Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a MvoPro Motion G mvoelectric orthosis for left arm device. There is a lack of evidence in current medical literature supporting the use of the requested device following a cerebral event, such as stroke, in assisting a patient regain neurological or muscular strength or function, such as the innate ability to use the arm for functional tasks when the orthosis is removed. The available medical literature regarding the potential of the device is limited and does not establish proven health outcomes, such as reduction in the incidence of overuse injury of the sound, unaffected limb. Harrison and Field note that following stroke, there is a risk of musculoskeletal pain including shoulder subluxation. Arya and colleagues note that rehabilitation efforts to reduce shoulder subluxation in post-stroke hemiparesis should aim to support and suspend the shoulder and arm weight. Due to its weight, the requested device may cause the shoulder to sublux and result in greater instability for a patient with hemiparetic gait by displacing the center of gravity. In this case, the patient is noted to have a chronically weak left arm following a stroke. In this clinical setting, the weight of the requested device would make it difficult for the patient to position her upper extremity for purposeful use of the device. The requested device is not proven to enhance or replace the role of conventional orthoses and is not expected to provide clinically or functionally significant marginal benefits over conventional orthotic therapy. Therefore, a MvoPro Motion G mvoelectric orthosis for left arm device is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested MvoPro Motion G mvoelectric orthosis for left arm 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 and 3 are board certified in physical medicine and rehabilitation and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an additional seven (7) physical therapy visits.The management of chronic benign low back and spinal pain can include pharmacological agents, rehabilitation, psychological treatment, complementary/alternative medicine and invasive approaches. The aim of rehabilitation is to reduce pain, reduce impairment/disability, and improve quality of life. Formal rehabilitative interventions are rendered, in conjunction with education, towards a goal of self-management, independent exercise and remaining active. Exercise and physical activity have low risk for adverse effects and are generally encouraged in the setting of chronic low back pain. The benefit of prolonged exercise in a formal therapy setting, however, is not established in the medical literature. Various exercise types (e.g., yoga and Tai Chi) and group exercise settings, moreover, may well suffice for management of this condition. There is, in addition, no proven marginal benefit of passive modalities such as massage/manual therapy, electrotherapy and thermal modalities provided in a formal setting on a prolonged basis on pain, health or functional outcomes over independently rendered interventions such as self-massage (e.g., using foam rollers, massage balls, etc.) and topical treatments such as ice or heat.In this case, the patient does not have any documented impairments that would preclude her from performing an appropriate independent exercise program, including stretching and strengthening, as well as independent soft-tissue and palliative interventions, e.g., self-massage using foam rollers or massage balls, etc., and topical treatments such as ice or heat. Although the patient has been making some nominal progress with therapy and has ongoing symptoms, there is no expectation of a marginally significant difference in clinical course or outcomes with the continued formal therapy in question over an appropriate, compliantly followed independent program based on the clinical documentation and current medical literature. The patient is no less likely to have recurrences of her symptoms with the continued formal therapy in question than without. Under these circumstances, the requested additional seven (7) physical therapy visits are 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Evrysdi. Spinal muscular atrophy (SMA) is an autosomal recessive, inherited genetic disease characterized by degeneration of alpha motor neurons in the spinal cord. Several innovative medications have recently been developed that improve or ameliorate symptoms in many patients. In 2020, the U.S. Food and Drug Administration (FDA) approved Evrysdi for the treatment of SMA in adults and children two months of age and older. Per the FDA, the clinical studies supporting the approval included patients ages two to 25 years of age. In this case, the patient is 30-years-old with a presumed diagnosis of SMA. The records lack formal testing for SMA, although the patients sister has SMA and she presented with similar signs and symptoms. The FDA has approved Evrysdi for the treatment of SMA in adults and children over two years of age. However, this approval was based on studies on patients from two years to 25 years of age. There is a lack of data demonstrating that Evrysdi is safe and effective in patients over 25 years of age. Therefore, the requested Evrysdi 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 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 Entyvio infusions every four weeks. Entyvio has been demonstrated to be safe and effective for the treatment of patients with moderate to severe ulcerative colitis (Park and Jeen). In addition, the American College of Gastroenterology (ACG) guidelines support Entyvio as a primary therapy for moderate to severe ulcerative colitis by (Rubin, et al.). Dose intensification of Entyvio with infusion more frequently than every eight weeks has been assessed in high-quality clinical trials. The randomized placebo-controlled GEMINI I and II trials demonstrated support for the U.S. Food and Drug Administration (FDA) approval of Entyvio. The studies found that patients who had not achieved remission by week six benefitted by Entyvio every four weeks rather than every eight weeks (Feagan, et al.; Sandborn, et al.). The GEMINI long-term safety study showed that a significant number of patients with ulcerative colitis who had lost response to Entyvio every eight weeks regained response with four-week dosing (Loftus, et al.). The records document that this patient with ulcerative colitis attained remission on Entyvio 300 mg every four weeks. If the patients Entyvio dose is decreased or Entyvio is discontinued and changed to an alternative medication, the patient is at risk for serious complications of ulcerative colitis. For these reasons, the requested Entyvio infusions every four weeks is 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 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.
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 Nutropin AQ NuSpin pen injector. Grimberg and colleagues note that the U.S. Food and Drug Administration (FDA) approves the use of growth hormone for the treatment of idiopathic short stature (ISS), defined by a height standard deviation score of 2.25. The authors do not suggest that there is a medical benefit in using one brand of growth hormone over another to treat children with ISS. In this case, the patients height was noted to be 2.44 standard deviations below the mean in growth. Given that the patient meets generally accepted diagnostic criteria for ISS, the requested medication is medically indicated. Therefore, a Nutropin AQ NuSpin 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 12 sessions of physical therapy. The management of chronic benign musculoskeletal pain affecting the neck, shoulders, and back can include pharmacological agents, rehabilitation, psychological treatment, and invasive approaches. The aim of rehabilitation is to reduce pain and impairment, while improving quality of life (Urits, et al.). Formal rehabilitative interventions are rendered, in conjunction with education, towards a goal of self-management, independent exercise, and remaining active (Bier, et al.; Chou, et al.). However, the benefit of prolonged exercise and formal modalities in a formal therapy setting has not been demonstrated in the medical literature. Prolonged formal therapy in the chronic pain setting has not been shown to yield improved patient health outcomes over independently pursued exercises and independently rendered interventions and topical treatments. With respect to cervical radiculopathy and radicular symptomatology, there is a paucity of high-quality evidence informing treatment for cervical radiculopathy, including with respect to the efficacy of exercise and therapy interventions such as manual therapy (Thoomes). This patient has a history of chronic neck pain, radicular pain into the arms, and back pain. She reports that her symptoms worsen when she is not participating in physical therapy. On review of the available records, there is a lack of indication that the patient has any impairments that preclude full transition to an independent program to include exercise and modalities that can be applied independently to manage her symptomatology. She underwent a series of physical therapy before starting another course. Physical examinations have consistently shown no neurological deficits. Based on current medical literature, there is no reasonable expectation that the patients clinical course or outcomes will improve with formal physical therapy over an independent program. Given these findings, the requested 12 sessions of physical therapy 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 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 for right cervical medial branch radiofrequency ablation (RFA) procedure at C3-4, C4-5 and C5-6. Findings:  The physician reviewer found that the efficacy of cervical RFA found that, The evidence shows a majority of patients were pain free at six months and over a third were pain free at one year. Manchikanti and colleagues concluded that, The evidence for long-term improvement with cervical radiofrequency neurotomy is Level II with moderate strength of recommendation, when performed after the diagnosis of cervical facet joint pain with controlled comparative local anesthetic blocks utilizing 80% pain relief criterion standard. In addition, the authors reported that repeat RFA procedures can provide the same benefit as with the initial procedure. In this case, the patient has chronic neck pain which is mechanical in nature. He has undergone multiple rounds of cervical facet joint injections, which were diagnostic. These diagnostic procedures were followed with cervical RFA procedures, which the provider reported have provided improvements in the patients pain, function, and quality of life. Based on the medical records and current medical literature, the requested right cervical medial branch RFA procedure at C3-4, C4-5 and C5-6 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 anesthesiology with subspecialty certification in pain management 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 Dupixent. This patient presents with atopic dermatitis with involvement of over 20% of his BSA. The patient has failed treatment with oral prednisone 20 mg, Keflex 500 mg, and clobetasol. His provider has recommended treatment with Dupixent. The treatment of atopic dermatitis initially involves the use of nonpharmacologic interventions like emollients. The next step in treatment includes topical interventions, such as topical corticosteroids. For patients with widespread disease not controlled by topical agents, systemic treatment is appropriate. Dupixent is a U.S. Food and Drug Administration (FDA) approved medication that is safe and effective for the treatment of atopic dermatitis (Gooderham, et al.; Eichenfield, et al.). Dupixent has an excellent safety and effectiveness profile, and its use is considered standard of care in the treatment of atopic dermatitis. Given this support, the requested Dupixent is 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 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 patients parent has requested authorization and coverage for a Dexcom G6 glucose monitoring system. Studies note that self-monitoring of glucose allows patients with diabetes mellitus to take control of their disease and thus directly affect the outcomes related to it. Studies note that while finger-prick devices have commonly been used to monitor blood glucose, continuous glucose monitoring (CGM) systems have recently been refined and improved for home use. Studies report that CGM systems may increase the effectiveness of glucose control and minimize hypoglycemia risk. In a comparison of the Dexcom and FreeStyle Libre CGM systems, Link and colleagues found that the Dexcom G5 Mobile generally appeared to be more accurate in measuring  blood glucose. In this case, the patient has a diagnosis of diabetes mellitus and reports a severe fear of needles. Given that current medical literature supports the use of CGM systems for home monitoring of glucose levels and the accuracy of the Dexcom CGM system, the requested equipment is medically indicated. Therefore, a Dexcom G6 glucose monitoring system is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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: The patient has requested authorization and coverage for Birmingham hip resurfacing surgery of both hips. Issa and colleagues report that when patients meet the appropriate selection criteria, hip resurfacing provides excellent results. In this case, the patient has a diagnosis of bilateral hip osteoarthritis at a relatively young age. In this clinical setting, current medical literature supports the use of the requested service as a less invasive surgical alternative. Therefore, Birmingham hip resurfacing surgery of both hips 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for photodynamic therapy. Patients with multiple actinic keratoses can benefit from the use of field treatment with multiple modalities including 5-fluorouracil cream, imiquimod, ingenol mebutate, and photodynamic therapy. Current guidelines recommend 5-fluorouracil cream and imiquimod as first-line treatments for actinic keratoses. A recent comparison study reported the greatest efficacy from 5-fluorouracil cream over other modalities (Jansen, et al.). This patient presents with a history of basal cell carcinoma of the right cheek and recurrent actinic keratoses on his face. Although the patient achieved adequate results with photodynamic therapy in the past, there is a lack of data supporting retreatment with photodynamic therapy for retreatment in this clinical setting. Therefore, the requested photodynamic therapy 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 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.