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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a duodenal switch procedure.There is a lack of support for the requested services in this clinical setting. Researchers noted, Clinical decision-making should be evidence-based within the context of a chronic diseasewith special attention to nutritional and metabolic issues. In this case, the patient underwent a gastric bypass procedure in 2009 for the treatment of morbid obesity. The patient may be a candidate for revisional or reoperative bariatric surgery. This would require an updated multidisciplinary evaluation documenting her diet, lifestyle and understanding of the potential risks and benefits of a very complex surgical revision. Although conservative efforts at subsequent weight loss are reported in the provider notes note and a pre-bariatric surgery nutrition evaluation was performed on 4/14/21, psychological evaluations were not performed for this procedure. Without this, reoperative bariatric surgery is not recommended. Thus, the requested duodenal switch procedure is not medically necessary for the treatment of the patients medical condition. 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 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 Synvisc One injections in the knees. 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 a history of moderate relief from prior injections. The patient has tried and failed other conservative treatments, 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, bilateral Synvisc One injections in the knees 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 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 Otezla.There is sufficient support for the requested medication in this clinical setting. Otezla has been demonstrated to be safe and efficacious for the treatment of psoriasis. The U.S. Food and Drug Administration (FDA) approved Otezla in 2014. Otezla (apremilast) is recommended for the treatment of moderate to severe psoriasis in adults. It receives an 'A' grade from the joint National Psoriasis/American Academy of Dermatology guidelines on the treatment of psoriasis. The guidelines of care do not state or show that treatment with a disease-modifying antirheumatic drug (DMARD), cyclosporine or soriatane is necessary or beneficial prior to treatment with Otezla. In this case, 10% of the patient has a body surface area is affected. Additionally, this patients treatment options are limited due to hypertension and his occupation. Therefore, Otezla 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 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 authorization and coverage for Freestyle Libre 14 Day System (reader and sensor).Researchers state that a continuous glucose monitoring system (CGMS) is one of several devices approved by the U.S. Food and Drug Administration (FDA) that record blood sugar levels at repeated intervals throughout the day and night. The main advantage of CGMS is that it can help identify fluctuations and trends that would otherwise go unnoticed and can thereby help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia. Medical literature states that CGMS can capture dangerously low overnight blood sugar levels, which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, and evaluate how diet and exercise affect blood sugars. CGMS can also be used as a precautionary device in order to prevent potentially dangerous consequences of uncontrolled diabetes. CGMS has been shown to improve hemoglobin A1c (HbA1C) levels of diabetic patients. In this case, the patient is on multiple daily injections of insulin for management of her diabetes. Her glycemic levels have been erratic so her provider has prescribed Freestyle Libre 14 Day System. By using the Freestyle Libre 14 Day System, the patient should be able to optimize her insulin management and reduce her glycemic variability. Therefore, Freestyle Libre 14 Day System (reader and sensor) is 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 internal medicine with sub-specialty 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: The patient has requested authorization and coverage for Siliq. Based on the psoriasis treatment guidelines put forth by the American Academy of Dermatology (AAD), patients who have psoriasis affecting between 3-10% of their body surface area (BSA) is defined as moderate, while patients with more than 10% BSA involvement have severe disease and are candidates for systemic medical therapy. There is a lack of step therapy guidelines for use in this clinical setting. Siliq is U.S. Food and Drug Administration (FDA) approved and indicated for treatment of moderate-to-severe psoriasis with adequate evidence to support its safety and efficacy. This patient has a documented history of severe disease recalcitrant to several therapies, but he experienced symptomatic relief with Siliq. Given this support, the requested Siliq 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 dermatology with subspecialty certification in dermatopathology 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 Xeljanz. Tofacitinib is a safe and effective treatment for severe alopecia areata and may be considered in patients with longstanding disease with worsening symptoms despite other available therapy. a study of 90 patients with at least 40% scalp hair loss. The authors found that 77% of patients treated with tofacitinib achieved a clinical response, with 58% of patients achieving greater than a 50% change in Severity in Alopecia Tool (SALT) score. They also found that tofacitinib was well tolerated, and without serious adverse effects. while treatment of alopecia totalis and alopecia universalis is often challenging and unsatisfactory, oral tofacitinib was more effective than diphenylcyclopropenone immunotherapy and more tolerable than conventional oral treatment after six months of treatment. Janus kinase (JAK) inhibitors have substantial efficacy in the treatment of alopecia areata. In this case, the patient has tried and failed standard topical and intralesional corticosteroids and reports previous success with Xeljanz. In this clinical setting, given the patients documented improvement with Xeljanz, the requested medication is more effective than any other standard therapy and is a well-known and commonly used therapeutic for alopecia areata. Therefore, Xeljanz is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Xeljanz 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 medication 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRIs) of the right hip and left hip.Findings: The American College of Radiology recommends plain x-rays for evaluation of chronic hip pain. When the plain x-rays are not diagnostic, MRI studies are appropriate as the next imaging test. A study found that, in addition to the history and physical examination, radiography, ultrasonography, or MRI may be needed for a definitive diagnosis. Radiography of the hip and pelvis should be the initial imaging test. Moreover, plain x-rays are generally performed prior to obtaining cross-sectional imaging. In this case, the patient presented with chronic hip pain. However, there is no submitted documentation that indicate initial plain x-rays were performed prior to the MRIs. Therefore, the MRIs of the right hip and left hip performed were not medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 orthotics.Orthotics have long been utilized to help correct abnormal biomechanics of the foot, alleviating stress and strain from certain muscles, tendons, and ligaments. Custom orthotics have been a mainstay treatment for plantar fasciitis and posterior tibial tendinitis. Orthotics work by mechanically controlling the foot. They reduce overpronation, subtalar joint valgus, strain to the posterior tibial tendon insertion, and allow for increased arch support. The patient is noted to have a flatfoot structure with hyperpronation, which generally allows for increased strain and pain to the plantar fascia and posterior tibial tendon. The patients pain has been managed with custom orthotics in the past. The patients current orthotics are noted to be worn down and not supportive, allowing for breakthrough foot pain. It has been recommended that the patient receive new orthotics. There is sufficient support for the requested equipment in this clinical setting. Thus, the requested custom orthotics 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: An enrollee has requested authorization and coverage for Orthovisc injection series for right knee. Findings:  The physician reviewer found that 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, the options are limited. The patient has tried and failed other treatments, including physical therapy, anti-inflammatory medications, and an intra-articular corticosteroid injection. Therefore, the requested Orthovisc injection series for the right knee is medically necessary for the 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 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 Otezla starter pack and Otezla 30 mg tablets.Otezla (apremilast) has been approved by the U.S. Food and Drug Administration and is indicated for the treatment of moderate-to-severe psoriasis and psoriatic arthritis. Medical literature stated, There is good evidence that many of the biologic treatments initially tested in psoriasis are also effective in psoriatic arthritis. Many published articles confirm that the use of Otezla with biologic medications is safe. In a trial by researchers, apremilast was proven to be safe. The authors noted, No significant adverse events emerged with continued apremilast exposure versus the placebo-controlled period. In this case, the patient has three distinct autoimmune inflammatory diseases that require therapy. The patients Crohns disease is now well-controlled on Humira, a biologic medication. However, her psoriasis and psoriatic arthritis are poorly controlled on Humira. As a result, her rheumatologist recommends Otezla to better control the psoriasis and psoriatic arthritis. There is sufficient support for the requested medication in this clinical setting. Therefore, the requested Otezla starter pack and Otezla 30 mg tablets are medically necessary for the treatment of the patients medical condition.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Fentanyl 100 mcg/hr patch every 48 hours. The Centers for Disease Control and Prevention (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. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The Federation of State Medical Boards guidelines noted that opioid therapy for chronic pain that is not cancer-related, or part of palliative care, is recommended only when non-opioid and non-pharmacological options have not been effective and clear and objective outcomes are being met. In this case, the patient is already on high dose opioid therapy with a daily morphine equivalent dose of 255 mg per day. The CDC states that morphine equivalent doses above 90 mg are considered high dose. In this clinical setting, the CDC recommends that providers re-evaluate opioid therapy and determine if non-pharmacologic treatments can be used as an alternative. The providers notes state that the current treatment plan includes weaning the patient off opioid therapy. All told, the requested Fentanyl 100 mcg/hr patch every 48 hours is not medically necessary for 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for V-Go 20. Ginsberg notes that the V-Go pump is one of a group of newly developed patch pumps that promise accurate and flexible insulin delivery. Thompson and Cook note that patch pump delivery systems offer several advantages over conventional insulin pump delivery systems, including being small, lightweight, and free of tubing. Grunberger and colleagues report that initiating V-Go therapy may significantly improve glycemic control and lead to significant insulin dose reductions for patients with type 2 diabetes previously managed with multiple daily injections of insulin. In this clinical setting, the requested device is medically indicated. Therefore, V-Go 20 is medically necessary for the 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 internal medicine with sub-specialty 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.