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

Nature of Statutory Criteria/ Case Summary: At issue is whether the Dupixent (dupilumab) subq injections for severe atopic dermatitis (AD) are medically necessary to treat the patients medical condition. The patient has extremely severe atopic dermatitis unresponsive to previous topical and systemic therapy. Dupixent is Federal Drug Administration (FDA) approved for the treatment of atopic dermatitis. Dupixent is appropriate for this patients AD. D'Ippolito et al 2018 reports that the topical steroids are categorized according to their potency and vasoconstrictive properties. All topical steroids can be applied once or twice a day but should not be used for more than 4 weeks. The topical inhibitors (such as tacrolimus or cyclosporine), cause less skin atrophy compared with the topical steroids; however, they do cause more burning and stinging and are accompanied by a boxed warning of an increased risk of lymphomas with long-term use. Systemic agents, such as oral corticosteroids, cyclosporine, azathioprine, and mycophenolate, may also be used for severe, refractory AD. In 2017, the FDA approved injectable dupilumab (Dupixent), which is indicated for the treatment of adults with moderate-to-severe AD whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. Dupilumab can be used with or without topical corticosteroids. Boguniewicz et al 2018 reports that dupilumab acts by blocking signaling, and inhibiting epidermal cell differentiation and synthesis of lipids and antimicrobial peptides. Dupilumab received FDA approval in March 2017 for adult patients with moderate to severe AD who had an inadequate response to, or could not use, topical therapy. It is an option for patients whose previous treatments have failed. Treatment with dupilumab was associated with major improvements in AD-associated symptoms, including pruritus and anxiety and depression. Vangipuram et al 2017 reports that dupilumab has demonstrated efficacy by reducing clinical activity and symptoms. It also has a favorable safety profile. Dupilumab (Dupixent) recently gained FDA approval for patients with moderate-to-severe AD.                                                      Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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 bilateral occipital nerve block procedure with ultrasound guidance (CPT 64405 x 2, 64450 x 2, and 01992). According to the International Classification of Headache Disorders, occipital neuralgia is associated with unilateral or bilateral paroxysmal, shooting, or stabbing pain in the posterior part of the scalp, following the distribution of the greater occipital nerve and/or the lesser occipital nerve. In this case, the patients symptoms and physical examination findings are consistent with occipital neuralgia. Her pain has been refractory to medical management. However, she underwent treatment with bilateral occipital nerve blockade with ultrasound guidance with improvement of pain and reduction of use of pain medications. Treatment with use of bilateral occipital nerve blockade with ultrasound guidance in this clinical setting is consistent with the current medical literature. Authors concluded that occipital nerve block is a safe, technically simple, and effective method that carries a minimal risk of side effects and can be applied for patients that do not achieve desired pain relief using conventional pain management methods. All told, the requested bilateral occipital nerve block procedure with ultrasound guidance (CPT 64405 x 2, 64450 x 2, and 01992) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested bilateral occipital nerve block procedure with ultrasound guidance (CPT 64405 x 2, 64450 x 2, and 01992) 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 services are 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 neurology 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 patients parent has requested authorization and coverage for a 19-day inpatient comprehensive multidisciplinary (including medical director, psychologist, registered dietician, and speech therapist) specialized feeding program. Pediatric feeding disorders involve severe disruptions in nutritional and caloric intake exceeding ordinary variations in hunger, food preference, and interest in eating. Young patients with feeding disorders also may have impaired cognitive and emotional development as well as compromised immune functioning. Expert consensus increasingly recognizes intensive multidisciplinary intervention at day hospital programs and inpatient settings as the standard of care for children with complex feeding problems. This level of support allows monitoring for potential complications including aspiration, severe weight loss, and allergic reactions associated with the introduction of new food types and textures, advancement of oral volumes, and reduction of enteral nutrition among children with little or no experience eating. In this case, the patient has participated in aggressive outpatient therapy for several years without discernible progress. Given the presence of his nutritional deficiencies, failure to thrive, and sensory difficulties, an inpatient feeding therapy program is the next logical treatment option. Therefore, the requested 19-day inpatient comprehensive multidisciplinary (including medical director, psychologist, registered dietician, and speech therapist) specialized feeding program 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 pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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

The enrollee requested coverage for the FreeStyle Libre 14-day system. The enrollee has type 2 diabetes mellitus (DM). His endocrinologist reports he has uncontrolled diabetes and prescribed the FreeStyle Libre 14-day system. The American Association of Clinical Endocrinologists (AACE) published a consensus statement stating that continuous glucose monitoring in type 2 DM can be useful in patients with unappreciated hyperglycemia, hypoglycemia unawareness or those at risk of hypoglycemia. Based on the information provided, this patient has no history of hypoglycemia or hypoglycemia unawareness. It is not clear how much he tried home glucose monitoring by doing finger sticks and adjusting the dose of medication to see if he is achieving improvement in his blood sugar control. The FreeStyle Libre 14-day system is not medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in endocrinology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: This is a patient with long-standing psoriatic arthritis with recurrent polyarthralgias (several joints with pain), rash, psoriatic lesions on the forehead, joint tenderness, swelling, synovitis, fatigue, disrupted sleep and pain 5/10 on a 1-10 scale. The patient also has type II diabetes, Hashimotos thyroiditis (underactive thyroid gland) and hypogammaglobulinemia (lower globulin protein level impairing the immune system). The patient is on methotrexate, Otezla and Humira and had been on prednisone up until recently. Although Acthar Gel is Federal Drug Administration (FDA) approved for adjunctive therapy for short-term administration for an acute episode or exacerbation in psoriatic arthritis, the current literature with respect to the long-term safety and efficacy (ability to produce a desired or intended result) is not well established. Acthar Gel was designed as a bridge therapy and not a maintenance therapy for inflammatory conditions. Researchers have documented multiple discontinuations of Acthar due to typical steroid side-effects such as weight gain, hyperglycemia and hypertension.  If this patient requires maintenance therapy with a biological agent other than those that may have failed in the past, there are available treatment options for psoriatic arthritis. Acthar has not been demonstrated to be superior to steroids or other biological agents in terms of efficacy or safety. Due to corticotrophin properties, Acthar gel is associated with the same adverse effects expected with any steroids. Treatment options include sulfasalazine or leflunomide (instead of methotrexate), other anti-tumor necrosis factor agents and other special inhibitor agents. These choices have demonstrated long-term anti-inflammatory and disease remittive properties. There is no evidence Acthar achieves disease remission.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for a lymphocyte transformation test. Metal hypersensitivity is a possible cause for arthrofibrosis and associated pain in patients after joint arthroplasty. For this patient, the requested lymphocyte transformation test is appropriate because it will help guide treatment. Researchers found that lymphocyte transformation testing shows promise in diagnosing metal allergy and components of bone cement are also being recognized as potential allergens. Further, additional studies have reported some clinical utility in performing the test for patients who have clinical signs of potential metal hypersensitivity, such as this patient. The results of the lymphocyte transformation test will help establish whether the patient requires a revision arthroplasty with special metals that limit hypersensitivity. For these reasons, the requested lymphocyte transformation test is 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 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for balloon sinuplasty. The records provided for review document that this patients computed tomography (CT) scan showed bilateral maxillary, sphenoid, and frontal sinusitis. The patient had recurrent infections despite treatment with antibiotics and steroid irrigations. Balloon sinuplasty is supported as safe and effective in well-selected patients with sinus disease that have failed conservative therapy. For this patient with sinus disease without polyps on CT and examination with recurrent symptoms and refractory to medical therapy, balloon sinuplasty was a reasonable option. Accordingly, the balloon sinuplasty was likely to be more beneficial for treatment 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 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 otolaryngology 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

The patients parent has requested authorization and coverage for 36 vision therapy sessions. The American Optometric Association (AOA) states that, studies suggest that vision therapy is effective in altering accommodation, with a resultant change in amplitude and facility and a decrease in symptoms. Studies have demonstrated that vergence therapy improves vergence ability, and that the effects persist over time. Saccadic training has been shown to help with early reading fluency and is an effective treatment over a period of six weeks. The AOA clinical practice guideline supports treatment with up to 20 visits. This patient was diagnosed with general binocular dysfunction, oculomotor dysfunction of pursuits and saccades, and accommodative dysfunction. The patients results on the Eye Optics Optometry Center supports an indication for the requested vision therapy. Given these findings, 20 vision therapy services are medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services 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 optometry 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 been diagnosed with cervical intervertebral disc degeneration, cervical spondylosis, cervical radiculopathy, lumbar facet arthritis, and myofascial muscle pain. The provider noted that Suboxone is not appropriate for the patients condition and that the purpose of the Belbuca is to provide longer lasting baseline pain relief without drastically increasing her daily opioid morphine equivalent daily dose (MEDD) and to reduce the use of hydrocodone for breakthrough pain. The provider noted that Belbuca is being added to the patients current regime of Vicodin to provide better pain control and to prevent further escalation of her opioid MEDD. The patient has been treated with cervical and lumbar epidural steroid injections and cervical facet joint blocks. The patient has also been treated with medications, including gabapentin and Vicodin. The patient reported low back pain with radiation to bilateral lower extremities. Per the provider, magnetic resonance imaging (MRI) of the lumbar spine obtained revealed multilevel disc bulging and bilateral L4-5 and L5-S1 facet joint hypertrophy. The provider also noted a MRI of the cervical spine obtained revealed multilevel degenerative disc bulges with facet arthropathy from C4-5 through C6-7. There is no indication in any of the medical records that the patient demonstrated behavior consistent with opioid use disorder or that there were any inconsistent urine toxicology screens. The patient has requested authorization and coverage for Belbuca 75 mcg buccal film. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Belbuca 75 mcg buccal film is medically necessary for the treatment of the patients medical condition. In this case, the patients provider noted prescribing Belbuca is to improve the patients pain control with a longer acting medication without increasing the total daily opioid requirements, which is consistent with the stated guidelines published by the CDC. The medical evidence supports the requested medication in this clinical setting. Therefore, Belbuca 75 mcg buccal film 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Korlym 300 mg tablets.Cushings syndrome, a collection of signs and symptoms due to prolonged exposure to cortisol, is associated with poor quality of life, morbidity, and increased mortality. While optimum treatment typically consists of selective and complete resection of the causative tumor, the development of new drugs offers clinicians several choices to treat patients with residual cortisol excess following the surgery. The U.S. Food and Drug Administration (FDA) has approved the antiprogestin Korlym (mifepristone) for control of hyperglycemia secondary to hypercortisolism in adults with endogenous Cushings syndrome who have type 2 diabetes/glucose intolerance and have not responded to, or are not candidates for, surgery. Multiple case reports and small series have suggested that mifepristone administration leads to clinical improvement (weight loss, decrease in glycemia and blood pressure, improvement in psychiatric symptoms) in the majority of patients with Cushings syndrome and does not pose the risk of hepatotoxicity, a rare but potentially serious side effect of ketoconazole. In this case, the patient has a history of Cushing disease and type 2 diabetes, and she has undergone two transsphenoidal surgeries for an ACTH secreting pituitary adenoma. The patient is unable to undergo another surgery because of a cerebrospinal fluid leak after a prior surgery. Under these circumstances, there is sufficient support for the requested medication in this clinical setting. Therefore, Korlym 300 mg tablets are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat 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 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 Xigduo XR 10 mg-1,000 mg tablets. Xigduo is a combination of metformin and dapagliflozin, which is a member of the sodium-glucose transport protein 2 (SGLT2) inhibitors (Chrysant). The U.S. Food and Drug Administration (FDA) has approved canagliflozin, dapagliflozin, and empagliflozin for the treatment of type 2 diabetes mellitus. Researchers reported glycemic control benefits, weight reduction, and systolic blood pressure lowering with Xigduo for patients with type 2 diabetes. This patient has type 2 diabetes complicated by hypertension and dyslipidemia. Based on the chart summary from the provider and current medical literature, treatment with Xigduo is appropriate to manage this patients type 2 diabetes. Accordingly, the requested Xigduo XR 10 mg-1,000 mg tablets are 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 diabetes, endocrinology, 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.