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 Xyosted 75 mg/0.5 mL autoinjector. A study reported that Xyosted is safe and effective for the treatment of patients with hypogonadism. Moreover, the U.S. Food and Drug Administration (FDA) has approved Xyosted for this indication. Studies have demonstrated that Xyosted is less painful than intramuscular injection therapy. Thus, Xyosted is a viable treatment option for patients who are unable to tolerate intramuscular injections. This patient presents with symptomatic hypogonadism. Based on the available documentation, the patient requires treatment with testosterone replacement therapy. Preparing conventional depot testosterone for self-injection requires patients to withdraw the appropriate prescribed dosage into a syringe prior to delivery. This patient has a history of intravenous drug use. Preparing testosterone for self-injection can be a trigger for patients with a history of intravenous drug use. The use of Xyosted autoinjector bypasses that procedure. All told, the requested Xyosted 75 mg/0.5 mL autoinjector 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injection series in both knees and an Orthovisc injection series in both knees in six months. Findings:  The physician reviewer found that patient presents with a history of chronic bilateral knee pain due to degenerative changes primarily in the patellofemoral joints secondary to patellofemoral malalignment, status post corrective surgery. The patient has a history of excellent relief from viscosupplementation with Orthovisc over the last 10 years. Her provider has recommended a series of Orthovisc injections followed by a repeat series in six months. 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. This patient has a history of substantial relief from viscosupplementation over the past 10 years. Furthermore, her remaining treatment options are limited. The patient has tried and failed other conservative treatments. For these reasons, the requested Orthovisc injection series in both knees and an Orthovisc injection series in both knees in six months 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 reimbursement and prospective authorization and coverage for oxycodone hydrochloride 15 mg tablets (#180 tablets per 30 day supply) already purchased, and oxycodone hydrochloride 15 mg tablet every four hours (#180 tablets per 30 day supply).Findings:  The physician reviewer found that (CDC) guidelines 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 . In addition, the American Society of Interventional Pain Physicians (ASIPP) advise that provider establish medical necessity by establishing appropriate physical diagnosis and psychological diagnosis if available . ASIPP recommends a pain management consultation to assist non-pain physicians, if high-dose opioid therapy is utilized. In this case, the patient has chronic low back pain. The patient required a recent visit to the emergency department for breathing related difficulties and he required a blood transfusion. The provider noted that the patient was being treated with oxycodone-acetaminophen 10-325 mg oral tablets every four hours prior to the provider increasing the dosage to oxycodone 15 mg every four hours. However, there is a lack of documentation by the provider of a change in the patients pain patterns or pain intensity scores to merit an increase in dosage. Based on the available documentation, the risk-to-benefit ratio for this patient does not support an increased dose of oxycodone. Moreover, the provider did not document attainable goals for pain improvement or function with use of the increased dosage. All told, the oxycodone hydrochloride 15 mg tablets (#180 tablets per 30 day supply) already purchased, and oxycodone hydrochloride 15 mg tablet every four hours (#180 tablets per 30 day supply) was not and is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication dosage at issue was not and 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rhizotomy neurosurgical procedure (CPT codes 64635, 64636, and 99152). The patients provider has recommended treatment with bilateral rhizotomies. A systematic review and a meta-analysis by Hansen and colleagues indicated that although sacroiliac joint lateral branch rhizotomy may have potential, there are limited and highly variable data that prevent recommendation for the procedure. Maas and colleagues noted that they found no high-quality evidence suggesting that radiofrequency denervation provides pain relief for patients with chronic low back pain. Schmidt and colleagues noted although radiofrequency ablation may offer a potential benefit as a therapeutic modality, limited data supports its use as a primary treatment modality. There are inadequate data supporting rhizotomy for the treatment of sacroiliac joint pain. Based on the available literature, the requested rhizotomy is not supported as medically necessary for the treatment of this patient. All told, the requested rhizotomy neurosurgical procedure (CPT codes 64635, 64636, and 99152) 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 neurological 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT) (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294). Accelerated partial breast irradiation (APBI) may be delivered using external beam radiotherapy, brachytherapy, or intraoperative radiation therapy (IORT). IORT to perform APBI is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria per current National Comprehensive Cancer Network (NCCN) guidelines. Researchers reported that at four-year follow-up, local control rates between IORT and external beam whole breast radiotherapy were largely equivalent. A study concluded that, Important radiation-related quality of life parameters after IORT were superior to external beam radiation therapy. Per the authors, toxicity may also be slightly improved with IORT. This patient meets ABPI criteria set by the American Society of Breast Surgeons (ASBS), given her age and the presence of a tumor measuring less than 3 cm. All told, the requested IORT (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294) 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 IORT (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294) 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 radiation oncology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for iontophoresis. This patient presents with palmar, plantar, and axillary hyperhidrosis that has only partially improved with Drysol, oxybutynin, and topical antiperspirants. The provider recommended treatment with iontophoresis. There are data from clinical trials reporting that iontophoresis can be successful in alleviating the symptoms of palmar or plantar hyperhidrosis in approximately 85% of patients treated. Iontophoresis is specifically indicated for the palms and soles of the feet, but there is a lack of data demonstrating similar efficacy in the axillae. Currently, iontophoresis is considered a first-line therapy for this patients palmar and plantar hyperhidrosis over the remaining alternative, Botox, given the pain associated with Botox injections at these sites. In summary, iontophoresis to the palms and feet soles is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while iontophoresis to the armpits is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  All three physician reviewers found a portion of the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined a portion of 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 partially overturned. Specifically, all three medical experts decided that iontophoresis to the palms and feet soles is likely to be more beneficial for you than any available standard therapy, while iontophoresis to the armpits is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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: An enrollee has requested authorization and coverage for the medication Posaconazole. Findings:  The physician reviewer found that Posaconazole, a fluorinated triazole antifungal drug, is approved by the U.S. Food and Drug Administration (FDA) for prophylaxis against Aspergillus and Candida infections in immunocompromised patients at high risk for these infections. Clark and colleagues have noted that posaconazole has potent in vitro activity against a broad range of fungi and molds, including Aspergillus, and has an excellent safety profile. In this case, the patient has had bilateral lung transplantation and is at high risk for the development of fungal infections including Aspergillus. Other medications such as voriconazole have a high incidence of side effects that limit their use in this patient population. Posaconazole has an advantageous side effect panel, it is effective for Aspergillus, and it is a standard prophylactic antifungal in this setting. Under these circumstances, the requested medication Posaconazole is medically necessary to treat the patient.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient. 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 administration of intravenous morphine 8 to 10 mg daily for a duration of two to four days, once or twice per month. The Centers of Disease Control and Prevention guidelines state, Nonpharmacologic 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 nonpharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. The Federation of State Medical Boards recommends, 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 nonpharmacological options have not been effective. Maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met.In this case, the patient has had a recent episode of pyelonephritis and was being treated with intravenous antibiotics along with intravenous morphine for pain control. The provider notes stated that the antibiotics were being changed due to bacterial sensitivities and that her kidney function had normalized. The provider notes stated that intravenous morphine was no longer indicated and that the patient was again able to use Toradol for her chronic kidney pain. There is no mention in national guidelines recommending the regular prescribing of intravenous opioid medication for outpatient use. Intravenous pain medications are used in supervised hospital settings and not for outpatient use. If the provider determines that opioid medication is indicated, an oral formulation could be used. The records show that the patient has not seen an in-Plan pain management provider in over ten years. Based on the available records for review and current guidelines, the requested medication regimen is not medically necessary. Therefore, administration of intravenous morphine 8 to 10 mg daily for a duration of two to four days, once or twice per month is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Elmiron capsules. Recent studies, questions have been raised about the efficacy of oral pentosan polysulfate (PPS) for the treatment of bladder pain syndrome and interstitial cystitis. The author found that while oral PPS remains a useful pharmacological agent, it may be effective only in a subgroup of patients.  The U.S. Food and Drug Administration approves the use of Elmiron for the treatment of relief of bladder pain or discomfort associated with interstitial cystitis at a recommended dosage of 300 mg daily, divided into three 100 mg capsules. Given a lack of evidence in current medical literature that dose escalation increases the efficacy of this medication, the requested medication regimen is not medically indicated. The Health Plans quantity limit of 90 capsules per month is medically appropriate. Therefore, Elmiron capsules are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dilaudid, Physical Therapy Sessions for lower back pain, and a Saunders cervical traction device.The submitted documentation does not support that the requested medication, physical therapy services, and device are medically necessary.Regarding the patients request for Dilaudid, there is no documentation supporting the medical necessity for this medication. The submitted documentation indicates that the patient did not return for two scheduled follow-up pain management appointments. The patients records do not establish that he has moderate to severe pain after having failed first-line non-opioid analgesics. There is no clear documentation that the patient has attempted medication management of his chronic pain with antiepileptic drugs (AEDs), antidepressants, or prescription NSAIDs. Under these circumstances, there is insufficient support for the use of short-acting opioids at this time. Therefore, the requested Dilaudid is not medically necessary for this patients medical condition.Regarding the patients request for physical therapy for the lower back, the medical records do not establish that the requested services are medically necessary. The submitted documentation indicates that the patient did not return for two scheduled follow-up pain management appointments. There is also no documentation of objective exam findings that would support the need for the skills and knowledge of a physical therapist over exercises to be performed within the context of a home exercise program. Accordingly, the requested 12 (twelve) Physical Therapy Sessions for lower back pain are not medically necessary for this patients medical condition.Regarding the patients request for a Saunders cervical traction device, the medical records do not establish that the requested device is medically necessary. The submitted documentation indicates that the patient did not return for two scheduled follow-up pain management appointments. There is also no documentation with objective exam findings that would support use of the requested device over that of ongoing active exercises. The combined medical records also do not document a provider recommendation for this device. Under these circumstances, the requested Saunders cervical traction device is not medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested medication, physical therapy services, and device are not medically necessary for this patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation, with subspecialty 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.