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 MyoPro elbow-wrist-hand-finger functional neuromuscular upper limb orthotic device (L8702). This patient presents with right hemiparesis status post left middle cerebral artery (MCA) ischemic stroke. The provider has recommended the MyoPro myoelectric orthosis to help restore the patients dominant arm function and range of motion. The standard of rehabilitative care in the setting of severe functional impairments due to central nervous system pathology such as stroke is to optimize function in all relevant domains with the assistance of services such as occupational therapy, orthotists, and assistive technology. Increased independence can be pursued and achieved in this clinical setting using assistive speech technology, adaptive utensils, gait implements, and environmental modifications (Mairami, et al.). However, there is a lack of data supporting a clinical role for the requested MyoPro elbow-wrist-hand-finger orthotic device in stroke management or rehabilitation (Maciejasz, et al.; Proietti, et al.; Peters, et al.). The device is not expected to practically assist the patient with any self-care tasks and the potential benefits have not been demonstrated to outweigh the potential adverse sequelae and safety issues. All told, the requested MyoPro elbow-wrist-hand-finger functional neuromuscular upper limb orthotic device (L8702) is not 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 MyoPro elbow-wrist-hand-finger functional neuromuscular upper limb orthotic device (L8702) 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 reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management 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

The patient has been diagnosed with atopic dermatitis, and is requesting authorization and coverage for a Dupixent 300 mg/2 mL syringe. Findings: Medical literature reported, for all patients, basic management and flare prevention consists of daily showers or baths followed immediately by the application of emollients and moisturizers, with avoidance of triggers such as irritants, aero- or food allergens, and extremes of heat, cold, or humidity. In mild AD, treatment involves as-needed use of low- to mid-potency topical corticosteroids (TCS); in moderate- to-severe AD, a mid-potency TCS should be regularly used. Topical calcineurin inhibitors (TCI) (pimecrolimus or tacrolimus) and crisaborole are U.S. Food and Drug Administration (FDA)-approved alternatives. The study also noted, Chronic or recurrent use of systemic corticosteroids is not recommended, but these medications may serve as bridge therapies to more appropriate, long-term treatment. In this case, the patient has been treated with topical steroids, a calcineurin inhibitor, and antibiotics for secondary infection. The patient has changed their skin care routine regarding moisturizers and laundry detergent. The patient has not maximized their topical steroid therapy, nor have they been tried on a short course of oral steroids. A trial of topical steroids, class I, in addition to consideration of a short prednisone taper would be recommended prior to initiation of Dupixent therapy. The medical evidence does not support the requested medication in this clinical setting. Therefore, a Dupixent 300 mg/2 mL syringe 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 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 parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin human growth hormone.Findings:  The physician reviewer found that the submitted documents support that the requested medication is medically necessary. In 1985, growth hormone deficiency became the first indication for recombinant human growth hormone approved by the U.S. Food and Drug Administration (FDA), which it described as the treatment of pediatric patients who have growth failure due to inadequate secretion of endogenous growth hormone.  In this case, the patient has growth hormone deficiency on lab testing, and according to the growth trends showing growth failure. His bone age is severely delayed, which is also seen in growth hormone deficiency. His predicted adult height is below the target height range for his family. The patients growth chart reflects that the patient is experiencing growth failure over multiple years (Growth Hormone Research Society). The patient has demonstrated growth failure, height staying down the percentiles, low IGF-1 levels and a predicted adult height that is less than mid-parental height even if his bone age is severely delayed bone age. The patients presentation is consistent with growth hormone deficiency with a severe delay in bone age. Under these circumstances, the requested Nutropin AQ Nuspin human growth hormone is medically necessary for the 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 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

An enrollee has requested authorization and coverage for Enhertu (fam-trastuzumab deruxtecan-nxki) infusions. This patient has stage IV adenocarcinoma of the rectum. She has been treated with extensive standard care options. The patient underwent next generation sequencing, which revealed the patients tumor is microsatellite stable, with amplification of RAS, BRAF, WT, and HER2. Given the finding of HER2 amplification in the setting of wild type RAS and BRAF sequences, the provider recommended treatment with Enhertu. According to the National Comprehensive Cancer Network (NCCN) guidelines, there are systemic therapy options for HER2-amplified disease. In a phase II trial, Meric-Bernstam and colleagues reported partial responses and one complete response in patients treated with trastuzumab in combination with pertuzumab. Based upon these data, this combination therapy is included in the algorithm of patients with advanced or metastatic colorectal cancer. Therefore, the requested Enhertu (fam-trastuzumab deruxtecan-nxki) infusions are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Enhertu (fam-trastuzumab deruxtecan-nxki) infusions are likely to be more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mohs surgery. For patients with superficial basal cell cancer (BCC) of the scalp, Mohs surgery may be appropriate if the lesion is greater than or equal to 6 mm. In this case, the patient has superficial basal cell carcinoma located on his scalp which measures  8 x 8 mm. Given the patients young age, and that he has successfully been treated with the Mohs technique before, Mohs surgery is appropriate in this case. Therefore, the requested Mohs surgery 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 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

A 59-year-old enrollee who has been diagnosed with left knee patellofemoral chondromalacia. In October of 2019, the patient reported left knee pain. She has been treated with physical therapy and cortisone injections, with minor pain relief. The provider noted magnetic resonance imaging (MRI) of the left knee dated September of 2018 revealed moderate grade cartilage fissuring along the median ridge of the patella and central trochlea. The patient was treated with three Euflexxa injections in November 2019. In August of 2020, the patient reported 100% pain relief with Euflexxa injections provided in November 2019. In August of 2020, the patient stated her left knee pain was rated as one out of 10 until two months ago. The provider noted the patient has been treated with prior Monovisc injections. The patient has requested authorization and coverage for a series of three Euflexxa injections for the left knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether a series of three Euflexxa injections for the left knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of excellent relief from prior viscosupplementation injections using Monovisc and Euflexxa. Furthermore, the patients options are limited. The patient has tried and failed other conservative options, including corticosteroid injections and physical therapy. A total knee arthroplasty is not an option at this stage. Researchers reported, Patients with patellar chondropathy of grades II or III treated with hyaluronic acid and physical therapy had less pain and better functional results after three and six months of treatment compared to patients undergoing physical therapy alone. The medical evidence supports the requested services in this clinical setting. Therefore, a series of three Euflexxa injections for the left knee are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for continued repetitive transcranial magnetic stimulation (rTMS) services. Perera and colleagues noted, TMS therapy can be used as a continuation or maintenance treatment for patients who benefit from an acute course. Per the authors, TMS therapy can be considered for intermittent use on an empirical basis as a continuation treatment for patients who responded to a prior standard acute course of treatment. In this case, the patient has tried multiple antidepressant medications, and met the criteria for treatment-resistant depression. Based on the consensus statement by Perera and colleagues, this patient may benefit from continued rTMS. Therefore, continued rTMS services were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services were and 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 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: The patient has requested authorization and coverage for an Inogen portable oxygen concentrator. Breathlessness is a symptom of COPD. Ekstrom and colleagues concluded that while oxygen can relieve breathlessness when given during exercise to mildly hypoxemic and non-hypoxemic people with COPD who would not otherwise qualify for home oxygen therapy, evidence does not indicate that oxygen decreases breathlessness in the daily life setting. In this case, while the symptoms of COPD could affect the patients  ability to carry portable oxygen concentrators and perform activities of daily living, based on the specifications provided, the patients current concentrator and the requested Inogen concentrator are comparable. Therefore, an Inogen portable oxygen concentrator is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 sub-specialty certification in pulmonary 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for an additional 2.5 hours per week (for a total 30 hours per week) of applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that Papatola and Lustig define medically necessary ABA services as (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Using this definition, ABA services are medically necessary for this patient. ABA therapy has been identified as the most evidence-based treatment for patients with autism, thus ABA is required to meet the essential health needs of the patient. To address the specific dosage of treatment, the Behavior Analyst Certification Board (BACB) support treatment recommendations made by a BCBA, as these providers have expertise and formal training in the provision of ABA for the treatment of autism. In this case, the patients BCBA recommended 30 hours per week of ABA services as clinically indicated for the treatment of this patients autism. This frequency of ABA services is consistent with Linstead and colleagues, who reported that there is a strong relationship between treatment intensity and mastery of learning objectives, where higher intensity predicted greater progress. Thus, lowering the patients ABA therapy hours could be detrimental to his continued skill development and safety. Given these findings, the requested additional 2.5 hours (for a total of 30 ABA therapy hours) per week are medically necessary for the 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 a licensed B.C.B.A, board certified in psychology, 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

An enrollee has requested reimbursement for dual energy x-ray absorptiometry (DEXA) scan. Per the National Osteoporosis Foundation (NOF), DEXA scans are recommended for Women age 65 years and older and men age 70 years and older, regardless of clinical risk factors. The guidelines suggest that providers perform bone mineral density (BMD) testing every two years thereafter. Medical literature noted that more frequent BMD testing may be warranted in certain clinical situations. The interval between repeat BMD screenings may be longer for patients without major risk factors and who have an initial T-score in the normal or upper low bone mass range. In this case, the patient has a history of osteoporosis and she is on medical therapy. Her fracture risk was noted to be moderate. The current national guidelines recommend DEXA every two years while on therapy. Therefore, the DEXA scan was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested authorization and coverage for 40 hours per week of direct one-on-one applied behavior analysis (ABA) therapy. Medical literature define medically necessary ABA services as (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Using this definition, ABA services are medically necessary for this patient. ABA therapy has been identified as the most evidence-based treatment for patients with autism, thus ABA is required to meet the essential health needs of the patient. To address the specific dosage of treatment, the Behavior Analyst Certification Board (BACB) support treatment recommendations made by a BCBA, as these providers have expertise and formal training in the provision of ABA for the treatment of autism. In this case, the patients BCBA recommended 40 hours per week of ABA services as clinically indicated for the treatment of this patients autism. This frequency of ABA services is consistent with researchers, who reported that there is a strong relationship between treatment intensity and mastery of learning objectives, where higher intensity predicted greater progress. Thus, lowering the patients ABA therapy hours could be detrimental to his continued skill development and safety. Recent literature also noted that the COVID-19 outbreak has resulted in increased difficulties among patients with autism. Given these findings, the requested 40 hours per week of direct one-on-one ABA therapy (CPT 97153) is medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. Findings:  The physician reviewer found that there is insufficient clinical data to support treatment with proton beam radiation when compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues compared intensity modulated radiation therapy (IMRT) and proton therapy. The authors concluded that the patients treated with IMRT resulted in a lower rate of gastrointestinal morbidity. The authors reported no other significant differences regarding toxicities between IMRT and proton therapy. Another analysis of early toxicity compared 421 patients treated for prostate cancer with proton therapy and 842 matched case controls treated with IMRT he authors found a statistically significant decrease in genitourinary toxicity at six months with proton therapy. However, this difference disappeared by one year and there were no other significant differences in toxicity between the two techniques. The National Comprehensive Cancer Network guidelines endorse the position statement by The American Society of Radiation Oncology (ASTRO) and state that there is a lack of benefit of proton therapy over standard treatment with photons and IMRT technique. Given these findings, the requested proton beam radiation 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 radiation oncology 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.