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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cardiology consultation and/or vascular/extremity study. The records provided for review document that this patient presents with possible post-thrombotic syndrome (PTS). A combination of reflux due to valvular incompetence and venous hypertension due to thrombotic obstruction is thought to underlie the pathophysiology of PTS. Symptoms and signs of PTS may include leg pain, leg heaviness, vein dilation, edema, skin pigmentation, and venous ulcers. The patient has requested a cardiology consultation with a provider who also performs vascular consultations given his dissatisfaction with the outcome of his vein ablation. Kahn and colleagues noted that, A number of clinical tools or scales have been used to help diagnose and define PTS. Of these, three were developed specifically to diagnose PTS after objectively diagnosed DVT: the Villalta scale, Ginsberg measure, and Brandjes scale. In this clinical setting, evaluation and treatment with a vascular surgeon, rather than a cardiologist, is appropriate. Based on the available documentation, additional imaging with a vascular/extremity study is not indicated. All told, the requested cardiology consultation and vascular/extremity study are not medically necessary for 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 internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology 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 radiofrequency ablation of the left and right perforator veins. The documentation reviewed does not provide adequate evidence that the requested radiofrequency ablation of the left and right perforator veins is likely to be more beneficial for this patient than standard treatment options. Specifically, it is not possible to attribute the patients pain to his residual superficial venous reflux without assessment of arterial perfusion. Routine assessment and treatment include assurance of satisfactory arterial perfusion to the lower extremities bilaterally prior to proceeding with further endovenous treatments. This is especially important for this patient since compression stockings and at least four endovenous procedures have failed to provide satisfactory pain relief. Therefore, the requested radiofrequency ablation of the left and right perforator veins 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 radiofrequency ablation of the left and right perforator veins 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 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 reviewers 1, 2, and 3 are board certified in surgery with subspecialty certification in general vascular 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Exondys 51 (eteplirsen) weekly infusions. Findings: Muscular dystrophies are an inherited group of progressive muscle disorders whose etiology stem from dysfunctions in genes associated with normal muscle function. A study noted that mutations in the Duchenne muscular dystrophy (DMD) gene result in Duchenne or Becker muscular dystrophy due to absent or altered expression of the dystrophin protein, with severe DMD typically presenting around ages two to five with gait disturbance, historically leading to the loss of ambulation by age 12. The U.S. Food and Drug Administration (FDA) approves the use of Exondys 51 (generic name eteplirsen) in patients who have a confirmed mutation of the DMD gene that is amenable to exon 51 skipping. Another study noted significant, clinically meaningful attenuation of respiratory decline, measured by percent predicted forced vital capacity (FVC% p), in patients treated with eteplirsen. In this case, the patient has a diagnosis of DMD amenable to exon 51 skipping. In this clinical setting, the requested medication is medically indicated. Therefore, for Exondys 51 (eteplirsen) weekly infusions 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ Nuspin. Idiopathic short stature is among the U.S. Food and Drug Administration (FDA) approved indications for growth hormone therapy. Idiopathic short stature is defined as standing height below -2.25 SDs in the absence of identified cause. This patients records do not include adequate documentation to meet the essential diagnostic criterion for idiopathic short stature. Specifically, his bone age has not been delayed recently, although his most recent growth velocity was slightly lower than expected for a prepubertal male his age. His most recent predicted adult height is within the normal range for North American males, which is above 64 inches. The clinical history and current presentation do not support an indication for treatment with growth hormone therapy. For these reasons, the requested Nutropin AQ Nuspin is not medically necessary for this patient. Final Result: The reviewer determined 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 pediatrics with subspecialty certification in pediatric 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 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 hypoglossal nerve stimulator implant procedure. The records document that this patient has failed CPAP therapy and is not an optimal candidate for oral appliance therapy due to the severity of her obstructive sleep apnea. There is adequate evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of patients with OSA with hypoglossal nerve stimulation or Inspire airway stimulation. The stimulation treatment for apnea reduction (STAR) trial showed that upper airway stimulation provides significant improvement in sleep-related quality of life outcome measures, with effects maintained across a five-year follow-up (Woodson, et al.). The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult OSA to be a safe and effective second-line treatment in patients who are intolerant or unable to achieve benefit with positive pressure therapy. All told, the requested hypoglossal nerve stimulator implant procedure is 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 hypoglossal nerve stimulator implant procedure 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 reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in otolaryngology with subspecialty certification in sleep medicine 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vumerity.There is sufficient support for the requested medication in this clinical setting. Adherence to a disease-modifying therapy (DMT) may be affected by medication adverse effects. In 2019, the American Academy of Neurology (AAN) issued practice guideline recommendations for DMTs for adults with multiple sclerosis (MS). Clinicians should offer DMTs to people with relapsing forms of MS.  Clinicians should inquire about medication adverse effects with people with MS who are taking a DMT and attempt to manage these adverse effects. Clinicians should discuss a medication switch for patients with MS for whom these adverse effects negatively influence adherence.According to the U.S. Food and Drug Administration (FDA), Tecfidera (dimethyl fumarate) is indicated for the treatment of relapsing forms of MS. Additionally, the FDA has approved Vumerity (diroximel fumarate) as a DMT for people with relapsing forms of MS, including clinically isolated syndrome (an initial neurological episode), relapsing-remitting MS, and active secondary progressive MS. In a study by Naismith and colleagues, diroximel fumarate demonstrated an improved gastrointestinal tolerability profile compared with dimethyl fumarate, with less severe gastrointestinal events and fewer days of self-assessed gastrointestinal symptoms, fewer gastrointestinal adverse events, and lower discontinuation rates because of gastrointestinal adverse events.In this case, the patient has multiple sclerosis and is experiencing adverse effects with his current DMT. Based on the AAN practice guidelines above, switching to another DMT is indicated. The references above indicate that Vumerity is similar to Tecfidera but has a distinct chemical structure that has been shown to have fewer reported gastrointestinal side effects than Tecfidera. Therefore, Vumerity is medically necessary for the treatment of the patients medical condition.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Pifeltro. Sax and colleagues noted that, Initiation of antiretroviral therapy (ART) often leads to weight gain. While some of this weight gain may be an appropriate return-to-health effect, excessive increases in weight may lead to obesity. This patient reports that he experienced weight gain with Biktarvy. However, the records provided for review do not include documentation to support weight gain. The only weight charted for this patient was on 3/19/21 when he weighed 198 pounds with a body mass index (BMI) of 28.4 kg/m2. Moreover, Pifeltro has also been associated with weight gain. Absent documented weight gain with his current regimen, there is a lack of clinical rationale to support a change in therapy. All told, the requested Pifeltro is not medically necessary for 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 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 patients parent has requested authorization and coverage for Nutropin AQ Nuspin. Findings:  The physician reviewer found that growth hormone deficiency (GHD), described as the treatment of pediatric patients who have growth failure due to inadequate secretion of endogenous GH, was the first indication for recombinant human GH approved by the U.S. Food and Drug Administration (FDA). The Growth Hormone Research Society reports that in the evaluation of GHD, short stature is defined as a height more than two standard deviations below the population mean. In this case, the patient has a growth hormone deficiency and a history of autoimmune hepatitis. He is being managed on Zomacton growth hormone and prednisone for autoimmune hepatitis. Visit notes reported that even on growth hormone therapy, the patient was at the 13th percentile of height, without a significant catch up in growth. Given that the patient does not have short stature, as his height predictions based on bone age have fallen within mid-parental height targets, the requested medication is not medically indicated. Therefore, Nutropin AQ Nuspin 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 pediatrics with sub-specialty certification in pediatric 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 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 Monovisc injection in the right 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, there is a history of lasting relief with viscosupplementation using Monovisc seven months ago. Furthermore, the options are limited. The patient has tried and failed other treatments, including physical therapy, a home exercise program, and topical and oral nonsteroidal anti-inflammatory drugs. Therefore, the requested Monovisc injection for the right knee is medically necessary for the treatment 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: An enrollee has requested authorization and coverage for brand name timolol maleate preservative-free ophthalmic solution 0.5% (Timoptic Ocudose).Many patients develop adverse reactions to glaucoma medications. According to medical literature, the preservative benzalkonium chloride (BAK) is one of the main culprits for these reactions. Further, medical literature state that the use of BAK can lead to ocular discomfort, poor intraocular pressure control, glaucoma surgery failure, and decreased patient compliance. Medical literature state that preservative-free treatment, like timolol, reduced dry eye symptoms and improved compliance. In this case, the use of preservative-free timolol has been shown to be tolerated by the patient and effectively lowered ocular pressure. Records also indicate that the patient has had adverse reactions to the timolol preparation with preservative in the past. Therefore, brand name timolol maleate preservative-free ophthalmic solution 0.5% (Timoptic Ocudose) is medically necessary for the treatment of the patients medical condition.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 Stelara SQ (90 mg every 4 weeks).According to a trial conducted by Sands and Marano, Stelara has shown efficacy for the treatment of ulcerative colitis. This trial demonstrated that a single intravenous dose of Stelara induced clinical remission in a significantly greater proportion of patients than placebo did, as measured by both clinical response and endoscopic response. Moreover, this result was attained in a patient population which was 50% biologic-refractory. Additional studies have demonstrated that Stelara 90 mg every four weeks is safe and well-tolerated for the treatment of inflammatory bowel disease. Patients may respond to dosing every 4 weeks when dosing every 8 weeks is ineffective. In this case, the patient has moderate to severe ulcerative colitis. The patient has had improvement on Stelara. Per the records, he has failed Stelara every 8 weeks, given ongoing inflammation on colonoscopy four months after starting Stelara. Continuation of dosing every 8 weeks may result in complications such as toxic megacolon, dysplasia leading to colorectal cancer, ulcerative colitis flare, hospitalization, need for surgery, or other complications. Therefore, the medical evidence supports a dose escalation to 90 mg every 4 weeks. Discontinuation of Stelara (even if an alternative is initiated immediately) may result in loss of disease control, and subsequent complications. The alternative medication, Xeljanz, is also associated with infectious complications. Thus, the requested Stelara SQ (90 mg every 4 weeks) is medically necessary for the treatment of this patients medical condition.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.