements. The ASIPP guidelines recommend referrals to pain specialists for chronic non-cancer pain unresponsive to conservative management or in cases where high-dose opioid therapy is required. The CDC and ASIPP guidelines support that a referral to a pain specialist is appropriate for this patient to provide non-pharmacological alternatives in light of the inconsistent urinalysis results. Based on the current national guidelines and medical records reviewed, the requested consultation with a pain management specialist is medically necessary for 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 anesthesiology with subspecialty certification in pain management 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 the LINX procedure. Scientific evidence has not been established via well-designed controlled studies with adequate follow-up demonstrating safety and efficacy of the use of the LINX procedure. In addition, direct comparative studies between surgical interventions are needed to better assess the safety and efficacy of the LINX procedure. There is lack of randomized controlled trials comparing LINX with other surgical anti-reflux interventions, such as the Nissen fundoplication. Researchers concluded that the long-term safety and efficacy of LINX remains to be determined by evaluating and investigating the safety, efficacy, and durability of the intervention over time. Adverse events including erosion through the esophagus have been reported. Although the LINX device has been approved by the U.S. Food and Drug Administration (FDA), based on current evidence and medical literature, the technology has not met a consensus opinion or recommendation by medical societies and governing organizations. Overall, the LINX procedure has not been thoroughly evaluated in randomized controlled trials against other alternative therapies to support its use in this patient with GERD who has experienced partial symptomatic relief with medical therapies. Accordingly, the requested LINX procedure (magnetic esophageal sphincter augmentation) 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 LINX procedure (magnetic esophageal sphincter augmentation) 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 internal medicine with Subspecialty certification in gastroenterology 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 Remicade infusions administered every five (5) weeks. The U.S. Food and Drug Administration (FDA) approves the use of Remicade for the treatment of chronic severe plaque psoriasis, psoriatic arthritis, and ulcerative colitis. The FDA approved dosage is at eight-week intervals. In this case, the patient is being prescribed both Skyrizi and Remicade at five-week intervals. It is unusual for a patient to be treated with both medications in tandem. Given that the submitted documentation does not reflect a reason why both Skyrizi and Remicade are being prescribed, or why the standard eight-week dosing regimen is insufficient, the requested medication is not medically indicated. Therefore, Remicade infusions administered every five (5) weeks are 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 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 patients parent has requested authorization and coverage for Dupixent. A study reports dupilumab (brand name Dupixent) is approved for the treatment of uncontrolled moderate-to-severe atopic dermatitis. In a systemic literature review, another study concluded for severe atopic dermatitis refractory to topical therapies, the strongest evidence currently existed for dupilumab and cyclosporine at improving clinical disease severity. An additional study notes during the COVID-19 pandemic, for patients with moderate-to-severe atopic dermatitis whose disease requires a new systemic agent during this time, starting dupilumab may be preferable to starting a traditional immunosuppressant. 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, Dupixent 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient admission from 10/12/20 to 10/14/20.The 2021 American Diabetes Association guidelines for diabetes care in the hospital indicate that management of hyperglycemia with or without ketoacidosis requires titration of rapid acting insulin and close monitoring of electrolytes. In patients with hyperglycemia with accompanying ketoacidosis, management goals include restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia, and correction of electrolyte imbalance and acidosis. It is also important to treat any correctable underlying cause of diabetic ketoacidosis (DKA), such as sepsis, myocardial infarction, or stroke. In critically ill patients with DKA or hyperosmolar hyperglycemia, continuous intravenous insulin is the standard of care. In this case, the patients blood sugar level on admission was 557 with documented ketoacidosis. In addition to the DKA, the patient also had diabetic-related hyponatremia, which has significant associated morbidities, including seizures. The patient was appropriately managed with intravenous (IV) fluid administration, IV insulin preparations (low dose sliding scale insulin), and close monitoring of electrolytes. Therefore, the inpatient admission from 10/12/20 to 10/14/20 was medically necessary for treatment of the patients medical condition.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 internal medicine with subspecialty certification in endocrinology, diabetes and metabolism, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom fit orthotics/shoe inserts.Custom functional orthotics have been standard of care for the treatment of plantar fasciitis for many years. Custom orthotics are fabricated to be firmer and more functional with respect to controlling the patients foot and allowing relief of stress and strain to the plantar fascia. Functional orthotics are made from a casting of the patients foot, allowing for a better and more precise fit. In this case, the progress notes document painful left plantar fasciitis. X-rays reveal no stress fracture. Records show that this patient has failed conservative treatments, including home stretching, local corticosteroid injection to left heel, physical therapy, and diclofenac. Therefore, the requested custom fit orthotics/shoe inserts are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 podiatry 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 Botox (botulinum toxin) every 12 weeks for one year.The American Headache Society (AHS) recommends preventive treatment when attacks significantly interfere with patients daily routines despite acute treatment; when there are four or more attacks per month; or when there is a contraindication to, failure, or overuse of acute treatment. Currently, Botox is approved for chronic migraine. The lack of need for slow dose escalation, the rapid onset of therapeutic benefits, and the favorable tolerability profiles are advantages of injectable therapies. (American Headache Society). In 2016, the American Academy of Neurology updated its 2008 guidelines on using botulinum neurotoxin for brain disorders. Botulinum toxin A is now recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. A 2018 review of the current evidence of onabotulinumtoxinA in the prevention of chronic migraine by Frampton and colleagues noted that the totality of evidence from clinical trials and real-world studies indicates that onabotulinumtoxinA is an effective and generally well tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics (Frampton, J. and Silberstein, S.). In this case, the patient has a history of chronic migraines that did not respond to oral preventive medications. The use of botulinum toxin in this case has proven to be effective in increasing the number of headache-free days. Therefore, the requested Botox (botulinum toxin) every 12 weeks for one year is medically necessary for the 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 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.