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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for a Dynasplint device. Findings:  The physician reviewer found that Furia and colleagues conducted a systematic review to evaluate the safety and efficacy of dynamic splinting as it is used to treat joint contracture in lower extremities, and to determine if duration on total hours of stretching had an effect on outcomes. They concluded that dynamic splinting is a safe and efficacious treatment for lower extremity joint contractures. John and colleagues conducted a randomized controlled trial to determine the efficacy of dynamic splinting in treating patients with postoperative hallux limitus. They concluded that dynamic splinting was effective in reducing contracture of postoperative hallux limitus. Experimental patients gained a mean 250% improvement in active range of motion (AROM). John and colleagues concluded that this modality should be considered for standard of care in treating postoperative hallux limitus.In this case, the patient had right foot bunionectomy performed and has developed a post-operative contracture of the big toe joint. This contracture has created a balance and gait disturbance. The patient has reportedly failed to adequately improve with splinting and exercise. Evidence based medical literature supports the use of dynamic splinting for treatment of this post-operative contracture as the standard of care. Under these circumstances, the requested Dynasplint device was, and is, medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested device was, and is, medically necessary for the patient's 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Beeks arch support shoes and a Simmons 6th generation bed including Super Plush Pillow Topper.Researchers state that excessive foot pronation during gait is a risk factor in medial tibial stress syndrome (MTSS). Researchers studied the effects of bilateral foot orthoses during running on dynamic foot-pressure distribution patterns in recreational runners with MTSS and found that arch-support foot-orthoses may help with conditions such as MTSS. Hsieh and colleagues conducted a randomized controlled trial to examine the short-term effects of customized arch support insoles on symptomatic flexible flatfoot in children. They concluded that children with flexible flatfoot who wore customized arch support insoles for 12 weeks exhibited significantly improved pain/comfort, physical health, stair ascent time, upper extremity and physical function, and transfer and basic mobility.In this case, the submitted records do not indicate that the patient has any musculoskeletal condition that would benefit from shoes with arch supports. Records specifically indicate that there are no musculoskeletal abnormalities (such as pes planus) in the patients feet and that the patients gait is normal. Moreover, records indicate that the patient has polyneuropathy, which is not a condition for which arch supports are an established treatment. Under these circumstances, the requested Beeks arch support shoes are not medically necessary to treat the patients condition.There are also no indications in the submitted records that the patient has any medical conditions for which she requires a specialty medical bed or specialty pillow/bedding/mattress surface. In addition, there are no features of the requested bed and pillow topper that are proven to provide any clinically and marginally significant benefit for any health condition over a standard, commercially available bed and pillow. Therefore, the requested Simmons 6th generation bed including Super Plush Pillow Topper is not medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested durable medical equipment is not medically necessary to treat the patients condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 of Prempro. The U.S. Food and Drug Administration (FDA) approves the use of Prempro for the treatment of vasomotor symptoms due to menopause. The American College of Obstetricians and Gynecologists (ACOG) notes some patients aged 65 years and older may continue to need systemic hormone therapy for the management of vasomotor symptoms, and the use of hormone therapy and estrogen therapy should be individualized based on each patient's risk-benefit ratio and clinical presentation. In this case, the patient presented with vasomotor symptoms associated with menopause and had tried and failed alternative treatments. Given the provider has recommended continued use of the requested medication and the patient has reported relief, the requested medication is medically indicated in this clinical setting. Therefore, Prempro is medically necessary for the treatment of this patient.Final Result: The reviewer determined the medication at issue 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tepezza infusions. Treatment with Tepezza for this patients exophthalmos is consistent with current medical literature recommendations based on the documentation supporting a diagnosis of dysthyroid orbitopathy and failure of steroid treatment. A study concluded that Tepezza for the treatment of active thyroid disease resulted in better outcomes with respect to proptosis, Clinical Activity Score, diplopia, and quality of life when compared to placebo without severe adverse events reported. Moreover, Tepezza has been shown to be beneficial and safe for patients with acute and active orbital inflammation related to dysthyroid orbital disease. The records show that the patients orbital inflammation is active despite treatment with steroids. Therefore, the requested Tepezza infusions 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla tablets.Findings: Based on the psoriasis treatment guidelines, patients who have psoriasis affecting between 3 to 10% (defined as moderate) and greater than 10% (defined as severe) of their body surface area (BSA) are candidates for phototherapy and systemic medical therapy. There are no step therapy guidelines recommended in this context, and the choice of therapy should be made at the discretion of the treating physician with attention paid to patient comorbidities. Otezla is FDA approved and is indicated for the treatment of patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. Otezla has Level `A` evidence to support its efficacy. In this case, the patient has documented evidence of moderate-to-severe disease with difficult to treat areas (nails and scalp). Under these circumstances, the requested medication, Otezla tablets, is medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology, with subspecialty certification in dermatopathology, 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 Dovato 50-300mg tablets.Van Wyk and colleagues state that Dovato has been shown in multiple clinical trials to achieve and maintain HIV viral suppression as effectively as three drug regimens such as Triumeq with less toxicity and adverse events. Dovato does not contain abacavir, which is associated with increased risk of stroke or myocardial infarction. According to U.S. Department of Health and Human Services (DHSS) guidelines for antiretroviral treatment in HIV, Dovato is recommended as a preferred regimen and Triumeq is not a preferred agent. Dovato is FDA indicated for both treatment naive starting treatment and treatment experienced HIV patients switching from their current three drug regimens. In this case, the patient has asymptomatic HIV disease, and his condition has been undetectable for several years on his current regimen of Triumeq. The patients provider has indicated that there is concern with the potential effects of long term highly active antiretroviral therapy (HAART) medication on the patients kidneys and liver. Given the effectiveness of Dovato as a viral suppressant, the patients provider has suggested replacing the more toxic abacavir with Dovato to maintain control of the patients viral condition while lessening the overall strain on the patients body. Under these circumstances, the requested medication, Dovato 50-300mg tablets, is 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 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 bilateral endovenous ablation therapy of the right and left perforator veins. The documentation does not support an indication for the requested bilateral endovenous ablation therapy of the right and left perforator veins for this patient. Based on the available documentation, the perforating vein reflux has not been fully assessed with lower extremity arterial perfusion to establish this as the source of the patients pain. Additionally, there has been no reassessment or follow-up studies described in the medical records regarding the patients response to the procedures already performed. As the risk-to-benefit ratio of perforator vein ablation is not as favorable as for saphenous vein ablation, perforator vein ablation is reserved for patients with recalcitrant venous ulcers or when the patients symptoms are directly attributable to the specific perforator vein to be ablated. For these reasons, the requested bilateral endovenous ablation therapy of the right and left perforator veins 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 surgery with subspecialty certification in general vascular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5 mg tablets. This patient presents with a history of alopecia areata that has been present for many years and is worsening. His area of involvement has been as severe as alopecia totalis, which affects the scalp, eyebrows, and eyelashes. The provider reports that the patient has been treated with intralesional steroids, topical steroids, topical tofacitinib, and pulsed dexamethasone. In December 2020,  photographs revealed about 70% of hair loss in the scalp and more than 50 % of loss of his eyebrows and eyelashes. The patients provider has recommended treatment with Xeljanz. Per the medical literature, in patients with severe alopecia, aggressive treatment is supported. Meah and colleagues reported that JAK inhibitors are the ideal choice of systemic therapy in adults. This patient has chronic alopecia areata that has progressed to totalis. He has failed typical first-and second-line therapies and current medical literature supports the use of JAK inhibitors as the next ideal choice for therapy in this clinical setting. For these reasons, the requested Xeljanz 5 mg tablets 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 Xeljanz 5 mg tablets 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 medication is 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 dermatology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to two prior overdose attempts, without current suicidal ideation or self-harm. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to family conflict and social isolation. The patient had refused to attend school via Zoom, but was noted recently to have registered for school and was reported to be less oppositional. With regard to comorbidity, the records support a score of 1. The patient does not have comorbidities. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to family conflict and struggles with school. With regard to level of support of the recovery environment, the records support a score of 2 due to the patients parents efforts to arrange treatment for the patient and their participation in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment due to a recent psychiatric hospitalization, followed by a deterioration in mood and functioning, but reported recent improvement in mood and functioning while receiving outpatient treatment. With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrated incomplete engagement as he participated in outpatient treatment but refused to participate in a virtual IOP . Thus, the patient has a total score of 17. In this case, the recommended level of care is high intensity community-based services. Therefore, RTC services are not medically necessary for the 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 with sub-specialty certification in child and adolescent 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an RTS300 FES Therapy System.Findings: In this case, the patient suffered a spinal cord injury. The patient has undergone therapies to strengthen and improve function. The evidence for the effectiveness of the RT300 functional electrical stimulation (FES) cycling in patients with spinal cord injuries is limited. There is insufficient evidence in the literature that supports that the use of the RT300 FES will be effective for this patients spinal cord condition or in individuals with quadriplegia in long term improvement of muscle strength, vascular blood flow, bone mineral density, reduction of spasticity and atrophy, facilitation of functional motor movement or reduction muscle atrophy in the upper and lower extremities. Accordingly, the requested RTS300 FES Therapy System is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested durable medical equipment is not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation, with subspecialty certification in neuromuscular 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for leukocyte histamine release test (CPT code 86343). This patient underwent leukocyte histamine release testing given her history of urticaria. According to current management guidelines for chronic urticaria, even though chronic autoimmune urticaria can be differentiated from chronic idiopathic urticaria by the presence of auto-antibodies, the etiologic, therapeutic, and prognostic value of this auto-antibody has not been established. According to the American Academy of Allergy, Asthma and Immunology (AAAAI), routine laboratory testing in patients lacking atypical features rarely yields clinically significant findings (Bernstein, et al.). Overall, the utility of leukocyte histamine release test has not been demonstrated in to provide improved health outcomes when compared to standard available testing. Therefore, the leukocyte histamine release test (CPT code 86343) was not 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 leukocyte histamine release test (CPT code 86343) was 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 services at issue were not likely to be more beneficial for evaluation 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 internal medicine with subspecialty certification in allergy and immunology 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.