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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Dupixent.There is evidence to support Dupixent for treatment of dyshidrotic eczema. Waldman and colleagues conclude, Dupilumab is a generally well tolerated and frequently effective treatment for dyshidrotic eczema. Other treatments of proven value for dyshidrosis include phototherapy of various forms, oral steroids, and oral immunosuppressants, but there is a lack of studies to show superiority of a particular treatment. Moreover, there are no agreed upon treatment guidelines for dyshidrotic eczema. In this case, the patients condition is consistent with dyshidrotic eczema. The clinical images and documentation do not support a diagnosis of atopic dermatitis, which does not present as an acral-limited bullous eruption. The medical literature supports the use of Dupixent for treatment of the patients condition. Therefore, Dupixent 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 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 sensors (HCPCS A9276) for use with the enrollees existing interstitial continuous glucose monitoring system.Zhou and colleagues indicate that, Glycemic variability (GV) is emerging as an important metric to consider when assessing glycemic control in clinical practice. The authors found, Accumulating evidence has suggested that GV, representing either short-term (with-day and between-day variability) or long-term GV, was associated with an increased risk of diabetic macrovascular and microvascular complications, hypoglycemia, mortality rates and other adverse clinical outcomes. According to Zheng and colleagues, continuous glucose monitoring systems (CGMS) have been used to manage diabetes by measuring interstitial fluid glucose levels to provide information about glucose levels, which identify fluctuations that would not have been identified with conventional self-monitoring. The immediate feedback and glucose trending provided by CGMS offer marked advantages in early intervention and limitation of glycemic excursions, as compared with traditional finger stick testing. Clinical studies have shown a significant decrease in hypoglycemic events with use of the CGMS as compared with finger stick testing alone. Therefore, the requested sensors for use with the patients existing interstitial continuous glucose monitoring system is medically necessary for treatment of the patients medical condition.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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for any or all of the chiropractic services provided by Dr. Douglas DeSalvo on 9/21/20, 9/30/20, 10/01/20, 10/05/20, 10/07/20, 10/09/20, 10/12/20, 10/16/20, 10/19/20, 10/23/20, 10/26/20, 10/30/20, and 11/02/20.Evans and colleagues found, Spinal manipulation combined with exercise was more effective than exercise alone over a 1-year period, with the largest differences occurring at 6 months. Additionally, Goertz and colleagues concluded, Chiropractic manipulative therapy (CMT) in conjunction with standard medical care offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care. In this case, the patient presented with right shoulder and lower back pain. The patient has chronic pain and has received chiropractic care. It was reported that the patient had 50% improvement with chiropractic care. Based on ongoing improvement with chiropractic care and frequent flare up of her symptoms chiropractic therapy was appropriate. Therefore, chiropractic services provided by Dr. Douglas DeSalvo on 9/21/20, 9/30/20, 10/01/20, 10/05/20, 10/07/20, 10/09/20, 10/12/20, 10/16/20, 10/19/20, 10/23/20, 10/26/20, 10/30/20, and 11/02/20 were medically necessary for treatment of the patients medical condition.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 chiropractic 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 Humira (CF) 40 mg/0.4 mL syringe. Findings:  The physician reviewer found that records provided for review document that this patient is undergoing IVF. Her provider has recommended treatment with Humira to improve the patients chances of conception due to systemic NK cell activation. However, there is a lack of support for treatment with Humira in the treatment of patients with infertility. Moreover, the U.S. Food and Drug Administration (FDA) has not approved Humira for the treatment of systemic NK cell activation for patients in the treatment patients in this clinical setting. Seshadri and Sunkara reported on a systematic review and meta-analysis to assess NK cells in female infertility. The authors concluded that, On the basis of current evidence, NK cell analysis and immune therapy should be offered only in the context of clinical research. All told, the requested Humira (CF) 40 mg/0.4 mL syringe 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 obstetrics and gynecology 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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary:  An enrollee has authorization and coverage for consultation referral to see an autonomic specialist.Palma and colleagues state, Autonomic nervous system (ANS) dysfunction (dysautonomia), as a cause of disease is an increasingly recognized health problem, not only in the field of neurology, but also in cardiology, gastroenterology, endocrinology, urology, psychiatry, and primary care medicine. Patients may present with a myriad of symptoms including orthostatic intolerance, recurrent syncope, labile blood pressure, disorders of sweating and thermoregulation, neurogenic bladder, sexual dysfunction, gastrointestinal dysmotility, pupil abnormalities, and sleep disorders. These symptoms may, in turn, be a consequence of genetic, neurodegenerative, autoimmune, or acquired disorders. The authors also indicate, Autonomic disorders specialists require a comprehensive knowledge of the anatomy, physiology, and pharmacology of the ANS, understanding of the pathophysiology and management of acute and chronic autonomic conditions, and expertise in the performance and interpretation of clinical and laboratory evaluation of the ANS. According to the American Academy of Neurology, The role of the clinician in routine clinical practice is to undertake a thorough evaluation of clinical autonomic symptoms, perform a bedside autonomic examination, and determine if there are strong indications for further studies. In this case, the patient presents with multiple symptoms that are not suggestive of autonomic nervous system dysfunction/dysautonomia. The patient has been evaluated by multiple specialists, including neurologists. A neurological examination and diagnostic work-up have been normal. Therefore, the requested consultation referral to see an autonomic specialist is not medically necessary for treatment of the patients medical condition.Final Result: The reviewers determined that the requested service is not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for dosage escalation for Simponi injections every week.Simponi (golimumab) has proven effective for the treatment of Crohns disease and has been used in cases refractory to anti-tumor necrosis factor (anti-TNF) therapy. American Gastroenterological Association guidelines for the treatment of Crohns disease recommend an increase in the dose of anti-tumor necrosis factor medications, such as Simponi, when the drug level is low. Additionally, Lichtenstein and colleagues note, Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy, or advance to treatment for moderate to severe disease according to their clinical status. In this case, the patient has a low Simponi drug level. This patient has limited alternatives, and the dosage escalation of Simponi is supported by current medical literature. Therefore, the requested dosage escalation for Simponi injections every week is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous immune globulin (IVIG) Gammagard. This patients records document a history of immune mediated necrotizing myopathy resistant to maximum steroid use. The patients provider has recommended treatment with Gammagard IVIG. The provider reports that the patient is at increased risk of aspiration due to her worsened condition and the presence of dysphagia. Treatment with IVIG therapy is indicated for patients with severe life-threatening weakness and those with severe dysphagia at risk for aspiration. In this clinical setting, patients may benefit from the addition of IVIG to initial treatment with glucocorticoids, which is likely to have a more rapid onset of action than glucocorticoids. Treatment with medications such as methotrexate, mycophenolate, and azathioprine are not likely to provide this patient with the positive response as treatment with Gammagard IVIG. For these reasons, the requested IVIG Gammagard 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 rheumatology 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 Supartz injections of both knees. Findings:  The physician reviewer found that 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 physical therapy, a home exercise program, medications, and cortisone injections without significant lasting benefit, 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 Supartz injections of both 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total left knee replacement with the Mako Robot (MAKOplasty).Findings: Three out of three physician reviewers found that the requested total left knee replacement with the Mako Robot is not likely to have been more beneficial for the enrollee than any available standard therapy.The current standard of care for total knee replacement is with the use of traditional instrumentation and techniques. Excellent long-term functional and patient reported outcomes have resulted with these methods as substantiated in many high-level published reports. Short-term and medium-term follow-up studies of robotic-assisted total knee replacement have shown slight improvements over traditional methods in terms of component alignment, but this has not yet translated to improved functional and patient reported outcomes. Given the current absence of robotic long-term outcomes, superiority over traditional total knee replacement has not yet been established. Therefore, total left knee replacement with the Mako Robot is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to have been more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in orthopedic surgery and is 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 reimbursement for monitored anesthesia care (MAC) during the colonoscopy procedure at Santa Maria Digestive Diagnostic Center. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that, Anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine.  In this case, the patient underwent a routine colonoscopy. She did not have any significant heart, lung, kidney, or liver disease.  There was no documentation of a  history of alcohol or substance abuse. There was no detailed description of a previous history of difficulties with anesthesia or sedation with past colonoscopies.  The patient had an ASA classification score of 2, a Mallampati airway grade of 1, and the records did not indicate that the patient presented with a difficult airway. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the services at issue were not medically indicated. Therefore, MAC during the colonoscopy procedure at Santa Maria Digestive Diagnostic Center was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 one-day hospital stay following body contouring surgery. The records provided for review document that this patient has a history of gender dysphoria. The patient is planned to undergo abdominoplasty with liposuction and fat injection to buttocks and hips. The provider has recommended a one-day hospital admission following the procedure. Per Boudreault and Sieber, abdominoplasty operations are routinely performed in the outpatient setting. Swanson and colleagues noted that, Although abdominoplasties have been traditionally done in a hospital setting with an overnight stay, today they are done more commonly in ambulatory surgery centers and accredited office surgical facilities. The authors commented that these changes are due to advances in technique and anesthesia to reduce surgery times, limit blood loss, improve pain management, and shorten recovery times. Based on these reports, abdominoplasty is commonly carried out as an outpatient with or without an overnight observation level of care stay at a hospital or an outpatient surgery facility. In addition, inpatient hospital care is reserved for patients who have identifiable risk factors that require either an advanced level of observation or intensive postoperative care and monitoring. For this patients, there is a lack of report of a clinically significant increased risk during recovery from the planned surgical procedure. Thus, outpatient surgery, including a less than 24-hour observational stay, is accepted medical practice for abdominoplasty with fat grafting. All told, the requested one-day hospital stay following body contouring surgery 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 plastic 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.