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 Botox 400 IU to be injected every 10 weeks (HCPCS J0585). Cervical dystonia is a movement disorder clinically characterized by involuntary contractions of cervical muscles, which cause abnormal head movements and postures, often associated with head tremor and chronic pain (Evidente and Pappert). Per the American Academy of Neurology (AAN) practice guidelines and U.S. Food and Drug Administration (FDA), Botox is accepted as first-line treatment for cervical dystonia (Simpson, et al.). The peak effect of Botox typically occurs between two to six weeks after the injections, and the effects begin to wear off after 10-12 weeks (Camargo, et al.). Clinical reviews of Botox treatment for cervical dystonia recommend using the lowest effective dose at the longest dosing interval that effectiveness can be maintained. The generally accepted interval between Botox injections is 12 weeks, but this regimen has not been assessed in comparison with alternative dosing intervals. In this case, the patient presents with spasmodic torticollis that has responded well to treatment with Botox. The patients provider documented that Botox provides the patient with clinical improvement that lasts about two months. The patients symptoms are described as severe and interfere with his ability to perform ADLs. Based on the medical literature and guidelines, an increase in the dosage frequency is supported as appropriate to manage this patients condition. For these reasons, the requested Botox 400 IU to be injected every 10 weeks (HCPCS J0585) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for mouth guard/oral appliance. Based on the provided documentation and the available peer-reviewed medical literature, the utilization of an oral orthotic appliance for this patient is not supported as medically necessary. As noted on the patients magnetic resonance imaging (MRI) study, the condylar heads, articular discs, and articular fossa were found to be in normal relationship and function, with the typical movements observed. Further, the records dated in April do not document that other treatment modalities typically attempted for patients with jaw pain such as including medications, exercises, food avoidance, or a basic dental guard for balancing of occlusion. In combination, these modalities have shown to be effective and with excellent long-term outcomes. The treating provider is fabricating an orthotic device that fits on the occlusal surface of the teeth in order to reposition the temporomandibular joint disc and glenoid fossa relationship. This is different from an occlusal guard. The requested device has not been established as medically necessary to treat the provided conditions, especially not as a first-line treatment before clinical attempts at using other modalities. For these reasons, the requested mouth guard/oral appliance is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is licensed D.D.S., board certified in dentistry, 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 Euflexxa injections. The records provided for review document that this patient presents with a history of osteoarthritis of the left knee. The patient has reportedly benefitted from a series of Euflexxa injections every six months for the last three years. The patient most recently underwent a series of injections. Physical examination at that time revealed restricted painful range of motion of the left knee with patellar grind, medial and lateral joint line tenderness, and normal range of motion of the right knee. The provider has documented the need for continued viscosupplementation with Euflexxa injections. 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 routine 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. In this case, there is a history of lasting benefit from viscosupplementation using Euflexxa injections every six months for three years. Furthermore, the alternative is a total knee arthroplasty. For these reasons, the requested Euflexxa injections 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: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for continuous glucose monitor (CGM).A CGM system is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. Over the last decade, CGM systems have been demonstrated to be clinically valuable. A CGM system can promote glycemic and weight control, help reduce the risk of hypoglycemia and hyperglycemia, and improve relevant lifestyle behaviors. It has become a useful tool for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. CGM systems have been confirmed to be a safe modality, with high accuracy in glycemic values and a low complication rate. Therefore, the requested CGM 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 authorization and coverage for Euflexxa injection series in the left knee.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 patients options are limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. Therefore, the requested Euflexxa injection series in the left knee is 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 patients parent has requested reimbursement and prospective authorization and coverage for skilled nursing care of a licensed skilled nurse (HCPCS Codes G0300 and G0299). On review of the available medical records, the skilled nursing care of a licensed skilled nurse was and is medically necessary for treatment of this patient. Specifically, the skilled nursing services will help prevent disability and disease progression given the patients elevated risk of aspiration pneumonia due to her medically intractable epilepsy, severe gastroesophageal reflux, neuromuscular respiratory weakness, and inability to protect and clear her airway. She is also at risk of pressure sores as she is unable to reposition herself. The skilled nursing services will help prolong life and promote physical and mental health efficiency as these services will directly reduce the patients risk of decompensation. As noted by the American Academy of Pediatrics (AAP) guidelines, home skilled nursing is recommended for children with medical needs in Level 1, which include the need for frequent suctioning, oxygen therapy in connection with apnea monitoring, and nutritional support (Harris, et al.). This patient meets these criteria based on the available documentation. Fratantoni and colleagues noted that, children with medical complexity often require pediatric home health care to meet their daily intensive care needs and to live safely outside of the hospital. Similarly, Boss and colleagues reported that, for children with complex medical conditions, pediatric home health care is a chronic need. It is a clinical service delivered entirely outside of clinical settings, granting families unparalleled expertise regarding service quality. Given this support, the skilled nursing care of a licensed skilled nurse was and is medically necessary to prevent disease, disability, and other health conditions and their progression, to prolong life, to promote physical and mental health and efficiency, and to correct or ameliorate any physical or behavioral conditions. Therefore, the skilled nursing care of a licensed skilled nurse (HCPCS Codes G0300 and G0299) was and is 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 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 Synvisc-One injections to bilateral knees.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 patient has a history of good response to viscosupplementation. The patients options are limited, with the alternative being bilateral total knee arthroplasties. Therefore, Synvisc-One injections to bilateral knees are 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 lumbar spine magnetic resonance imaging (MRI) without dye.According to the American Pain Society, surgical referral for chronic low back pain should be reserved for patients with disabling low back pain impacting the quality of life for greater than one year. However, there is mixed evidence for some of the most widely used interventional pain procedures, such as epidural steroid injections, facet injections, and radiofrequency ablation of the medial branch. Surgical procedures include spinal fusion or lumbar disc replacement. Additionally, lumbar degenerative disc disease without disc herniation, also known as discogenic pain, can be diagnosed as the pain source in the presence of a high intensity zone on the MRI. When the diagnosis is confirmed, appropriate treatment may be rendered, relieving the chronic pain. In this case, the patient was involved in a motorcycle accident in 2017 and has reported low back pain since then. An MRI scan of the lumbar spine is requested to make an accurate diagnosis with regard to the decreased height at L5-S1 prior to referral for invasive treatment. In light of the history of chronic low back pain lasting more than a year, he meets the American Pain Society criteria for surgical referral, and the MRI scan would therefore be appropriate. Therefore, the requested lumbar spine MRI without dye is medically necessary for the evaluation of the patients medical condition.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 Humira 80 mg weekly. The U.S. Food and Drug Administration (FDA) approves the use of Humira (generic name adalimumab) for the treatment of moderate to severe hidradenitis suppurativa. For patients with hidradenitis suppurativa who did not respond sufficiently, or in patients with progressive response loss to an adalimumab dose of 40 mg weekly, Zouboulis and colleagues reported enhanced levels of effectiveness with adalimumab dose intensification to 80 mg weekly. Sanchez Martinez and colleagues found improved efficacy with adalimumab dose intensification to 80 mg weekly, with minor adverse effects such as mild infections or injection-site reactions. In this case, the patient has a diagnosis of severe hidradenitis suppurativa. She has tried and failed antibiotics, isotretinoin, and biologic therapies including Humira at standard dosing, Stelara, and infliximab. In this clinical setting, given that the patient has failed numerous therapies and as current medical literature supports the safety and efficacy of Humira 80 mg weekly, the requested medication regimen is medically indicated. Therefore, Humira 80 mg weekly is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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: The patient has requested authorization and coverage/reimbursement for a Saxenda pen injector. Findings: A study describes liraglutide as a glucagon-like peptide 1 (GLP-1) receptor agonist that has emerged as an effective therapy for type 2 diabetes and obesity. The authors further note that as an adjunct to a reduced-calorie diet and increased physical activity, treatment with liraglutide 3.0 mg may provide statistically significant and clinically meaningful weight loss. Another study notes that obesity treatment guidelines recommend the use of pharmacologic therapy in adults who have a BMI of 30 or higher. Given this patients history of obesity and as obesity may lead to the development of comorbidities such as diabetes and hypertension, the requested medication is medically indicated. Therefore, Saxenda pen injector 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for durable medical equipment (DME) Elite Seat knee extension device. Findings:  The physician reviewer found that This patients records document a history of chronic flexion contracture due to longstanding osteoarthritis. The patients provider has recommended use of an Elite Seat knee extension device. Knee stretching devices, particularly the static progressive types, can be useful as an adjunct to physical therapy following an injury or surgery. Given that this patients condition is chronic in nature, with no reported recent injury or surgery, use of a knee extension device is not likely to provide significant improvement. In addition, the Elite Seat is a serial stretching device which has shown to be inferior to static progressive devices in randomized controlled clinical trials and case studies. For these reasons, the requested DME Elite Seat knee extension device is not 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 DME Elite Seat knee extension device is not 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 device is 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery 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.