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 Tepezza home infusions.Findings: Although Tepezza has been shown to be beneficial and safe for patients with acute and active orbital inflammation related to dysthyroid disease, there is no evidence that it would be safe or effective for patients with long-standing disease who have undergone previous treatments such as orbital irradiation, or patients with longer-standing disease (> 9 months). In this case, the patient has a long-standing history of dysthyroid orbitopathy with complaints of double vision over a period of five years. The submitted documentation does not show a history or signs that the patients orbital inflammation is active. Records also reflect that the patient has had previous treatments including orbital radiation. Under these circumstances, the requested Tepezza home infusions are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in ophthalmology 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 reimbursement for   laboratory services. Testing for specific genetic mutations was indicated for this patient given her history of retinal artery occlusion and retinal vein occlusion. Although they are listed as separate diagnoses, it is considered a singular clinical entity with different implications for treatment and comorbidity. There is evidence in the medical literature that laboratory investigation for hypercoagulability is recommended in the setting of combined retinal artery and retinal vein occlusion (Sengupta and Pan; Parchand; Desai, et al.). Given this support, the laboratory services were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the laboratory services were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation 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 ophthalmology 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 Mavyret (glecaprevir-pibrentasvir) 100-40 MG tablets for eight (8) weeks. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (ISDA) includes Mavyret  among recommended therapies for treatment-naive patients with hepatitis C, genotype 1b, without cirrhosis. In this case, the patient has a diagnosis of hepatitis C, genotype 1b. Given current medical guidelines, and as the documentation does not reflect any contraindications, the requested medication is medically indicated. Therefore, the requested Mavyret (glecaprevir-pibrentasvir) 100-40 MG tablets for eight (8) weeks 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 internal medicine with sub-specialty 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 total knee replacement with use of robotic arm and three-dimensional (3D) modeling. This patient presents with severe and function-limiting right knee pain. Clinical examination findings are consistent with radiographic evidence of right knee osteoarthritis, bone-on-bone in the lateral compartment. She has failed long-term reasonable and comprehensive conservative treatment. Her provider has recommended right total knee replacement. She has requested that this procedure be performed by a tertiary center orthopedic surgeon with use of robotic arm and 3D modeling. However, the current evidence-based medical literature does not support the routine use of computer-assisted total knee arthroplasty over conventional total knee arthroplasty. Young and colleagues reported no mid-term functional or radiographic differences between total knee arthroplasties with mechanical alignment or kinematic alignment. The authors noted that the anticipated improvements in patient-reported outcomes with kinematic alignment were not realized, and since kinematic alignment results in a high proportion of patients whose tibial components are inserted in varus, loosening remains a potential long-term concern. Lee and colleagues concluded that their present study revealed no significant differences in clinical or radiological outcomes between computer-navigated total knee arthroplasty and conventional total knee arthroplasty. It remains unclear which total knee arthroplasty technique yields better results in terms of mid- to long-term clinical and radiological outcomes. Given these findings, the requested right total knee replacement with use of robotic arm and 3D modeling 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 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 Ubrelvy (ubrogepant) 100 mg tablets. The U.S. Food and Drug Administration (FDA) describes Ubrelvy (generic name ubrogepant) as a calcitonin gene-related peptide receptor antagonist indicated for the acute treatment of migraine with or without aura in adults. In a randomized trial to evaluate the efficacy, safety, and side-effect profile of ubrogepant, Dodick and colleagues concluded that a higher percentage of participants who received ubrogepant than of those who received placebo had freedom from pain and absence of the most bothersome symptom at two hours after the dose. In this case, the patient has chronic migraines and has tried and failed a combination of abortive and prophylactic therapies. Given current medical literature, the requested medication is medically indicated. Therefore, Ubrelvy (ubrogepant) 100 mg tablets 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 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 a Monovisc injection (HCPCS J7327) in the right knee. 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 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, a Monovisc injection (HCPCS J7327) in the right knee is medically necessary for the treatment of this patient. 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 bilateral upper lid blepharoplasties. Findings:  The physician reviewer found that Hahn and colleagues note that upper lid blepharoplasty is a common procedure that can be performed safely and reliably. In this case, a physical examination and photographs show that the patient has significant dermatochalasis. The patient reports functional deficits related to her decreased vision due to her eyelids. In this clinical setting, the requested services are medically indicated. Therefore, bilateral upper lid blepharoplasties 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 ophthalmology 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 a PET computed tomography (CT) scan with dotatate. The National Comprehensive Cancer Network (NCCN) guidelines recommend appendectomy for tumors that are less than 2 cm and confined to the appendix, and surgery or right hemicolectomy for tumors that are larger than 2 cm or in cases of incomplete resection. In this case, the patient has opted for active surveillance rather than a right hemicolectomy. NCCN guidelines for surveillance include a history, physical examination, biochemical testing, and CT or magnetic resonance imaging (MRI) tests for the first three to twelve months after surgery. Surveillance, with imaging as clinically indicated, is recommended at one to two year intervals thereafter. Given that standard of care in this clinical setting is CT or MRI scan, the requested service is not medically indicated. Therefore, a PET CT scan with dotatate 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 internal medicine with sub-specialty certifications in medical oncology and hematology 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 eye movement desensitization and reprocessing (EMDR) for integration therapy. The American Psychological Association (APA) recommends offering cognitive behavioral therapy (CBT), cognitive processing therapy, cognitive therapy or prolonged exposure therapy to patients with PTSD. The APA guidelines provide conditional recommendation for EMDR. The International Society for Traumatic Stress Studies (ISTSS) guidelines also include a sequencing of treatment with initial emphasis on safety with skills for emotional regulation and life stabilization. EMDR is not considered treatment for the acute intervention of PTSD symptom exacerbation but is a valid option for the longer-term treatment of this complex disease entity. In this patients clinical setting, cognitive therapies and exposure therapy are more strongly supported than EMDR. The emphasis is to first stabilize the patient in terms of safety and risk as well as emotion regulation prior to initiating any specific trauma-focused psychotherapy. In reviewing this patients history and current presentation, safety and emotion regulation have not yet been established. The patient requires stabilization prior to initiating a trauma-focused therapy, particularly since the trauma-focused therapy can be further destabilizing initially. Given these findings, the requested EMDR services are 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 psychiatry 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 a Monovisc injection in the knee. 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 relief from a 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, a Monovisc injection in the knee is 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 enrollees parent has requested authorization and coverage for allergy laboratory testing (CPT-82784) (CPT-82785) (CPT-82787 x 4 units) (CPT-83520 x 4 units) (CPT-85025) (CPT-86001 x 11 units) (CPT-86003 x 41 units) (CPT-86008 x 64 units) (CPT-88184) and (CPT-88185 x 2 units). Findings:  The physician reviewer found that Current medical evidence has not established the efficacy of tolerance induction for the management of food allergies. Sicherer and Sampson note that the diagnosis of food allergy is largely reliant on medical history, tests for sensitization, and oral food challenges. The authors further note that management remains largely based on allergen avoidance. While it is standard of care to measure immunoglobulin E (IgE) levels to specific foods in question that the patient may have an allergic reaction to, there is a lack of support for an extensive array of blood tests examining foods to which the patient has not had a reaction. Additionally, there is a lack of support for oral desensitization to a multitude of foods to which the patient does not have a history of anaphylaxis. There is a lack of evidence in current medical literature supporting tolerance or sustained unresponsiveness with oral food desensitization. Therefore, allergy laboratory testing (CPT-82784) (CPT-82785) (CPT-82787 x 4 units) (CPT-83520 x 4 units) (CPT-85025) (CPT-86001 x 11 units) (CPT-86003 x 41 units) (CPT-86008 x 64 units) (CPT-88184) and (CPT-88185 x 2 units) is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested allergy laboratory testing (CPT-82784) (CPT-82785) (CPT-82787 x 4 units) (CPT-83520 x 4 units) (CPT-85025) (CPT-86001 x 11 units) (CPT-86003 x 41 units) (CPT-86008 x 64 units) (CPT-88184) and (CPT-88185 x 2 units) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in board certified in internal medicine and allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology and pediatrics 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: An enrollee has requested authorization and coverage for referral to a dermatologist.The U.S. Preventive Services Task Force (USPSTF) has concluded that the current evidence is insufficient and that the balance of benefit and harms of visual skin examination by a clinician to screen for skin cancer in asymptomatic adults cannot be determined. Memorial Sloan Kettering, a prominent melanoma treatment center, also does not recommend routine skin cancer screening. Researchers performed an updated systematic review for the US Preventive Services Task Force regarding clinical skin cancer screening among adults. They concluded that limited evidence was identified for skin cancer screening, particularly regarding potential benefit of skin cancer screening on melanoma mortality. In this case, the patient does not have a personal or family history of skin cancer, and he does not have any reported symptomatic lesions. In addition, records reflect that the patient was evaluated by his primary care physician, and the progress note for this appointment states that the patients skin revealed no rashes or lesions. It would be within the scope of practice of the primary care physician to screen the patients skin and make appropriate referrals if necessary. Under these circumstances, the requested referral to a dermatologist is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.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.