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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Aimovig 140 mg. Findings: Calcitonin gene-related peptide receptor antagonists (CGRP) are biologic agents with demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine that do not require dose titration, may achieve rapid treatment effects, and are effective in patients who have failed prior preventive treatment and in patients on concurrent oral preventive treatments. Aimovig (erenumab) is a CGRP approved by the U.S. Food and Drug Administration (FDA) for the preventive treatment of migraine in adults.  The American Headache Society (AHS) notes that treatment with monoclonal antibodies to CGRP may be indicated for patients with chronic migraines with an inadequate response to topiramate, Depakote, metoprolol, and nortriptyline. A study found that in patients with chronic migraines, erenumab 70 mg and 140 mg reduced the number of monthly migraine days with a safety profile similar to placebo. Another study reports that erenumab 140 mg monthly may be preferred over the 70 mg monthly dose in patients with episodic migraine or chronic migraine and prior preventive treatment failures. In this case, the patient has a history of chronic headaches and has not responded to multiple oral preventative medications. Given that the patient fits AHS criteria for treatment with CGRP monoclonal antibody therapy, the requested medication is medically indicated. Therefore, Aimovig 140 mg 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 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 Gammagard Liquid 10% vial. The treatment of patients with small fiber neuropathy is dependent on the underlying etiology and management of associated neuropathic pain, which can include several different classes of medications. Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. Intravenous immunoglobulin (IVIG) is considered first-line treatment for immune-mediated neuropathies such as chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy (Liu, et al.). Current neuropathic treatment options are generally inadequate to control the pain associated with small fiber neuropathy (Finnerup, et al.). Oaklander reviewed various studies regarding immunotherapy for distal small fiber polyneuropathy. The author noted that the reports provide a rationale for treating carefully selected patients with immunomodulatory therapies. In addition, the author stated that, Candidates should have symptoms consistent with small fiber polyneuropathy, objective confirmation of diagnosis, exclusion of other causes, failure to improve with symptom management, and, ideally, serologic markers of immunity/inflammation. In this case, the patient has progressive painful progressive length-dependent sensory and autonomic small fiber neuropathy that developed post-transplant. The patients symptoms have not been controlled with conventional medical therapy. A work-up has been inconclusive, although the provider suspects an autoimmune process. Based on the peer-reviewed medical literature, patients with presumed autoimmune small fiber neuropathy may improve clinically with IVIG such as Gammagard. Further, IVIG may be recommended in patients with post-transplant neuropathy with a high clinical suspicion of immunologic origin. For these reasons, the requested Gammagard Liquid 10% vial 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 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: An enrollee has requested authorization and coverage for Repatha Sureclick 140 mg/mL.Findings: A study indicates that, among the various risk factors of atherosclerosis, dyslipidemia plays the main role in the initiation and progression of the atherosclerotic process. Another study states, Clinicians have long used statin medications for the treatment of hypercholesterolemia, hyperlipoproteinemia, and hypertriglyceridemia as an adjunct to diet and exercise. The primary use of these agents is for the primary and secondary prevention of coronary artery disease. According to the study, Large phase 3 trials showed that both of the available medications in this class produce mean reductions in low-density lipoprotein (LDL) cholesterol of approximately 60% when added to standard statin treatment or when given alone, with a good safety profile. In addition to LDL reduction, the study indicates that Evolocumab (Repatha) also reduced lipoprotein (a) levels and improved those of other lipids in clinical studies. In this case, the patient was diagnosed with hypercholesterolemia. The patient successfully lowered his cholesterol after the initiation of Repatha. The medical literature supports the use of Repatha in this case. Therefore, the requested Repatha Sureclick 140 mg/mL is medically necessary for 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 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 Injectafer 750 mg/15 mL vial. Findings: The U.S. Food and Drug Administration (FDA) approves the use of Injectafer as an iron replacement for the treatment of iron deficiency anemia in adult patients who have an intolerance to or unsatisfactory response to oral iron. In this case, the patient has a history of persistent anemia and iron deficiency. The records noted that with oral iron replacement and Venofer, the patients ferritin was 32 ng/mL. Given that the records show that the patient has achieved normal hemoglobin and ferritin levels on Injectafer, the requested medication is medically indicated. Therefore, Injectafer 750 mg/15 mL vial 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 obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and infertility 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 proton beam radiation therapy of 30 Gy in 10 fractions.There is insufficient high quality clinical outcomes published in the medical literature to support the appropriateness of proton beam therapy for management of the patients condition. Proton radiation is not proven to yield superior clinical outcomes as compared with photon-based radiotherapy. Proton radiation therapy is not widely utilized in patients with breast cancer. The use of proton radiation therapy for management of metastatic disease not previously treated with radiation is not well studied. In this case, the patient has a history of stage IV breast cancer with metastatic disease involving her right pelvis and hip. The medical literature does not support the use of proton beam radiation therapy for treatment of breast cancer. Therefore, the requested proton beam radiation therapy of 30 Gy in 10 fractions is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for inpatient hospital stay at the acute level of care. The records provided for review document that this patient does not currently have high risk indicators for an acute coronary ischemic syndrome. The patient has a history of atypical chest pain. Prior treatment has included placement of an ICD and multiple stents. However, the patients biomarkers and EKG results have been negative for infarction or ischemia. In addition, the patient underwent cardiac catheterization during both hospitalizations and was not found to have any obstructive disease. Moreover, the patients chest pain was not improved with nitroglycerine but only with narcotic medication. Given these findings, the requested inpatient hospital stay at the acute level of care 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 internal medicine with subspecialty certification in cardiology 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 monthly occipital nerve block injections.Findings: Two out of three medical experts decided that monthly occipital nerve block injections are likely to be more beneficial for you than any available standard therapy.Researchers indicated that occipital nerve block as adjunctive therapy has shown safety and efficacy in treating patients with migraines, measured by the reduction in pain. Additionally, another study demonstrated that greater occipital nerve (GON) block intervention is able to significantly reduce pain intensity and analgesic medication consumption in migraine patients. Moreover, other research states, Conservative therapeutic approaches are considered first-line. Anesthetic nerve blocks may have a dual role in both supporting diagnosis and providing pain relief. Newer minimally invasive procedures, such as pulsed radiofrequency (PRF) and occipital nerve stimulation (ONS), represent an exciting therapeutic avenue for severe/refractory cases. Surgical interventions should be reserved for select patient populations who have failed all other conservative and minimally invasive options, to be weighed against potential risk. Another study indicates, Occipital nerve block is often the initial treatment of choice for occipital neuralgia as it can potentially be both diagnostic and therapeutic. Alternative or adjunctive local and oral agents are used in patients who report partial or transient benefit from occipital nerve blocks. The author also states, The procedure can be repeated when pain recurs. A review by the American Headache Society recommended at least three-month interval between injections if corticosteroids are used.In this case, the patient has been diagnosed with occipital neuralgia, which has been unresponsive to numerous medications in many different categories. Additionally, documentation indicates that occipital nerve blocks have improved pain, improved function, and reduced the number and severity of headaches. Furthermore, guidelines support repeat injections when pain recurs. Therefore, requested monthly occipital nerve block injections are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1 and reviewer 3 are board certified in anesthesiology with sub-specialty certification in pain medicine. Reviewer 2 is board certified physical medicine and rehabilitation with sub-specialty certification in pain medicine. All reviewers 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 patient has requested authorization and coverage for lidocaine 5% patch. Findings:  The physician reviewer found that patient presents status post right inguinal hernia repair with resulting abdominal wall seroma that has required repeat drainage. The patient has been treated with lidocaine patch 5% and her provider has recommended continued treatment with this medication. The U.S. Food and Drug Administration (FDA) has approved the lidocaine patch 5% for the treatment of patients with post-herpetic neuralgia and diabetic neuropathy. McColgan and colleagues found that there is a lack of evidence to support the use of lidocaine patches for musculoskeletal pain. Similarly, Santana and colleagues evaluated the medical evidence supporting the use of lidocaine patches for chronic low back pain. The authors assessed seven clinical studies and concluded that, We found no randomized controlled trials with substantial evidence to support the use of 5% lidocaine patch in chronic low back pain. For this patient, the lidocaine patch was recommended for musculoskeletal pain. Currently the FDA has not approved the patches for this use and the recent reviews on this subject reinforce the lack of evidence demonstrating the safety and efficacy of lidocaine patches in musculoskeletal related chronic pain. Given these findings, the requested lidocaine 5% patch 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 anesthesiology with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz. This patients alopecia areata has reportedly responded well to treatment with topical and oral corticosteroids with almost complete regrowth of hair. The current medical literature and guidelines recommend treatment with oral and intralesional corticosteroids, cyclosporine, methotrexate and JAK kinase inhibition, or squaric acid. Overall, the records document that this patient is doing well on their current regimen of intralesional and oral steroids. Thus, treatment with Xeljanz is not indicated. Given these findings, the requested Xeljanz 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Adderall medication. While the patient fits the criteria for a diagnosis of attention deficit hyperactivity disorder (ADHD), the records document a context of relatively recent substance use. Despite having undergone rehabilitation for substance use, the records note repeated misuse of substances in the relatively recent past and a history of misusing Adderall. Further, none of the providers involved in this patients care are recommending treatment with Adderall. In this clinical setting, treatment guidelines recommend a three to six-month period of sobriety from all substances, following which a reevaluation of stimulant treatment of ADHD may be considered. For stimulant treatment, medical literature shows that long-acting formulations allow once-daily simple treatment regimens and are more effective than short-acting preparations, such as Adderall, and less prone to abuse and diversion. In this patients case, Adderall medication is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medication is not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, Adderall medication 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks. Findings: The records provided for review document that this patient has a history of hepatitis C virus, genotype 3. The provider has recommended treatment with Epclusa for 12 weeks based on the patients genotype and treatment naive status. According to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. The guidelines noted that these recommendations apply in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment naive genotype 3 patients. This recommendation is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. The AASLD/IDSA guidelines state that resistance testing is not supported, given the high efficacy of Epclusa. The guidelines further cite data showing reduced survival with delayed treatment. For these reasons, the requested Epclusa 400-100 mg tablets for 12 weeks 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for kyphoplasty.Findings:  The physician reviewer found that the patient has a lumbar compression fracture with complaints of progressive pain despite six weeks of conservative care including bracing and medications. The patients provider has recommended treatment with kyphoplasty. As noted in the peer-reviewed medical literature, kyphoplasty is supported by current high-grade evidence to be more effective at controlling pain than nonsurgical treatment options in this patients clinical setting. In addition, kyphoplasty is supported by recent large-volume studies on patients with simple osteoporotic fractures (Papanastassiou, et al.; Ma, et al.). Overall, there is adequate support for kyphoplasty to increase this patients kyphosis angle that has not improved despite nonsurgical management. For these reasons, the requested kyphoplasty 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 kyphoplasty 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 orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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.