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 bilateral Euflexxa injections for treatment of the enrollee who has a history of bilateral knee pain and torn meniscus of the left knee. Findings: The physician reviewer found that Johal and colleagues concluded that there is a general lack of reliable evidence that any specific brand is superior to others. Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with osteoarthritis of the knee who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. If there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. The medical literature has noted that there are no maximum amount of injections established by high quality scientific evidence, nor is one type of viscosupplementation supported over another. This patient presents with a long history of bilateral knee pain and has been diagnosed with osteoarthritis. The patient had failed previous conservative treatment with anti-inflammatory medications, analgesic medications, corticosteroid injection, and Synvisc injections. Since 2008, the patient had received good improvement in pain and function with the use of Euflexxa injections for the bilateral knees for six months at a time. Evidence based medical guidelines support repeat viscosupplementation injections for patients with osteoarthritis with documented significant improvement in symptoms for six months of more. There is a general lack of reliable medical evidence that any specific brand is superior to others. Given the patients response to prior Synvisc and Euflexxa injections, the continued use of Euflexxa injections is medically indicated. Therefore, Euflexxa injections are 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 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 parent of an enrollee has requested authorization and coverage for Symbicort 80 mcg-4.5 mcg. Findings:  The physician reviewer found that Symbicort is a combination medication, using both budesonide (inhaled corticosteroid) and formoterol (long-acting beta agonist). This combination has been well-studied, and studies have shown that for patients experiencing an acute exacerbation despite routine use of an inhaled corticosteroid controller medication, addition of budesonide/formoterol is more effective in controlling bronchospasm than simply increasing the dose of inhaled corticosteroid. The combination is so effective that some advocate for its use as maintenance as well as reliever therapy. In this patients case, he is limited by age and developmental ability to only a few of the recommended options. He is also limited by the fact that he already uses an inhaled corticosteroid as a controller medication. He has been successfully treated with Symbicort as a reliever medication in the past. The current medical evidence supports the requested medication in this clinical setting. Therefore, Symbicort 80 mcg-4.5 mcg 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 pediatrics with sub-specialty certification in pediatric critical care 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 upper airway stimulation (UAS) device for the hypoglossal nerve for treatment of the enrollees obstructive sleep apnea syndrome. Findings:  The physician reviewer found that The medical literature and the submitted documentation demonstrate the medical necessity of the requested device. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation in animal and human subjects, the three and four year results of a large multicenter, prospective trial were published in January 2016 and February 2017. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This trial demonstrated that hypoglossal nerve stimulator was safe and effective in a small subset of patients with OSA who had  failed CPAP.  In this patients case, he meets the criteria for placement of this device. The patient has a BMI of 22.6, AHI of 50 and nonconcentric airway collapse. The patient has failed CPAP, which is the gold standard treatment for OSA and is at risk for untoward cardiac sequelae of untreated OSA. Therefore, the UAS device for the hypoglossal nerve is medically necessary for 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 otolaryngology 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 parent of an enrollee has requested reimbursement and prospective authorization and coverage for 35 hours per week of direct applied behavioral analysis (ABA) therapy (CPT code H2019) at the frequency of five days per week. Findings:  The physician reviewer found that the request for 35 hours per week of direct ABA therapy (CPT code H2019) at the frequency of five days per week provided during the dates of service in question were and are medically necessary to address the patients maladaptive behaviors that pose a danger to the patient. According to the documentation submitted for review, the patient presents with elopement, and licking and chewing nonedible items. ABA therapy as recommended by the treating provider is medically appropriate for treatment of the patients autism. All told, the request for the services at issue were not and are not medically necessary for this patient. Final Result: The reviewer determined that the services at issue were and 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 pediatrics and neurology with special qualification in child 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: An enrollee has requested authorization and coverage for Queen Kings Down 4000 and Temp Curve Pillow for treatment of the enrollees back and neck pain. Findings:  The physician reviewer found that the patient presents with chronic neck and back pain. The patient has completed a course of physical therapy and continues to have chronic pain interfering with the ability to work. The patient has comorbid medical and psychiatric conditions that limit medication options. Thus, the use of a neck support pillow while sleeping in conjunction with daily exercise in the treatment of chronic neck pain is clinically indicated. The patient has completed physical therapy and the requested pillow as an adjunctive treatment with her home exercise program has been established as medically necessary for the treatment of the patients medical condition. In terms of the request for Queen Kings Down 4000, there is a lack of high-quality studies to support purchase of any type of specialized mattress or bedding as a treatment for low back pain. There is no deformity that would indicate a need for positioning that would require a special bed. For these reasons, the requested Queen Kings Down 4000 mattress is not considered medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested equipment 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 physical medicine and rehabilitation 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's parent has requested authorization and coverage for a high frequency chest wall oscillation system for treatment of the enrollees Cockayne syndrome and microcephaly. Findings:  The physician reviewer found that Cockayne syndrome is a rare form of dwarfism associated with microcephaly, prognathism, abnormal dentition, kyphosis, hypohidrosis, cataracts, hypertension, hepatomegaly, and others. High frequency chest wall oscillation was developed to improve airway clearance in patients where the normal mucociliary transport system has failed. Research supports the utility of these systems in airway clearance in this clinical setting. Vest therapy has been studied in children with cystic fibrosis and quadriplegic cerebral palsy. In patients with familial dysautonomia, high frequency chest wall oscillation effected significant improvements in all health outcomes and oxygen saturation. In one study of children with either cerebral palsy or neuromuscular diseases, the authors concluded that, our data suggest safety, tolerability, and better compliance with high-frequency chest wall oscillation. Improvement in airway clearance may help prevent hospitalizations. This patient has severe developmental delay, poor airway clearance, and is an aspiration risk. She is not able to participate in most methods of airway clearance effectively as a result. She has used high frequency chest wall oscillation during her many hospitalizations for airway issues, and has tolerated it with good results. The literature supports use of this airway clearance technique in patients with deficiencies in airway clearance. Given these findings, the requested high frequency chest wall oscillation system is supported as medically necessary for treatment of this 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 pediatrics and pediatric critical care 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 intravenous immunoglobulin (IVIG). Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has demonstrated a clinical response to steroids. Additionally, the patient is not on the maximal dose of CellCept. Also, the records do not document contraindication to the use of Imuran or methotrexate, and the medical evidence supports trying these medications first in combination with steroids prior to the use of IVIG. The provider argues that the use of Cytoxan will increase risk of malignancy. Systemic sclerosis and chronic inflammatory conditions are associated with increased malignancy risk. Thus, aggressive therapy may actually decrease this risk and should not be a reason to avoid treatment with Cytoxan. All told, there are alternative treatments available for this patient. Therefore, the requested IVIG 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 internal medicine with sub-specialty 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: An enrollee has requested authorization and coverage for Zepatier 50/100 mg tablets daily for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50/100 mg tablets daily for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 sub-specialty certification in gastroenterology 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 amlodipine-valsartan-hydrochlorothiazide (Exforge) for treatment of the enrollee who has a history of hypertension.Findings: The physician reviewer found there is a lack of support for the requested medication in this clinical setting.  The records do not document an adequate trial, allergy or intolerance to a preferred angiotensin receptor blocker, a preferred diuretic or a preferred calcium channel blocker. Current guidelines for treatment of hypertension do not recommend combination antihypertensive medication such as Exforge over other generic medication in the same antihypertensive class. All told, Exforge is not medically necessary for the treatment of this patients medical condition.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 internal medicine with sub-specialty certification in cardiovascular 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: An enrollee has requested authorization and coverage for magnetic resonance imaging for evaluation of the enrollees bilateral knee pain. Findings:  The physician reviewer found that An MRI may be an optimal means to evaluate an internal derangement but the question of when or whether to obtain an MRI of the knee, in the clinical setting of knee pain, is debatable. In this patients case, the requested MRI is not supported as medically necessary. An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment for 3-6 weeks. The studies have shown that MRI alone has little to offer patients who have been diagnosed with non-traumatic knee pain, or those who have no mechanical symptoms and no findings of degenerative arthritis on plain films (Miller). A trial of conservative treatment is not unreasonable in this patients case as acute pain will often resolve without more aggressive intervention. The primary reason to obtain an MRI is in preparation for surgery. Evidenced based studies regarding the use of MRI of asymptomatic knee injury recommend a conservative trial of therapy prior to imaging. The medical literature supports 3 to 4 weeks of intensive anti-inflammatory therapy.  In this case, the submitted documentation fails to demonstrate that the patient has attempted a trial of conservative treatment or that treatment had failed to relieve him of his symptoms. All told, MRI is not medically necessary for the evaluation of the patients knee pain. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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: The patients parent has requested authorization and coverage for tacrolimus 0.03% for treatment of the enrollees vitiligo. Findings:  The physician reviewer found that Vitiligo is an autoimmune disease leading to destruction of melanocytes which are the cells in the skin which make pigment. This condition is not only a cosmetic issue as it is an autoimmune condition and carries the risk of development of skin cancers in depigmented skin. The use of tacrolimus ointment as a non-steroidal anti-inflammatory topical medication is reasonable and considered to be the standard of care. This patient has failed treatment with topical steroids including triamcinolone ointment and betamethasone ointments, as well as clotrimazole and gentamicin. Thus, the requested tacrolimus 0.03% is supported as medically necessary for treatment of this patients vitiligo. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for laparoscopic total hysterectomy for treatment of the enrollees uterine fibroids, ovarian cyst and pelvic pain syndrome.  Findings:  The physician reviewer found that Uterine fibroids are the most common solid pelvic tumors in women and the leading indication for hysterectomy. The two most common symptoms for which women seek treatment for this diagnosis are abnormal bleeding and pelvic pressure. Symptoms and treatment options are affected by the size, number, and location of the leiomyomas. Furthermore, acute pelvic pain is a common presenting complaint in women. The differential diagnosis includes gynecologic, urologic, musculoskeletal, gastrointestinal, vascular and metabolic disorders. A thorough history and physical examination is necessary to narrow the possible diagnoses and focus the work-up. In this case, it is likely that the patients pelvic pressure and potentially her back pain are caused by the location of her fibroid. However, it is not clear whether the acute onset of left lower quadrant pain can be explained by her fibroid uterus, especially in light of the fact that the uterus has markedly decreased in size in the last few years and this has been a longstanding diagnosis. Thus, the differential diagnosis of her complaints includes both urologic and gastrointestinal etiologies. These two etiologies have not yet been adequately addressed in the patients preoperative work-up. In addition, there is no documentation of an endometrial biopsy. Since the patients acute onset of left lower quadrant pain with no ovarian abnormality has not been adequately evaluated, the requested laparoscopic total hysterectomy is not supported as medically necessary. Final Result: The reviewer determined that the requested surgery 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.