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 oxymorphone HCL (10 mg) 90 tablets every 15 days. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, 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 Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers 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. In this case, the patient has intractable migraines. He has tried and failed several other opioid medications and is currently on several oral prophylactic agents and non-opioid therapy including Botox and Emgality injections. He is under the care of a neurologist and a pain management specialist. The patient has been consistent with monthly appointments and his CURES report and urine drug screens have been appropriate with no evidence of drug seeking behavior. Given that the patient is currently experiencing relief with the requested medication, and that the provider and patient are following current evidence-based guidelines pertaining to the use of opioids for the management of non-cancer pain, the requested medication is medically indicated. Therefore, oxymorphone HCL (10 mg) 90 tablets every 15 days are 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injection series in the left 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. 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, there is a history of lasting benefit from prior viscosupplementation. Furthermore, the options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Thus, the requested Euflexxa injection series for the left knee is medically necessary for the treatment of the patients medical condition.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 cervical area/lumbar injections. Findings:  The physician reviewer found that systematic review of therapeutic lumbar, cervical, and thoracic facet joint interventions for the treatment of chronic spinal pain, Manchikanti and colleagues concluded that evidence supporting the use of cervical facet joint nerve blocks for relief lasting significantly longer than the pharmacological duration. The authors noted that an 80% or greater pain relief report was a criterion standard. In this case, the patient reported 80% pain relief following cervical medial branch blocks bilaterally, with the relief lasting 28 hours, which would indicate that the patients neck pain is originating from the cervical facet joints. In this clinical setting, the requested services are medically indicated. Therefore, cervical area/lumbar injections 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.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.
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 foot orthotics/shoe inserts.Orthotics have been utilized for the treatment of painful metatarsalgia as a standard of care conservative treatment. The orthotics are used to offload pressure from the plantar forefoot. Particular accommodations may be added to the orthotic, such as a metatarsal raise pad, which further alleviates pressure from the plantar forefoot/metatarsal heads. In this case, the records document painful hammertoe contractures and metatarsalgia to bilateral feet. Therefore, the requested custom foot orthotics/shoe inserts are medically necessary for the treatment of 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: The patient has requested authorization and coverage for Vumerity. Findings:  The physician reviewer found that Multiple sclerosis (MS) is a progressive immune disease affecting the central nervous system (CNS), causing neurological dysfunction and is one of the most common neurological immunologic diseases. Multifocal inflammation of the CNS characterizes the disease and causes impaired nerve conduction, which is what causes the many different symptoms of MS. MS is not a curable pathology; however, today there are several therapies that can manage the disease. The U.S. Food and Drug Administration approves the use of Vumerity for the treatment of relapsing forms of MS. In this case, the patient had been stable on Tecfidera but was experiencing adverse effects.  In this clinical setting, given that current medical literature supports the use of Vumerity in the treatment of MS, the requested medication is medically indicated. Therefore, Vumerity is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication 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 psychiatry and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Gamunex-C (immune globulin injection). Chang and colleagues note that pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) is defined by an acute prepubertal onset of tics or obsessive-compulsive disorder symptoms, association with group A  Streptococcus (GAS), and specific neuropsychiatric symptoms. Although the exact etiology is unknown, post-streptococcal autoimmunity has been postulated as one possible mechanism. In a study of 25 children with PANDAS, Williams and colleagues concluded that while IVIG was safe and well tolerated, the study failed to demonstrate the superiority of IVIG over placebo. Given the lack of data in current medical literature supporting the benefits of IVIG in the treatment of PANDAS, the requested service is not medically indicated. Therefore, Gamunex-C (immune globulin injection) 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for islet cell transplant. Hypoglycemia, typically the result of the interplay of therapeutic hyperinsulinemia and compromised defenses resulting in hypoglycemia-associated autonomic failure in diabetes, is a serious problem for people with type 1 diabetes mellitus that causes recurrent morbidity and is occasionally fatal. Beta cell replacement therapy through islet transplantation provides a potential alternative to exogenous insulin. Gamble and colleagues note that intraportal islet transplantation has proven effective in preventing severe hypoglycemia and restoring insulin independence in selected patients with type 1 diabetes. Hering and colleagues conclude that transplanted purified human pancreatic islets provide glycemic control, restoration of hypoglycemia awareness, and protection from severe hypoglycemic events in subjects with intractable impaired awareness of hypoglycemia and severe hypoglycemic events. In this case, the patient has diabetes type 1 with frequent episodes of severe hypoglycemia, greatly increasing her risk of morbidity and mortality. In this clinical setting, current medical literature supports the use of the requested service. Therefore, islet cell transplant is 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 islet cell transplant is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services 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 certification in endocrinology, diabetes and metabolism 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 linezolid and/or omadacycline (Nuzyra). This patient presents with multiple lung nodules and a diagnosis of M. chelonae on sputum culture. Her provider has recommended treatment with a regimen of linezolid and Nuzyra. As noted in the medical literature, atypical mycobacteria infections are difficult to treat. The regimen ordered for this patient is appropriate since Nuzyra has been shown to be active against M. abscessus, which is a closely related organism to M. chelonae. In addition, the recommended regimen consisting of linezolid will avoid the potential toxicities associated with long-term use of aminoglycoside antibiotics (Pecho-Silva and Navarro-Solsol). Therefore, the requested linezolid and Nuzyra are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications 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 infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vyepti infusions. Current medical literature does not support the safe and effective  treatment of migraines with a combination of Vyepti and Botox. In this case, the patient has tried and failed medical and surgical interventions in the management of her condition. While Vyepti monotherapy may be considered to manage her condition, given the lack of data supporting combination therapy with Botox, the requested service is not medically indicated. Therefore, Vyepti infusions are not medically necessary for the 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 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 Ajovy and/or Nurtec. The records provided for review document that this patient has been treated with multiple migraine prophylactic medications without adequate control of her condition. The patients provider has recommended treatment with Ajovy and Nurtec. The patients records do not document failure of Aimovig or Emgality, which are available on the Health Plans formulary. Medical literature found that Aimovig administered subcutaneously at a monthly dose of 70 mg or 140 mg significantly reduced migraine frequency, the effects of migraines on daily activities, and the use of acute migraine-specific medication over a period of six months. The patient previously failed acetaminophen, norethindrone, and Maxalt. Thus, treatment with Nurtec for the management of this patients acute migraine is consistent with the medical literature and current guidelines. All told, the requested Nurtec is medically necessary while the requested Ajovy is not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nalu Neurostimulation System (peripheral nerve stimulation). This patient presents with chronic intractable pain of peripheral nerve origin. There is documentation that the patient has been treated with standard therapies including medications, physical therapy, behavior modification, chiropractic care, and psychiatric services for more than six months. The patient reportedly obtained at least 50% of pain relief with a diagnostic nerve block and a three to seven day trial of percutaneous peripheral nerve stimulation. The provider has recommended implantation of the Nalu Neurostimulation System. Peripheral nerve stimulation has been used in the treatment of several chronic pain conditions including pain due to peripheral nerve dysfunctions, complex regional pain syndrome, and cranial neuralgias. Current data supports that peripheral nerve stimulation can be effective for chronic, intractable pain that is refractory to conventional therapies such as physical therapy, medications, and nerve blocks. Multiple studies have shown that peripheral nerve stimulation can be helpful to decrease pain in patients with severe pain in the distribution of a peripheral nerve (Walsh, et al.). Therefore, the requested Nalu Neurostimulation System (peripheral nerve stimulation) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Nalu Neurostimulation System (peripheral nerve stimulation) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facet block injections. The records provided for review document that this patient has chronic low back pain status post four lumbar surgeries including hemilaminectomy. He currently reports low back pain with radiation into the left leg. Physical examination demonstrated a positive straight leg test bilaterally as well as positive sacroiliac joint provocation maneuvers. The patients MRI from 2019 showed severe degenerative disc and joint disease affecting multiple lumbar levels there is also evidence of previous lumbar laminectomy, severe impingement of the left S1 nerve root, and moderate to severe foraminal stenosis at the L3-4 and L4-5 levels. His provider has recommended lumbar facet joint injections. The patient has documented signs and symptoms of lumbar radiculopathy into the left leg, which is supported by MRI evidence of left S1 impingement. The patients physical examination findings do not support a diagnosis of axial back pain, for which facet joint injections may be effective. Cohen and colleagues found that facet blocks have not been shown to be effective for therapeutic purposes. The authors concluded that, The higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation. A review by Manchikanti and colleagues stated that the best evidence for the use of medial branch blocks is for diagnostic purposes leading to a radiofrequency ablation procedure, in patients who do not have concurrent signs or symptoms of radicular low back pain. Overall, the medical literature or guidelines do not support facet block injections for the treatment of patients with lumbar radiculopathy. Therefore, the requested facet block injections are 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 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.